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1.  Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners 
Despite wide distribution and promotion of clinical practice guidelines, adherence among Dutch general practitioners (GPs) is not optimal. To improve adherence to guidelines, an analysis of barriers to implementation is advocated. Because different recommendations within a guideline can have different barriers, in this study we focus on key recommendations rather than guidelines as a whole, and explore the barriers to implementation perceived by Dutch GPs.
A qualitative study using six focus groups was conducted, in which 30 GPs participated, with an average of seven per session. Fifty-six key recommendations were derived from twelve national guidelines. In each focus group, barriers to the implementation of the key recommendations of two clinical practice guidelines were discussed. Focus group discussions were audiotaped and transcribed verbatim. Data was analysed by using an existing framework of barriers.
The barriers varied largely within guidelines, with each key recommendation having a unique pattern of barriers. The most perceived barriers were lack of agreement with the recommendations due to lack of applicability or lack of evidence (68% of key recommendations), environmental factors such as organisational constraints (52%), lack of knowledge regarding the guideline recommendations (46%), and guideline factors such as unclear or ambiguous guideline recommendations (43%).
Our study findings suggest a broad range of barriers. As the barriers largely differ within guidelines, tailored and barrier-driven implementation strategies focusing on key recommendations are needed to improve adherence in practice. In addition, guidelines should be more transparent concerning the underlying evidence and applicability, and further efforts are needed to address complex issues such as comorbidity in guidelines. Finally, it might be useful to include focus groups in continuing medical education as an innovative medium for guideline education and implementation.
PMCID: PMC2734568  PMID: 19674440
2.  Management of children's urinary tract infections in Dutch family practice: a cohort study 
Optimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young children's UTIs in Dutch primary care and to compare this to the national guideline recommendations.
In this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral.
Of the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had ≤ 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred.
Treatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.
PMCID: PMC1829394  PMID: 17355617
3.  Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): protocol for a cluster randomized trial 
Trials  2013;14:441.
The overuse of antimicrobials is recognized as the main selective pressure driving the emergence and spread of antimicrobial resistance in human bacterial pathogens. Urinary tract infections (UTIs) are among the most common infections presented in primary care and empirical antimicrobial treatment is currently recommended. Previous research has identified that a substantial proportion of Irish general practitioners (GPs) prescribe antimicrobials for UTIs that are not in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The aim of this trial is to design, implement and evaluate the effectiveness of a complex intervention on GP antimicrobial prescribing and adult (18 years of age and over) patients’ antimicrobial consumption when presenting with a suspected UTI.
The Supporting the Improvement and Management of Prescribing for urinary tract infections (SIMPle) study is a three-armed intervention with practice-level randomization. Adult patients presenting with suspected UTIs in primary care will be included in the study.
The intervention integrates components for both GPs and patients. For GPs the intervention includes interactive workshops, audit and feedback reports and automated electronic prompts summarizing recommended first-line antimicrobial treatment and, for one intervention arm, a recommendation to consider delayed antimicrobial treatment. For patients, multimedia applications and information leaflets are included. Thirty practices will be recruited to the study; laboratory data indicate that 2,038 patients will be prescribed an antimicrobial in the study. The primary outcome is a change in prescribing of first-line antimicrobials for UTIs in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The study will take place over 15 months with a six-month intervention period. Data will be collected through a remote electronic anonymized data-extraction system, a text-messaging system and GP and patient interviews and surveys. The intervention will be strengthened by the implementation of a social marketing framework and an economic evaluation.
Trial registration
This intervention is registered at, ID NCT01913860.
PMCID: PMC3880352  PMID: 24359543
Antimicrobial; Intervention; Prescribing; Primary care; Social marketing; Urinary tract infection
4.  Resistance profiles of urinary tract infections in general practice - an observational study 
BMC Urology  2012;12:33.
Guideline recommendations on therapy in urinary tract infections are based on antibiotic resistance rates. Due to a lack of surveillance data, little is known about resistance rates in uncomplicated urinary tract infection (UTI) in general practice in Germany. In a prospective observational study, urine cultures of all women presenting with urinary tract infections in general practice were analysed. Resistance rates against antibiotics recommended in German guidelines on UTI are presented.
In a prospective, multi-center observational study general practitioner included all female patients ≥ 18 years with clinically suspected urinary tract infection. Only patients receiving an antibiotic therapy within the last two weeks were excluded.
40 practices recruited 191 female patients (mean age 52 years; range 18–96) with urinary tract infections. Main causative agent was Escherichia coli (79%) followed by Enterococcus faecalis (14%) and Klebsiella pneumoniae (7.3%).
