Sepsis: it started with a dip.

Urosepsis is one of the most common causes of sepsis. Up to 30% of all sepsis cases begin in the urinary tract. Cleveland Clinic [1]

Urinary Tract Infection (UTI) is a very common infection, with 10m presentations to GPs annually in the UK, a 30% repeat infection rate and 20% retest rate of urine specimens due to contamination and unreliable collection methods. The picture is not pretty for women, who make up the majority of sufferers. By 2021 the annual global incidence of UTI reached 4.6bn cases, with three quarters of sufferers being women. [2]

This is a costly infection for Governments and healthcare providers, yet the quality of its analysis diagnosis and treatment are often left to chance because no protocols exist around the essential component of diagnosis: the urine specimen.

Guidance recommends midstream urine for UTI diagnosis, with an immediate three-day broad-spectrum antibiotic prescription; if this hasn’t worked, clinicians may consider another, while urine culture takes place. Like every dipstick process, the outcome of the culture relies upon a midstream urine specimen. If that specimen is contaminated it can lead to a false-positive diagnosis leading to unnecessary antibiotics, in turn fueling AMR.

Then we get to Sepsis, the development of which, through a poorly treated UTI, is more common than we would like. It happened to me. And it is frightening.

My story
Seeing my GP for a “wellness” consultation, she requested an on-the-spot urine specimen for a routine dip. Unprepared as I was, I did my best to collect midstream (MSU) into the 22mm diameter Universal tube she provided, whilst attempting the recommended start-stop-start method of MSU collection [3]. GP dipped the urine.

You have a UTI, she said.

I have no symptoms, I replied. I feel fine.

She insisted I accept a 3-day Nitrofurantoin prescription and told me to come back at the end of the course. Upon my return, the hit-and-miss MSU collection and dip process was repeated.

You still have a UTI, she said. I’ll give you a seven-day course of a stronger Nitrofurantoin.

I don’t need it, I said. I still have no symptoms and I feel fine. And anyway, shouldn’t you culture before giving me a seven-day course to make sure it’s the right treatment? [4]

My observations clearly annoyed the GP, and I received chapter and verse on her expertise, knowledge and extensive training. She insisted I take the seven-day Nitro and return for another dip at the end of the course. I dared not refuse.

Later that day, Husband and I hopped onto a ferry for a dear friend’s birthday celebrations on the Isle of Wight. That evening and the next day, I felt Not Quite Myself. Sitting at the party I began to feel fuzzy, unwell and hot, unable even to hold a conversation. I slipped away to our B&B and there began to sweat and shake uncontrollably, my head and eyes hurt and it became difficult to focus. I sat on the edge of our bed and cried. What to do?

Concerned that his Party Animal had bailed so unexpectedly from her natural habitat, Husband returned early to find a trembling, weak, hot, soggy and very unhappy mess where he expected his wife to be. I could barely string a sentence together. He did what comes naturally in our family … he rang my brother, Dr. Vincent Forte, NHS GP for over 20 years and co-author of Symptom Sorter, best-selling Primary Care reference book.

Take her to A&E right now, he instructed, sounding grave. NOW! Waste no time.

Minutes later we were in A&E at St Mary’s Hospital, Newport, Isle of Wight and reader, thank heavens for our Emergency Doctor who, having examined me thoroughly with more tests (Blood? Urine? I cannot remember it was all such a blur). Then he declared:

Sepsis. You are developing sepsis and it can get very bad quickly. The bugs you have are known to be resistant to the antibiotic you’ve been given. You should never have been prescribed such a long course of any antibiotic, let alone the same one, without culture. Then, head in hands he asked angrily:

When will GPs stop doing this?

He began to complete admission forms for overnight observation, but Husband made the case for returning to the B&B under his responsible and watchful eye and my brother on ‘virtual’ call. It took some persuasion but he agreed on the basis that if things deteriorated in the slightest I must come back for admission; we left with a powerful, targeted and well considered antibiotic prescription.

