CUTE LOWER RESPIRATORYtract illness is the most common condition treated in primary care. 1,2 Assuming 75% of patients are prescribed antibiotics 1 and using conservative national morbidity survey estimates, 2 acute cough costs the UK National Health Service at least US $270 million in consultation costs and US $35 million to 70 million antibiotic prescription costs annually. In the United States, excess antibiotic prescribing is mainly for pharyngitis and acute bronchitis, amounting to 55% of prescriptions and costing $726 million per year. 3 A consensus has been made for limiting antibiotic use in acute lower respiratory tract infection. [4][5][6] However, recent systematic reviews 7,8 have come to diverse conclusions about the likely effectiveness of antibiotics, and the most recent Cochrane review 7 confirms a moderate effect of antibiotics on illness course; the debate continues unabated about the role of antibiotics be-For editorial comment see p 3062.

National Research Register N0484094184 ISRCTN: 03525333.

Objective To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance. Design Observational study. Setting Primary care. Participants 839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection. Main outcome measure Duration and severity of symptoms. Results 684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline. Conclusion Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.

BackgroundDipsticks are one of the most commonly used nearpatient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed. AimTo confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI). Design of studyValidation study. SettingPrimary care. MethodA total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines. ResultsSixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule -based on presence of nitrite, or both leucocytes and blood -was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features. ConclusionA clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.

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