Susceptibiliy of E.coli as the main causative agent was highest against fosfomycin and nitrofurantoin, with low resistance rates of 4,5%; 2,2%. In 17,5%, E.coli was resistant to trimethoprim and in 8,5% to ciprofloxacin.
Resistance rates of uropathogens from unselected patients in general practice differ from routinely collected laboratory data. These results can have an impact on antibiotic prescribing and treatment recommendations.
PMCID: PMC3534546  PMID: 23171154
Urinary tract infection; Primary care; Drug resistance; Anti-bacterial agents
5.  Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. 
BACKGROUND: Urinary tract infections (UTIs) are very common and have been treated with apparent success with antimicrobials for many years. However, there is a paucity of placebo-controlled clinical trials. AIM: To measure the symptomatic and bacteriological short-term effect of nitrofurantoin treatment versus placebo, in the treatment of uncomplicated UTI in adult non-pregnant women. DESIGN OF STUDY: Randomised placebo-controlled trial in general practice. SETTING: Non-pregnant women, aged between 15 and 54 years old, consulting a general practitioner for symtoms suggestive of uncomplicated lower UTI and with pyuria (positive for leucocyte esterase test). METHOD: A dipslide was inoculated in first-void midstream urine and sent for examinion. The patients were randomised to receive nitrofurantoin 100 mg or placebo four times daily for three days. After three, seven, and 14 days a new dipslide was inoculated and symptoms of UTI were checked or improvement of symptoms and bacteriuria. RESULTS: Of 166 women consulting with symptoms suggestive for UTI, 78 had pyuia and agreed to participate in the study (the clinically suspected UTI group); of these, 40 received nitrofurantoin and 38 received placebo. The result for combined symptomatic improvement and cure after three days was 27/35 in the nitrofurantoin group and 19/35 in the placebo group (c2 with Yates' correction P = 0.008; number needed to treat [NNT] = 4.4, 95% confidence interval [CI] = 2.3 to 79). After seven days, combined improvement and cure was observed in 30/34 and 17/33 respectively (P = 0.003, NNT = 2.7, 95% CI = 1.8 to 6.0). At inclusion, 56 women had bacteriuria of > or = 10(5) CFU/ml (the bacteriologically proven UTI group). Of these, 29 received nitrofurantoin and 27 received placebo. After three days the bacteriological cure was 21/26 in the treatment group, compared with 5/25 in the placebo group (P < 0.001; NNT = 1.6, 95% CI= 1.2 to 2.6). After seven days the bacteriological cure rate was 17/23 in the intervention group and 9/22 in the placebo group (P = 0.05, NNT = 3, 95% CI = 1.7 to 17). CONCLUSION: In women with bacteriologically proven UTI, nitrofurantoin was significantly more effective than placebo in achieving bacteriological cure and symptomatic relief in just three days; this was still present after seven days. In patients with clinically suspected UTI the symptomatic effect was statistically significant after
PMCID: PMC1314413  PMID: 12236276
6.  Effect of a Stewardship Intervention on Adherence to Uncomplicated Cystitis and Pyelonephritis Guidelines in an Emergency Department Setting 
PLoS ONE  2014;9(2):e87899.
To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.
The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).
Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.
A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.
PMCID: PMC3912125  PMID: 24498394
7.  Identifying barriers and tailoring interventions to improve the management of urinary tract infections and sore throat: a pragmatic study using qualitative methods 
Theories of behaviour change indicate that an analysis of factors that facilitate or impede change is helpful when trying to influence professional practice. The aim of this study was to identify barriers to implementing evidence-based guidelines for urinary tract infection and sore throat in general practice in Norway, and to tailor interventions to address these barriers.
We used a checklist to identify barriers and possible interventions to address these in an iterative process that included a review of the literature, brainstorming, focus groups, a pilot study, small group discussions and interviews.
We identified at least one barrier for each category. Both guidelines recommended increased use of telephone consultations and reduced use of laboratory tests, and the barriers and the interventions were similar for the two guidelines. The complexity of changing routines involving patients, general practitioners and general practitioner assistants, loss of income with telephone consultations, fear of overlooking serious disease, perceived patient expectations and lack of knowledge about the evidence for the guidelines were the most prominent barriers. The interventions that were tailored to address these barriers included support for change processes in the practices, increasing the fee for telephone consultations, patient information leaflets and computer-based decision support and reminders.
A systematic approach using qualitative methods helped identify barriers and generate ideas for tailoring interventions to support the implementation of guidelines for the management of urinary tract infections and sore throat. Lack of resources limited our ability to address all of the barriers adequately.