The following morning, weak, but feeling more normal we agreed: the danger had passed.

What is Sepsis?
Sepsis is a blood infection. In sepsis, the chemicals released into the bloodstream to combat infection trigger widespread inflammation instead. This can cause blood clots to form, blood vessels to leak, and blood pressure to drop, all of which reduce blood flow and oxygen delivery to limbs and organs like the kidneys, liver, lungs, and brain. Not good.

Why is Sepsis dangerous?
Left untreated, this response can lead to organ failure and septic shock, which is a state of dangerously low blood pressure that can be fatal, even with treatment. Sepsis progresses quickly, sometimes within hours, which is why early recognition matters so much.

What are symptoms of Sepsis? [5]
• Confusion or slurred speech
• Uncontrollable shivering
• Muscle pain
• Difficulty breathing
• Blue, pale, grey or blotchy skin, lips or tongue
• High or low temperature
• Not peeing or peeing very little in the past 18 hours

Sepsis and UTI in the UK today
By far the most common source [of E. coli blood stream infections] is urinary infections. [6]

Abigail’s story: What had started as a UTI she initially dismissed, had progressed into life-threatening sepsis in a matter of days.[7]

Karin’s story: Karin had a UTI when gram negative E.coli bacteria went from her kidneys into her bloodstream, triggering sepsis. [8]

Kim Smith’s story: Kim had all four limbs amputated after developing a UTI whilst on holiday [9]

Conclusions
The Dip: a technology designed in the 1950s to give clinicians a quick approximation at the bedside has, over decades, drifted into use as a quasi-definitive screening test in populations where its accuracy was never actually validated for that job. [10]

Guidance: until Primary Care Guidance recommends immediate urine culture for the first presentation of UTI, broad spectrum antibiotics will continue to fuel AMR, especially in women. [11]

Antibiotic stewardship: Doctors tell us that patients insist on an immediate antibiotic. Instead, why not help them to understand that poor antibiotic use could mean there will be no effective antibiotics left in around ten years from now? An AMR toolkit is critical for Clinicians and their patients, for whom knowledge is a lifeline.

Reliable urine specimen: Midstream urine is the globally recognised specimen for UTI analysis, yet there is no protocol or established system for its collection. This has to change.

Lab culture: if culture takes three days, then a pain killer can help to dim the symptoms while the targeted medicine is identified to tackle the bugs directly.

Rapid UTI testing: the advent of rapid UTI testing will soon ameliorate the wait for culture results. With identification of problem bacteria within the hour or half-hour; these technologies will change the face of UTI analysis, diagnosis and treatment. They will relieve burden on GP Practices and labs dealing with repeat and false-positive tests (which takes us back to urine collection).

1. https://my.clevelandclinic.org/health/diseases/25008-urosepsis
2. https://www.nature.com/articles/s41598-025-89240-5
3. https://patient.info/mens-health/urine-infection-in-men/midstream-specimen-of-urine-msu
4. https://www.nice.org.uk/guidance/ng109/chapter/recommendations
5. https://www.nhs.uk/conditions/sepsis/
6. https://ukhsa.blog.gov.uk/2017/11/29/health-matters-your-questions-on-preventing-infections-and-reducing-amr/
7. https://sepsisresearch.org.uk/sepsis-stories/abigail-sepsis-story/
8. https://sepsistrust.org/sepsisvoices/karin/
9. https://sepsisresearch.org.uk/sepsis-stories/kims-sepsis-story/
10. https://forte-medical.co.uk/uncategorized/midstream-urine-and-the-humble-dipstick-why-is-a-150-year-old-test-still-shaping-womens-uti-diagnoses/
11. https://www.dropbox.com/scl/fi/stiuy7j8b970jyw215qmg/20250918_Women_AMR_Frontline.pdf?rlkey=v9hmnf9j2dsuxqx9f9xud4qk1&dl=0

AI was used to research this article.

© Giovanna Forte 2026