When the global SARS-CoV-2 (COVID-19) pandemic took hold, the face of primary care changed dramatically. Telephone and even video consultations became the norm, and people were being discouraged from visiting their GPs if they had any COVID-19 symptoms. Naturally, this resulted in a marked decrease in the number of patients accessing primary care services and a drop in diagnoses, including for urinary tract infections. The weekly rate of UTI diagnosis per 100,000 population dropped substantially from a 5-year average of 30 to 35 to less than 10 between 30 March and 24 April 2020. Since April, the rate has risen to no higher than 50% of its usual rate.
Not only did the pandemic result in fewer presentations to primary care, including for urinary tract infections, but also to fewer requests for urine samples to be handed in to practices on first UTI presentation for culture. Whilst for many (mainly women) whose symptoms may be relatively mild, this may not cause any significant problems, as they will take their empirically prescribed antibiotic and recover, for others (men, those whose symptoms worsen), this could put them at a disadvantage. For patients who may have to re-consult due to ongoing symptoms, or due to recurrent infections, there is no recent urine culture history to help guide the most appropriate choice of antibiotic.
Naturally, the fewer infections that are seen in primary care, the fewer antibiotics are prescribed; this in turn is likely to impact on AMR prevalence. Whether this impact will be positive or negative remains to be seen, but if we are not taking urine samples from those who do present first or even second time around, we remain in the dark about the most appropriate management strategy for them, and could therefore be encouraging bacterial resistance to antibiotics. Primary care clinicians have in recent years been incentivised through the NHS Quality Premium to reduce their prescribing of broad-spectrum antibiotics, including cefalexin, co-amoxiclav and ciprofloxacin – all of which are possible treatment options for a UTI, particularly in the elderly population. Bacterial resistance to broad-spectrum antibiotics can seriously limit effective treatment options in some cases. Interestingly, prescribing of all three of these antibiotics has increased since March 2020 in the over 80s in England compared to the previous 12 months.
Broad-spectrum antibiotic prescribing is often favoured when clinicians do not know what is causing the patient’s symptoms, nor which antibiotic will be most effective. Not only can this practice encourage antimicrobial resistance, it can also be especially risky in the elderly population who have a greater likelihood of developing more serious infections as a result of a UTI, including sepsis.
The increased pressure to manage elderly patients at home during the pandemic, given their higher risk of acquiring COVID-19, could have led to increased prescribing of broad-spectrum antibiotics during the pandemic. Of greater concern, however, is the 30% decrease observed in the number of sepsis hospital admissions between March and April 2020. According to data reported by the Office for National Statistics, deaths at home in England which were not related to COVID-19 increased by almost 47% during the same time period. This certainly raises suspicions about whether sepsis patients are being missed due to changes in patient management brought about by COVID-19.
We are very much still in the midst of the pandemic, looking ahead to what could be a difficult winter for healthcare services. The true impact of the pandemic on the management of common community-acquired infections including UTIs remains unknown, and certainly presents a unique opportunity for a natural experiment in terms of AMR. Reduced presentation and diagnoses could reduce selection pressure related to antibiotic challenge. However, reliance on broad-spectrum antibiotics to manage potentially vulnerable populations in the community could have disastrous consequences. We must continue not only to promote prudent use of antibiotics, but also to continue requesting urine samples from patients as this can prove invaluable in the management of complicated UTIs, particularly in our elderly population who could be more likely to suffer serious consequences of inappropriate infection management.
Dr Ashley Hammond, Senior Research Associate, University of Bristol