PMCID: PMC150569  PMID: 12622873
8.  Diagnostic approach to urinary tract infections in male general practice patients: a national surveillance study 
The British Journal of General Practice  2012;62(604):e780-e786.
Diagnostic urinary tract infection (UTI) studies have primarily been performed among female patients.
To create a diagnostic algorithm for male general practice patients suspected of UTI.
Design and setting
Surveillance study in the Dutch Sentinel General Practice Network.
Clinical information and dipstick results were collected from 603 patients. Algorithm-predicted care was compared with care as usual in terms of sensitivity (antibiotic recommended when UTI was confirmed) and specificity (no antibiotic recommended when no UTI was observed).
Complete information was available from 490/603 (81%) males, of whom 66% (321/490) had a UTI. A diagnostic algorithm recommending antimicrobial prescription in the case of a positive nitrite test or a positive leukocyte esterase test in males aged ≥60 years, had a positive predictive value (PPV) of 83% (95% confidence interval [CI] = 78 to 87) and a negative predictive value (NPV) of 60% (95% CI = 52 to 66), respectively (area under the ROC curve: 0.78, 95% CI = 0.74 to 0.82). When both dipstick results were positive in males aged ≥60 years, PPV increased to 90% (95% CI = 83 to 94), whereas NPV was highest in males <60 years with negative dipstick results (71%, 95% CI = 59 to 81). Sensitivity and specificity of predicted UTI care and usual care did not differ (75% versus 79%, P = 0.30, and 70% versus 63%, P = 0.17, respectively).
UTI care provided to Dutch male GP patients is as accurate as predicted care from a diagnostic algorithm. The studied clinical information and dipstick tests are useful for ruling in UTI in males, but have limited value in ruling out this diagnosis.
PMCID: PMC3481519  PMID: 23211182
general practice; male; patients; urinary tract infections
9.  Immediate versus conditional treatment of uncomplicated urinary tract infection - a randomized-controlled comparative effectiveness study in general practices 
BMC Infectious Diseases  2012;12:146.
Uncomplicated urinary tract infections (UTI) are usually treated with antibiotics as recommended by primary care guidelines. Antibiotic treatment supports clinical cure in individual patients but also leads to emerging resistance rates in the population. We designed a comparative effectiveness study to investigate whether the use of antibiotics for uncomplicated UTI could be reduced by initial treatment with ibuprofen, reserving antibiotic treatment to patients who return due to ongoing or recurrent symptoms.
This is a randomized-controlled, double-blind, double dummy multicentre trial assessing the comparative effectiveness of immediate vs. conditional antibiotic therapy in uncomplicated UTI. Women > 18 and < 65 years, presenting at general practices with at least one of the typical symptoms dysuria or frequency/urgency of micturition, will be screened and enrolled into the trial. During an 18- months recruitment period, a total of 494 patients will have to be recruited in 45 general practices in Lower Saxony. Participating patients receive either immediate antibiotic therapy with fosfomycin-trometamol 1x3g or initial symptomatic treatment with ibuprofen 3x400mg for 3 days. The ibuprofen group will be provided with antibiotic therapy only if needed, i.e. for persistent or worsening symptoms. For a combined primary endpoint, we choose the number of all antibiotic prescriptions regardless of the medical indication day 0–28 and the “disease burden”, defined as a weighted sum of the daily total symptom scores from day 0 to day 7. The study is considered positive if superiority of conditional antibiotic treatment with respect to the first primary endpoint and non-inferiority of conditional antibiotic treatment with respect to the second primary endpoint is proven.
This study aims at investigating whether the use of antibiotics for uncomplicated UTI could be reduced by initial treatment with ibuprofen. The comparative effectiveness design was chosen to prove the effectiveness of two therapeutic strategies instead of the pure drug efficacy.
Trial registration
Clinicaltrials.Gov: NCT01488955
PMCID: PMC3412701  PMID: 22742538
Urinary tract infection; Comparative effectiveness design; Antibiotic prescription; General practice
10.  Perceived barriers to guideline adherence: A survey among general practitioners 
BMC Family Practice  2011;12:98.
Despite considerable efforts to promote and support guideline use, adherence is often suboptimal. Barriers to adherence vary not only across guidelines but also across recommendations within guidelines. The aim of this study was to assess the perceived barriers to guideline adherence among GPs by focusing on key recommendations within guidelines.
