Patient Safety: how today’s UTI guidance fails patients

The World Health Organization (WHO) defines patient safety as “a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies, and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely, and reduce its impact when it does occur.”[1]

This official description of patient safety points firmly to the failure of our own healthcare policy and guidance around the diagnosis and treatment of UTI. Why? Because despite being fundamental to an accurate analysis, diagnosis and treatment, urine specimen collection guidance for UTI dip and analysis is routinely ignored.

According to the National Institute for Healthcare Research (NIHR) UTIs are the most common bacterial infection treated in the NHS. They are generally treated using antibiotics prescribed by GPs and nurses in primary care.

Up to 50% of bacteria which cause UTIs are resistant to at least one antibiotic, meaning that particular antibiotics are no longer an effective treatment. This results in people getting longer, more severe infections. They may also need more antibiotics. AMR is a serious threat to health. If nothing is done to combat AMR, bacteria will become resistant to more antibiotics until infections become untreatable.

According to some estimates, by 2050 more people will die from AMR infections than cancer.[2]

What happens in the real world? When we ask midwives and GPs why they don’t ensure the guideline-compliant midstream for UTI and prenatal screening, the answers demonstrate a willful oversight of patient safety around diagnosis and treatment:

• We don’t ask for a midstream because it’s too difficult and takes up too much time.
• If the sample is contaminated or fails, we’ll just do another one
• If the three-day antibiotic doesn’t work, we’ll try another one

Why is midstream important for patient safety? UTI diagnosis relies heavily on urine culture and colony counts; contaminated samples can produce false positives (showing bacteria that aren’t actually causing infection) or mixed growth that’s hard to interpret.

Additionally, a false positive or ambiguous culture can lead to unnecessary antibiotic treatment, contributing to antibiotic resistance (AMR) and side effects all without clinical benefit. Furthermore, if contamination leads to an uninterpretable or discarded sample, a true infection might be missed or a precise diagnosis delayed.

Compared to more invasive collection methods (like catheterization or suprapubic aspiration, which guarantee the “gold standard” sample), midstream collection achieves reasonably good accuracy without the risks, discomfort, or resource use of invasive procedures, making it the practical first-line choice for most patients. This reassurance and practicality can only stand firm if clinicians and healthcare professionals themselves ensure the ”clean” sample is collected.

Peezy Midstream has been designed by Dr Vincent Forte, a Primary Care Physician of over 20 years; he conceived the device precisely to meet the needs of accuracy, patient safety and infection control, as well as hygiene and dignity for women in a moment of stress and often significant pain because collecting urine is harder than you think … midstream is a delicate dance.[3]

Midstream urine collection is simple and non-invasive, yet reduces specimen contamination compared to a random or first-catch sample that may carry bacteria and debris off the skin.

Midstream gives doctors and midwives a urine sample that reliably reflects what’s actually happening in the urinary tract. The growing evidence behind Peezy Midstream points to significant reduction of false positive and contaminated (mixed growth) urines [4].

It is important to note that these trials and evaluations show that a quick, first-time explanation of use is essential; in the one instance this did not happen with Oxford Nuffield, (although conversely, detailed instructions on how to provide a “traditional” MSU were given) the trial reported “no clinical benefit”. If the public hadn’t been shown how to take a Covid test before it was rolled out, the outcome may well have been similar.

What does poor urine collection mean for patient safety? While UTIs are a common, often “minor” infection to so many GPs (and in the popular imagination) they are a genuinely significant contributor to global AMR mortality.

Based on the most comprehensive global data available (the Global Burden of Disease/ GRAM project, 2019), UTIs account for 311,000 deaths, roughly 5% of the global AMR mortality burden. This is a modest but substantial number given that a total 6.22m AMR deaths were caused by or associated with AMR [5].

In conclusion, it has become clear that UTIs are one of the largest single drivers behind the global rise of AMR, not primarily because of their mortality burden, but because of their sheer volume, prescribing patterns, and role as an amplifier of resistant organisms.

Why empirical prescribing patterns have a lot to answer for. Most UTIs are treated before culture results come back, or without a culture ever being sent at all, especially in primary care and low-resource settings.

This “treat first, confirm later” pattern is efficient for patients but creates a systemic AMR risk. In short, empirical prescribing has become the norm rather than the exception, to the detriment of women everywhere.

• Guidelines recommend immediate broad-spectrum “just in case” prescribing, which tackles a much wider range of organisms than necessary, and has a negative impact on the body’s microbiome, throwing digestion and other functions off-balance;
• The escalating use of antibiotics is likely a primary factor to drive antibiotic resistance development and spread, and resistance to first-line medicines;
• A Pharmacy consultation will provide an immediate broad-spectrum antibiotic based on two verbal symptoms presented at the counters.

Why Pharmacy First exacerbates the problem. This policy was introduced on the 31st January 2024. It allows pharmacists to dispense a broad-spectrum antibiotic without culture or any diagnostic process taking place.

The cost of this consultation costs the NHS £15, which is the exact cost of an NHS Lab culture that would yield a targeted antibiotic recommendation.

Yet the hit-and-miss immediate antibiotic prescription recommended by our healthcare policy makers can arguably do more harm than good, putting women firmly on the frontline of AMR.

Delayed and erroneous targeted treatment for UTI also causes exacerbated pain, distress and inconvenience to the woman for whom work, children and other commitments will be impacted leading to loss of earnings, days off sick and unwarranted loss of resource and cost to employers.

For those to whom none of this means much: the economy is a major victim here.

First Do No Harm. A microbiologist commenting on a recent LinkedIn post of mine said: “In the 1970s a urine would be sent to the lab and cultured. The probable pathogen would be tested against an antibiotic panel. The clinician would select the most cost-effective antibiotic with the narrowest spectrum. The decline of that practice was an important factor in increasing problems with antibiotic resistance.”

UTIs contribute to the global AMR through their role as a high-frequency, high-volume driver of antibiotic consumption as well as a breeding ground for resistant E. coli that can later cause more severe infections (bacteraemia, sepsis) elsewhere in the body

This is why global AMR strategy documents consistently flag UTIs as a priority target for stewardship, better diagnostics.

This being the case, why are our healthcare policy makers not working to change pathway guidance and reduce unnecessary empirical prescribing for urinary tract infections?

Why are they not protecting women from AMR?

What happened to First Do No Harm?

© Giovanna Forte 2026

Sources
1. WHO’s Global Patient Safety Action Plan 2021–2030
2. https://www.nihr.ac.uk/news/study-improve-antibiotic-prescribing-urinary-tract-infections
3. Collecting urine is harder than you think … midstream is a delicate dance, John Oliver, This Week Tonight, March 2026
4. https://forte-medical.co.uk/clinical-evidence/
5. https://pubmed.ncbi.nlm.nih.gov/35628941/

Notes
• Peezy Midstream is available on the NHS Supply Chain Catalogue and through Una Health
• AI was used in some research for this article