Strengths and limitations
The study provides information about UTI management in primary care beginning with the consultation, investigations and tests and proceeding to the physicians’ treatment decisions and the women’s actual management strategies at home, including interactions with and outcomes of the symptom course.
We did not reach the calculated sample size, but the data suggest that the study population was representative compared with other UTI studies in Germany. Baseline data, such as the proportion of patients with a positive urine culture (ca. 75%) [14–17], the proportion of patients with E. coli infections (ca 75%) and the susceptibility data, were comparable with the results of other observational studies in Germany [18, 19].
An observational study is not adequate to compare the outcomes of the two treatment approaches. Therefore, we cannot conclude that a symptomatic approach is more or less equivalent to antibiotic treatment. However, we can conclude that women had a good chance of recovery irrespective of whether they decided to take antibiotics.
Due to the small sample size and the design of the study, we were not able to assess the safety of the symptomatic treatment approach but should emphasize that only one case of pyelonephritis occurred in a woman who was treated with antibiotics first and that only 13 women had a second episode of a UTI in the following 3 weeks, nearly half of whom had been treated with antibiotics.
The observational study allowed us to investigate the daily symptoms of patients with UTIs. Growth curve modelling allows the estimation of different growth patterns and the estimation of inter-individual differences in intra-individual change over time, and it is more robust to violations of assumptions than, for example, repeated-measures ANOVA.
Comparison with existing literature
Previous research investigated both the physicians’ treatment approach [20–22] and the patients’ management of UTIs [3, 10, 23]. These studies provided data about tests used in local practices, the susceptibility and resistance of UTI bacteria and/or physicians’ guideline adherence [24–26]. In patient-focused studies, variations in symptom presentation or patient views of the reason for their infection have been investigated. Our study sheds light on whether the decisions made in the consultation were implemented by patients at home, illuminating the gap in the doctor-patient interaction.
Although not all women were prescribed antibiotics, the rate of antibiotic prescriptions was rather high (87%), but it is in accordance with data from other countries [24, 27], for example, an antibiotic prescription rate of 82% in a recent Hong Kong study in primary care, and data from a Spanish study with an even higher proportion of antibiotic treatment (96%).
In several randomized controlled trials [14–17], the symptom course of UTIs, usually assessed and documented by the women themselves, was compared between those immediately prescribed antibiotics and those prescribed symptomatic treatment. The symptoms mostly resolved in both groups, with a somewhat longer duration with symptomatic treatment. In our observational study, the UTI symptoms declined rather quickly, independent of the treatment approach, as also reported by Little et al  under standardized conditions. Symptoms in women treated with antibiotics resolved faster than those in women who were not, but these women had more severe symptoms at baseline. Heytens et al.  investigated the symptom course of women with UTIs in an observational study and found that women with more severe symptoms at inclusion had a longer duration of symptoms. The results of our study may underline this correlation insofar as women with severe symptoms who decided to take antibiotics had to wait longer until recovery, compared to those with mild or moderate symptoms, but still recovered faster than women who decided to undergo treatment with NSAIDs alone.
We found only moderate, non-significant associations between dipstick results, which were immediately available at the consultation and the women’s decision whether to take antibiotics. There was no association between the results of the urine culture, available several days after the first consultation, and the initial decision to take antibiotics. On first view, this result may be surprising because one might have supposed that their decision intuitively follows the ‘real biochemical facts’. This is obviously too simplistic a view that reduces patients to their disease, as Di Paleo et al.  suggested it in their review of personalized medicine; rather, the women seem to balance the invasive character of an antibiotic drug against the severity of symptoms.
Implications for practice
This study is another plea for patient participation and shared decision making to form key parts of patient-centred care , this time in the case of UTIs. Women seem to know the best treatment approach to manage their UTI symptoms. Sensitive listening to patient preferences in the consultation may encourage physicians to recommend and prescribe symptomatic treatment more often than antibiotic medicines. However, GPs who prefer to delay antibiotic treatment are sometimes frustrated with patients who expect to get well quickly with antibiotics. They are faced with a complex diversity of factors influencing the culture of antibiotic prescribing, as described in an Irish study , and have to accept that the path to prudent prescribing is long and strenuous. In this respect, studies such as ours may provide physicians with arguments that can motivate and support more women in choosing a symptomatic treatment, at least initially.
Following the NICE  principles of medicines optimization, physicians could help women by discussing their preferences and what is important to them about managing their condition and their medicines and recognize and accept that the women’s values and preferences may be different from their own.
Doctors should understand that women’s disease management will be affected by individual preferences for particular treatment modalities, the avoidance of certain side effects and a personal benefit-harm trade-off analysis of the available interventions and may differ in the level of priority they give to health and symptom recovery compared to other problems . In the end, their decisions seem to have been wise because those who decided to take only NSAIDs fared nearly as well as those who took antibiotics.