We conducted a cross-sectional electronic survey among 703 GPs in the Netherlands. Sixteen key recommendations were derived from four national guidelines. Six statements were included to address the attitudes towards guidelines in general. In addition, GPs were asked to rate their perceived adherence (one statement) and the perceived barriers (fourteen statements) for each of the key recommendations, based on an existing framework.
264 GPs (38%) completed the questionnaire. Although 35% of the GPs reported difficulties in changing routines and habits to follow guidelines, 89% believed that following guidelines leads to improved patient care. Perceived adherence varied between 52 and 95% across recommendations (mean: 77%). The most perceived barriers were related to external factors, in particular patient ability and behaviour (mean: 30%) and patient preferences (mean: 23%). Lack of applicability of recommendations in general (mean: 22%) and more specifically to individual patients (mean: 25%) were also frequently perceived as barriers. The scores on perceived barriers differed largely between recommendations [minimum range 14%; maximum range 67%].
Dutch GPs have a positive attitude towards the NHG guidelines, report high adherence rates and low levels of perceived barriers. However, the perceived adherence and perceived barriers varied largely across recommendations. The most perceived barriers across recommendations are patient related, suggesting that current guidelines do not always adequately incorporate patient preferences, needs and abilities. It may be useful to provide tools such as decision aids, supporting the flexible use of guidelines to individual patients in practice.
PMCID: PMC3197492  PMID: 21939542
11.  Characteristics of effective clinical guidelines for general practice. 
BACKGROUND: The use of clinical guidelines in general practice is often limited. Research on barriers to guideline adherence usually focuses on attitudinal factors. Factors linked to the guideline itself are much less studied. AIM: To identify characteristics of effective clinical guidelines for general practice, and to explore whether these differ between therapeutic and diagnostic recommendations. DESIGN OF STUDY: Analysis of performance data from an audit study of 200 general practitioners (GPs) in The Netherlands conducted in 1997. SETTING: Panel of 12 GPs in The Netherlands who were familiar with guideline methodology. METHOD: A set of 12 attributes, including six potential facilitators and six potential barriers to guideline use, was formulated. The panel assessed the presence of these attributes in 96 guideline recommendations formulated by the Dutch College of General Practitioners. The attributes of recommendations with high compliance rates (70% to 100%) were compared with those with low compliance rates (0% to 60%). RESULTS: Recommendations with high compliance rates were to a lesser extent those requiring new skills (7% compared with 22% in recommendations with low compliance rates), were less often part of a complex decision tree (12% versus 25%), were more compatible with existing norms and values in practice (87% versus 76%), and more often supported with evidence (47% versus 31%). For diagnostic recommendations, the ease of applying them and the potential (negative) reactions of patients were more relevant than for therapeutic recommendations. CONCLUSION: To bridge the gap between research and practice, the evidence as well as the applicability should be considered when formulating recommendations. If the recommendations are not compatible with existing norms and values, not easy to follow or require new knowledge and skills, appropriate implementation strategies should be designed to ensure change in daily practice.
PMCID: PMC1314503  PMID: 12569898
12.  Management of urinary tract infection in general practice: a cost-effectiveness analysis. 
BACKGROUND: Symptoms associated with urinary tract infection (UTI) are common in women in general practice and represent a significant burden for the National Health Service. There is considerable variation among general practitioners in the management of patients presenting with these symptoms. AIM: To identify the most appropriate patient management strategy given current information for non-pregnant, adult women presenting in general practice with symptoms of uncomplicated UTI. METHOD: A decision analytic model incorporating a variety of patient management strategies was constructed using available published information and expert opinion. This model was able to provide guidance on current best practice based upon cost-effectiveness (cost per symptom-free day). RESULTS: Empiric treatment was found to be the least costly strategy available. It saved two days of symptoms per episode of UTI at a cost of 14 Pounds. The empiric-and-laboratory strategy involves an incremental cost-effectiveness ratio of 215 Pounds per symptom day averted per episode of UTI. The remaining patient management strategies are never optimal. CONCLUSION: Empiric treatment of patients presenting with symptoms of UTI was found to be cost-effective under a range of assumptions for this patient group. However, recognition of the impact of this strategy upon antibiotic resistance may lead to the dipstick strategy being considered a superior strategy overall.
PMCID: PMC1313774  PMID: 11042915
13.  A survey of the management of urinary tract infection in children in primary care and comparison with the NICE guidelines 
BMC Family Practice  2010;11:6.
The aim of this study was to establish current practices amongst general practitioners in the West of Ireland with regard to the investigation, diagnosis and management of urinary tract infection (UTI) in children and to evaluate these practices against recently published guidelines from the National Institute for Health and Clinical Excellence (NICE).
