Giovanna Forte

How traditional urine collection methods are fuelling AMR


Giovanna Forte, CEO of Forte Medical

Date: 16 November 2018

“You have a raging urinary tract infection that is known to be resistant to the antibiotic your GP gave you,” said the sympathetic Sexual Health Clinic Doctor. “This one is targeted – it will sort you out. But you shouldn’t have had to come here.”

A week earlier I had visited my GP with symptoms of UTI. As the purveyor of the world’s only midstream urine collection device, I brought her a urine sample collected by my own innovation. She insisted that instead I use a universal container from the surgery; my reward for filling this tube using the recommended start-stop-start method was a three-day course of broad-spectrum antibiotics. She told me to come back if things were not better by the end of the course. 

The next three days were hell and on the fourth, fuzzy with painkillers, I returned to the surgery. Instead of a repeat test to identify the real problem, I received an old fashioned look and told to “go to the sexual health clinic,” the grounds for this referral were not given; shocked and puzzled, I headed for Barts Walk-In Clinic.

The kind and understanding team here told me that they regularly deal with untreated and painful UTI, because default, empirical prescribing fails, driving patients to Out of Hours, Emergency and Walk-in Clinics.

In 2015 NICE launched the Start Smart then Focus antimicrobial stewardship toolkit. This says: “do not start antimicrobial therapy until there is clear evidence of infection …..avoid inappropriate use of broad spectrum antibiotics.” That seems clear enough.

But what’s this? Whilst Public Health England’s guidelines for treating UTI asks doctors to target antibiotic use, it also recommends consideration of immediate antibiotic if a dipstick shows positive leukocyte. The problem here is that dipstick methodology is not always accurate.

The 2017 study To Dip Or Not To Dip points out that 75% of antibiotic prescribing comes from GPs. It also confirms that a positive dipstick is more likely to lead to antibiotic treatment which may not be appropriate. This study was carried out with a senior cohort of patients; urines were analysed before treatment was given, leading to a significant reduction in antibiotic use.

Turning to a different patient population, a recent evaluation of Peezy Midstream across 647 women in antenatal clinic demonstrated a 70% reduction of false-positive dipped urines. The Patient Safety Midwife who championed the study points out that not only is the clinic sending only 3 out of 10 specimens to the lab instead of 7, making a direct saving of around £18,000 in a year, but with no suspected infection patients are less likely to receive an antibiotic, do not have to return for a retest and are reassured as to their health.

Happily guidelines are catching up with Antimicrobial Stewardship but how they translate in to busy frontline practice is another matter.

A recent NHS Improvement Horizon Scanning Report paper on point-of-care testing for urinary tract infections specifies – as do all guidelines - that a midstream specimen is needed, yet there is no protocol around guaranteeing its collection. Whereas there is a very specific method for collecting blood, urine is left to individual hit-and-miss methods. Not only does this stand in the way of accurate analysis, diagnosis and treatment but wastes clinical time and resources and most of all can lead to unnecessary use of broad-spectrum antibiotics, fuelling the AMR crisis from the frontline, which is precisely where positive action needs to take place.

Whilst new digital technology, AI, robotics and apps have their place in innovation adoption, the focus on smart technology means that a basic flaw in diagnostic practice is being overlooked; a novel evidence-based device that collects accurate urine specimens may not be as glamourous as its high-tech counterparts, but in the context of modern, basic frontline medicine, its preventative role in pinpointing bacteria can help stem a global crisis like AMR.

When you get the basics right, the rest will follow – to the relief, no doubt, of overburdened Emergency, Out of Hours and Walk-in clinics … not to mention NHS finances.

The global AMR crisis points to the need for a radical change in attitudes to urine and its collection because without it, AMR can only get worse. To quote Henry Ford, “if you do what you’ve always done, you’ll get what you’ve always gotten.”

Giovanna Forte is CEO of Forte Medical, the company she set up with her brother, NHS GP Dr Vincent Forte (retired). Vincent’s innovation Peezy Midstream was conceived to promote right-first-time UTI diagnosis and reduce repeat visits to surgery. It also promotes infection control and patient dignity by eliminating spills, wet bottles and wet hands.

The NIHR Trauma Management MedTech Co-operative (NIHR Trauma MIC) collaborated with Forte Medical Ltd on a usability study for the Peezy Midstream device.   


Liquid gold: why urine is important:

  • 50% of global increase in antimicrobial resistance (AMR) in the last five years has a urinary source*
  • 47% of Gram-negative blood infections (that can lead to sepsis) have a urinary source*


  • 65m urine specimens are collected in the UK annually
  • 25% is the average urine specimen contamination rate
  • 14.6m people suffer annually from failed diagnosis due to contamination
  • Contaminated specimens give rise to empirical broad spectrum antibiotic prescribing before problem bacteria are identified
  • 184,000 UTI-related annual unplanned hospital admissions costs the NHS £434 million**

* NHS Improvement

** Unplanned Admissions Committee 2013/14

The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health and Social Care.
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    Giovanna Forte, CEO of Forte Medical, explains why there is a basic flaw in current practices for diagnosing UTIs and how this is contributing the global AMR crisis.
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    Giovanna Forte, CEO of Forte Medical

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