Background

Antimicrobial resistance, known as AMR, is a serious threat to public health. Unmonitored, bacteria become resistant to more antibiotics until infections become untreatable. Experts predict that by 2050, more people will die from untreatable infections than from cancer.

Urinary Tract Infections, or UTIs, are the most common bacterial infection treated in the NHS. These are most often treated with antibiotics prescribed by GPs and nurses.

Recent research suggests up to 50% of bacteria that cause UTIs are resistant to antibiotic treatment. Antibiotic resistant bacterial infections can cause longer, more severe infections requiring multiple antibiotic courses and in some cases hospital admission.

GPs and nurses have recently been encouraged to prescribe nitrofurantoin instead of trimethoprim (both first-line, NICE recommended, antibiotics for UTI). Some studies suggest this has reduced trimethoprim AMR rates. However, this has not happened everywhere and, more concerningly, may have led to higher AMR against other antibiotics.

These results lead policy makers to ask two key questions:

1. Are these results reliable?
2. What should be done?

Firstly, the data are not reliable (because methods used mean there could be other reasons for the changes), and secondly, nobody knows what to do next. There are lots of ideas, but we do not know if the benefits will outweigh the risks of further AMR harms.

Design

A randomised controlled trial (RCT) is the only reliable way to investigate the effects of an intervention or treatment. An RCT allows a fair comparison to be made between the effects of an intervention of interest and usual practice, without the risk of bias.

Within the IPAP-UTI study, we will conduct three RCTs, with some GP practices randomly chosen to receive an intervention encouraging them to use an alternative antibiotic/s, instead of one where AMR levels are problematic; and the rest will continue with usual care.  Both will continue to prescribe appropriate and NICE recommended antibiotics for UTIs. Your GP will use their best clinical judgement regarding prescribing of antibiotics, and decision on whether to adhere to the RCT intervention rests solely with the prescribing clinician.

At the end of the study, we will compare antibiotic use and AMR rates between the two groups. We expect that any differences will be due to the intervention.

The IPAP-UTI study will focus on  the areas with the worst AMR problems in the UK, and will include the groups most affected. We will report differences across socioeconomic and ethnic groups.

Funding

This study is funded by the National Institute for Health and Care Research (NIHR) under its Programme Grants for Applied Research Programme (Ref:NIHR204400). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Collaboration

The IPAP-UTI programme is a collaboration between the UK Health Security Agency (UKHSA), Bristol, North Somerset and South Gloucestershire Integrated Care Board (BNSSG ICB) and the University of Bristol.

Investigators

The IPAP-UTI programme is led by Dr Ashley Hammond and Professor Alastair Hay from the Centre for Academic Primary Care at the University of Bristol.

Contact

To contact the study team, email: ipap-uti@bristol.ac.uk

If you have any concerns regarding your clinical care, please discuss this with your GP.

---