Point of care urine culture to inform appropriate antibiotic prescribing for uncomplicated urinary tract infection in primary care (POETIC): a randomised controlled trial of clinical and cost effectiveness

Background: urinary tract infection (UTI) is common and widespread use of antibiotics contributes to antimicrobial resistance. The effectiveness of point of care test (POCT) for urine culture is unknown. Aim /Design: individually randomised trial of the clinical and cost effectiveness of Flexicult™ SSI-Urinary Kit (that identifies and quantifies bacterial growth and antibiotic susceptibility) to guide antibiotic treatment of uncomplicated UTI in adult women in primary care vs. standard care. Methods: multi-level regression compared outcomes between the two groups controlling for clustering. Results: 329 were randomised to POCT and 325 to standard care. Mean age was 47.6, and 90% had two or more of dysuria, frequency and urgency. 82.4% of women randomised to POCT and 88.4% to standard care were prescribed antibiotics at the initial consultation. Clinicians indicated that they had changed management in response to the test result for 190 (63.1%) of 301: 14 (7.4%) were advised not to start taking an antibiotic, 10 (5.3%) were advised to stop taking an antibiotic they had already started, 29 (15.3%) to start taking an antibiotic, 63 (33.2%) to keep taking an antibiotic that was prescribed at the baseline visit, and 74 (38.9%) were prescribed a new antibiotic. Despite this, there was no significant difference in antibiotic use that was concordant with laboratory culture results (primary outcome) at day 3 (39.3% POCT culture vs. 44.1% standard care, OR 0.84, 95% CI 0.58 to 1.20), and there was no evidence of any differences in recovery, patient enablement, UTI recurrences, re-consultation and hospitalisations at follow up. POCT culture was not cost-effective. Conclusions: point of care urine culture marginally reduced initial antibiotic prescribing and resulted in changed management for two thirds of women, but it did not achieve more concordant antibiotic use overall or improve patient reported outcomes including patient enablement, and therefore was neither clinically nor cost effective when used mainly to adjust immediate antibiotic prescriptions. Further research should explore approaches to encourage use of the test to guide initiation of ‘delayed antibiotics’.