A postal survey was performed using a questionnaire that included short clinical scenarios. All general practices in a single health region were sent a questionnaire, cover letter and SAE. Systematic postal and telephone contact was made with non-responders. The data was analysed using SPSS version 15.
Sixty-nine general practitioners were included in the study and 50 (72%) responded to the questionnaire. All respondents agreed that it is important to consider diagnosis of UTI in all children with unexplained fever. Doctors accurately identified relevant risk factors for UTI in the majority (87%) of cases. In collecting urine samples from a one year old child, 80% of respondents recommended the use of a urine collection bag and the remaining 20% recommended collection of a clean catch sample. Respondents differed greatly in their practice with regard to detailed investigation and specialist referral after a first episode of UTI. Co-amoxiclav was the most frequently used antibiotic for the treatment of cystitis, with most doctors prescribing a five day course.
In general, this study reveals a high level of clinical knowledge amongst doctors treating children with UTI in primary care in the catchment area of County Mayo. However, it also demonstrates wide variation in practice with regard to detailed investigation and specialist referral. The common practice of prescribing long courses of antibiotics when treating lower urinary tract infection is at variance with NICE's recommendation of a three day course of antibiotics for cystitis in children over three months of age when there are no atypical features.
PMCID: PMC2823660  PMID: 20102638
14.  The Importance of Gender-Stratified Antibiotic Resistance Surveillance of Unselected Uropathogens: A Dutch Nationwide Extramural Surveillance Study 
PLoS ONE  2013;8(3):e60497.
Few studies have been performed on urinary tract infections (UTIs) in men. In the present study, general practitioners (n = 42) from the Dutch Sentinel General Practice Network collected urinary samples from 560 male patients (≥18 years) suspected of UTI and recorded prescribed antibiotic treatment. In this way, the antibiotic susceptibility of Gram-negative uropathogens, including extended-spectrum beta-lactamase (ESBL-) producing Escherichia coli could be determined. In addition, E. coli susceptibility and antibiotic prescriptions were compared with data from a similar UTI study among women and with data collected 7 years earlier. Of 367 uropathogens (66%) identified (≥103 cfu/mL), most were Gram-negative (83%) and E. coli being isolated most frequently (51%). Antibiotic susceptibility to ciprofloxacin, norfloxacin and nitrofurantoin was 94%, 92% and 88%, respectively, whereas co-amoxiclav (76%) and co-trimoxazole (80%) showed lower susceptibilities. One ESBL (0.5%) was found. A significantly higher proportion of female UTIs was caused by E. coli compared with men (72% versus 51%, P<0.05). E. coli susceptibility tended to be lower in men compared with women, although not reaching statistical significance. No changes in E. coli susceptibility were observed over time (all P>0.05). Co-amoxiclav and nitrofurantoin prescriptions increased over time (11% versus 28% and 16% versus 23% respectively, both P<0.05), whereas co-trimoxazole prescriptions decreased (24% versus 14%, P<0.05). In conclusion, given the observed gender differences in uropathogen distribution and (tendency in) E. coli antibiotic susceptibility, empirical male UTI treatment options should be based on surveillance studies including men only. When awaiting the culture result is clinically not possible, fluoroquinolones are advised as first-choice antibiotics for male UTIs in Dutch general practices based on current antibiotic susceptibility data. The prevalence of ESBL-producers was low and no differences were observed in antibiotic susceptibility over a 7-year period. In addition, antibiotic prescriptions changed in accordance with national guidelines during this time period.
PMCID: PMC3612053  PMID: 23555983
15.  Diagnosis and Management of Pediatric Urinary Tract Infections 
Clinical Microbiology Reviews  2005;18(2):417-422.
Urinary tract infection (UTI) is among the most commonly diagnosed bacterial infections of childhood. Although frequently encountered and well researched, diagnosis and management of UTI continue to be a controversial issue with many challenges for the clinician. Prevalence studies have shown that UTI may often be missed on history and physical examination, and the decision to screen for UTI must balance the risk for missed infections with the cost and inconvenience of testing. Interpretation of rapid diagnostic tests and culture is complicated by issues of contamination, false test results, and asymptomatic colonization of the urinary tract with nonpathogenic bacteria. The appropriate treatment of UTI has been controversial and has become more complex with the emergence of resistance to commonly used antibiotics. Finally, the anatomic evaluation and long-term management of a child after a UTI have been based on limited evidence, and newer studies question some of the tenets of prior recommendations. The goal of this review is to provide an up-to-date summary of the literature with particular attention to practical questions about diagnosis and management for the clinician.
