677 practitioners describe where their confidence in urinary tract infection stops: children, men, older patients, recurrence

Design

Qualitative evidence synthesis, reflexive thematic analysis, CASP quality appraisal

Population

32 studies reporting on 677 primary care practitioners, international general practice

Primary outcome

Views, perceptions and experiences of managing urinary tract infection

Effect

Five themes; confidence in the routine case contrasted with uncertainty in children, men, older patients and recurrent infection

Urinary tract infection is among the commonest reasons a patient consults, and among the commonest reasons an antibiotic is prescribed. This synthesis drew on 32 qualitative studies covering 677 primary care practitioners internationally, rated high quality against the Critical Appraisal Skills Programme checklist.

Five themes emerged, and the first two belong together: practitioners were confident — until what the authors call patient X presented. Patient X is a child, a man, an older patient, or someone with recurrent infection. For the typical non-pregnant woman with dysuria, management felt routine. Outside that, the same clinicians described genuine uncertainty about whether to treat, whether to culture, and what the symptoms even meant.

The remaining themes are about the system rather than the disease. Practitioners described themselves as working in an overstretched service, weighing antibiotic benefit against stewardship, and ultimately falling back on the relationship with the patient when the evidence did not decide it. That last point is not a failure of rigour — it is what a clinician does when a guideline written for the typical case meets someone outside it.

• Name your own patient X list, and make it a prompt to culture rather than to prescribe empirically
• In older patients, distinguish an abnormal dipstick from an infection — asymptomatic bacteriuria is common and usually does not need treating
• Men with urinary symptoms need a different assessment, not a shorter course of the same antibiotic
• Recurrence is a reason to review the diagnosis, not only to extend the prescription
• Local resistance patterns matter more than any international guideline for empirical choice, particularly in India

Why it matters

It locates antibiotic overprescribing in a specific, recognisable moment of clinical uncertainty rather than in general carelessness.

Don't overread it

A synthesis of what practitioners say about their practice. It describes perception and reasoning, not prescribing rates or patient outcomes.

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