PMCID: PMC1082801  PMID: 15831830
16.  Unexplained extra visits to general practitioners before the diagnosis of first urinary tract infection: a case-control study 
Archives of Disease in Childhood  2002;87(6):530-532.
Aims: To determine: (1) whether children diagnosed with a urinary tract infection (UTI) visited their general practitioner (GP) more frequently before the diagnosis of UTI was established compared to children never diagnosed with a UTI; and (2) whether those children with evidence of renal scarring at their first diagnosed UTI visited their GPs more frequently before diagnosis compared to children who did not have evidence of renal scarring when their first UTI was investigated.
Methods: Case-control study of 77 children with a UTI identified from a hospital radiology database (37 with and 40 without renal scarring), and 77 age, sex, and general practice matched controls. Main outcome measures were entries in general practice clinical records for types of illness, antibiotic prescriptions, and urine samples requested prior to the diagnosis of first UTI (cases) or equivalent time periods for controls.
Results: Cases had a mean 2.94 additional visits or 21% more visits (95% CI 1% to 41%) in the period (mean 2.4 years) prior to the visit at which their first UTI was diagnosed, including a mean 2.5 additional visits or 23% more visits for infectious illness (95% CI 1% to 45%). The cases had 114% (95% CI 41% to 184%) more visits for symptoms relating to the genitourinary tract, though the actual number of these visits was small. They were febrile at 49% more visits (95% CI 1% to 99%) and received significantly more courses of antibiotics than controls (5.2 v 4.1). They had more urine samples requested (37 v 3). Both the cases with and without renal scarring had similar excess GP visits.
Conclusion: Compared to controls, children diagnosed with a first UTI had more visits at which symptoms of infection were recorded and more antibiotics prescribed prior to the visit at which the first UTI was diagnosed. These excess visits may have included undiagnosed UTIs. Both those with and without renal scarring had a similar degree of excess visits; additional aetiological factors must have played a role in scar formation.
PMCID: PMC1755815  PMID: 12456556
17.  Acceptance and perceived barriers of implementing a guideline for managing low back in general practice 
Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.
Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.
Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.
Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.
Trial registration
BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 [25].
PMCID: PMC2275295  PMID: 18257923
18.  Antibiotic treatment of acute uncomplicated cystitis based on rapid urine test and local epidemiology: lessons from a primary care series 
BMC Infectious Diseases  2014;14:137.
Acute uncomplicated cystitis (AUC) is an ideal target of optimization for antibiotic therapy in primary care. Because surveillance networks on urinary tract infections (UTI) mix complicated and uncomplicated UTI, reliable epidemiological data on AUC lack. Whether the antibiotic choice should be guided by a rapid urine test (RUT) for leukocytes and nitrites has not been extensively studied in daily practice. The aim of this primary care study was to investigate local epidemiology and RUT-daily use to determine the optimal strategy.
General practitioners included 18–65 years women with symptoms of AUC, performed a RUT and sent urines for analysis at a central laboratory. Different treatment strategies were simulated based on RUT and resistance results.
Among 347 enrolled patients, 78% had a positive urine culture. Escherichia coli predominated (71%) with high rates of susceptibility to nitrofurantoin (100%), fosfomycin (99%), ofloxacin (97%), and even pivmecillinam (87%) and trimethoprim-sulfamethoxazole (87%). Modelization showed that the systematic use of RUT would reduce by 10% the number of patients treated. Fosfomycin for patients with positive RUT offered a 90% overall bacterial coverage, compared to 98% for nitrofurantoin. 95% for ofloxacin, 86% for trimethoprim-sulfamethoxazole and 78% for pivmecillinam.
Local epidemiology surveillance data not biased by complicated UTI demonstrates that the worldwide increase in antibiotic resistance has not affected AUC yet. Fosfomycin first line in all patients with positive RUT seems the best treatment strategy for AUC, combining good bacterial coverage with expected low toxicity and limited effect on fecal flora.
Trial registration
The current study was registered at (NCT00958295)
PMCID: PMC3975248  PMID: 24612927
Acute uncomplicated cystitis; Urinary tract infection; Primary care; Rapid urine test; Antibiotic policy
19.  Urinary tract infections in adult general practice patients. 
Urinary tract infections (UTIs) are symptomatic infections of the urinary tract, mainly caused by the bacterium Escherichia coli. One in two women suffers from a UTI at least once in her life. The young and sexually active are particulaly affected, but it is also seen in elderly, postmenopausal women. The likelihood of recurrence is high. Diagnosis is made with regard to typical complaints and the presence of leucocytes and nitrites in the urine. A culture is unnecessary in most cases. Uncomplicated UTI should be distinguished from complicated UTI, which has a risk of severe illness. The treatment of choice--short-term therapy with trimethoprim or nitrofurantoin--is successful in over 80% of the cases. Co-trimoxazol fluoroquinolones or cephalsporins are not considered first-choice drugs. There are indications that general practitioners' (GPs') management of UTI is not always optimal, specifically concerning diagnostic tests, the application of second-choice antibiotics, and the length of prescribed treatment courses. Many points relevant to GPs requirefurther research, such as epidemiology and resistance of urinary pathogens in the community and natural history of UTI, as well as optimal management in elderly or complicated patients and men.
PMCID: PMC1314418  PMID: 12236281
20.  Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study 
BMC Family Practice  2013;14:71.
Women presenting with symptoms of acute uncomplicated urinary tract infection (UTI) are often prescribed antibiotics. However, in 25 to 50% of symptomatic women not taking antibiotics, symptoms recover spontaneously within one week. It is not known how many women are prepared to delay antibiotic treatment. We investigated how many women presenting with UTI symptoms were willing to delay antibiotic treatment when asked by their general practitioner (GP).
From 18 April 2006 until 8 October 2008, in a prospective cohort study, patients were recruited in 20 GP practices in and around Amsterdam, the Netherlands. Healthy, non-pregnant women who contacted their GP with painful and/or frequent micturition for no longer than seven days registered their symptoms and collected urine for urinalysis and culture. GPs were requested to ask all patients if they were willing to delay antibiotic treatment, without knowing the result of the culture at that moment. After seven days, patients reported whether their symptoms had improved and whether they had used any antibiotics.
Of 176 women, 137 were asked by their GP to delay antibiotic treatment, of whom 37% (51/137) were willing to delay. After one week, 55% (28/51) of delaying women had not used antibiotics, of whom 71% (20/28) reported clinical improvement or cure. None of the participating women developed pyelonephritis.
More than a third of women with UTI symptoms are willing to delay antibiotic treatment when asked by their GP. The majority of delaying women report spontaneous symptom improvement after one week.
PMCID: PMC3671219  PMID: 23721260
Urinary tract infections; General practice; Antibiotics; Delayed treatment; Natural course
21.  Awareness of antibiotic resistance and antibiotic prescribing in UTI treatment: A qualitative study among primary care physicians in Sweden 
Objectives. To improve education and information for general practitioners in relation to rational antibiotic prescribing for urinary tract infection (UTI), it is important to be aware of GPs’ views of resistance and how it influences their choice of UTI treatment. The aim of this study was to explore variations in views of resistance and UTI treatment decisions among general practitioners (GPs) in a county in Sweden. Design. Qualitative, semi-structured interviews were analysed with a phenomenographic approach and content analysis. Setting. Primary care in Kronoberg, a county in southern Sweden. Subjects. A purposeful sample of 20 GPs from 15 of 25 health centres in the county. Main outcome measures. The variation of perceptions of antibiotic resistance in UTI treatment. How UTIs were treated according to the GPs. Results. Three different ways of viewing resistance in UTI treatment were identified. These were: (A) No problem, I have never seen resistance, (B) The problem is bigger somewhere else, and (C) The development of antibiotic resistance is serious and we must be careful. Moreover, GPs’ perceptions of antibiotic resistance were mirrored in how they reported their treatment of UTIs in practice. Conclusion. There was a hierarchal scale of how GPs viewed resistance as an issue in UTI treatment. Only GPs who expressed concerns about resistance followed prescribing guidelines completely. This offers valuable insights into the planning and most likely the outcome of awareness or educational activities aimed at changed antibiotic prescribing behaviour.
PMCID: PMC3587295  PMID: 23281925
Antibiotics; bacterial resistance; general practice; general practitioners; interviews; urinary tract infection; Sweden; views
22.  Different recommendations for empiric first-choice antibiotic treatment of uncomplicated urinary tract infections in Europe 
Uncomplicated urinary tract infection (uUTI) is a common reason for antibiotic treatment in primary health care. Due to the increasing prevalence of antibiotic-resistant uropathogens it is crucial to use the most appropriate antibiotics for first-choice empiric treatment of uUTI. Particularly, it is important to avoid antibiotics associated with a high rate of antimicrobial resistance. This study compares national recommendations from six European countries, investigating recommendations for first-choice antibiotic therapy of uUTI.
General practice in six European countries.
Searches were undertaken on PubMed, the Cochrane Library databases, Google, and Google Scholar. Recommendations from different geographical regions in Europe were investigated: Northern Europe (Denmark, Sweden), Western Europe (Scotland), Central Europe (Germany), Southern Europe (Spain), and Eastern Europe (Croatia).
The six countries recommended seven different antibiotics. Five countries recommended more than one antibiotic as first-choice treatment. Half of the countries recommended antibiotics associated with a high rate (> 10–20%) of resistant E. coli. All countries recommended at least one antibiotic associated with a low (< 5%) resistance rate.
The differences in first-choice treatment of uUTI could not be explained by differences in local bacterial aetiology or by different patterns of antimicrobial resistance. Despite resistance rates exceeding 10–20%, sulphamethizole, trimethoprim. or fluoroquinolones were recommended in half of the countries.
Within the European countries there are considerable differences in recommendations for empiric first-choice antibiotic treatment of uUTI. In order to reduce the increasing antimicrobial resistance in Europe, it is important to agree on the most appropriate antibiotics for empiric treatment of uUTI.
PMCID: PMC3860300  PMID: 24102498
Antibiotics; antimicrobial resistance; Denmark; general practice; primary health care; recommendations; uncomplicated urinary tract infection
23.  Urinary tract infections in women: etiology and treatment options 
Urinary tract infections (UTI) are common among the female population. It has been calculated that about one-third of adult women have experienced an episode of symptomatic cystitis at least once. It is also common for these episodes to recur. If predisposing factors are not identified and removed, UTI can lead to more serious consequences, in particular kidney damage and renal failure. The aim of this review was to analyze the factors more commonly correlated with UTI in women, and to see what possible solutions are currently used in general practice and specialized areas, as well as those still under investigation. A good understanding of the possible pathogenic factors contributing to the development of UTI and its recurrence will help the general practitioner to interview the patient, search for causes that would otherwise remain undiscovered, and to identify the correct therapeutic strategy.
PMCID: PMC3108201  PMID: 21674026
urinary tract infection; women; etiology; diagnosis; treatment
24.  Are prophylactic antibiotics indicated after a urinary tract infection? 
Current opinion in pediatrics  2009;21(2):203-206.
Purpose of review
Many children with urinary tract infection (UTI) and urinary tract abnormality such as vesicoureteral reflux (VUR) are given prophylactic antibiotic to prevent recurrence of UTI and permanent kidney damage. Occasionally, children with normal urinary tract receive prophylactic antibiotic to alleviate the patient suffering and family inconvenience associated with recurrent symptomatic UTI. These recommendations are mostly opinion based and are derived from studies that were not randomized and were done before the current renal imaging modalities became available. The purpose of this review is to discuss these recommendations in the context of recent research findings.
Recent findings
Recent studies have raised serious doubts about the role of antibiotic prophylaxis after UTI by demonstrating the presence of preexisting renal scars without UTI in some patients, systematic reviews of published literature on UTI and VUR, and by comparing randomized patients with VUR who received antibiotic prophylaxis with those who did not receive any prophylaxis. However, the new knowledge has also highlighted that, apart from skilful management of individual patients, well designed studies are needed to answer the questions on antibiotic prophylaxis across the spectrum of UTI in different clinical situations. One such study currently underway is the Randomized Intervention for Children With Vesicoureteral Reflux study, which will evaluate the role of antibiotic prophylaxis in preventing recurrent UTI and renal scarring in young children with VUR.
It is advisable that until the results of more appropriately designed studies become available, UTI in young children is considered as a risk factor for renal scarring and each patient is treated with prudence.
PMCID: PMC2725357  PMID: 19663037
prophylactic antibiotic; urinary tract infection; vesicoureteral reflux
25.  Children's UTIs in the new millennium. Diagnosis, investigation, and treatment of childhood urinary tract infections in the year 2001. 
Canadian Family Physician  2001;47:1603-1608.
OBJECTIVE: To provide an effective approach for family physicians treating children presenting with urinary tract infections (UTIs). QUALITY OF EVIDENCE: The information presented, and articles quoted, are drawn from both review of the literature and recent consensus guidelines. Data and recommendations come from prospective multicentre trials; retrospective reviews; expert consensus statements; and some smaller trials, commentaries, and editorials. MAIN MESSAGE: Urinary tract infections are often seen in family practice. Diagnosis requires suspicion and a realization that children, especially those younger than 2 years, often have very few, nonspecific signs of infection. Obtaining a proper urine sample is vital, because true infections require radiographic studies. Antibiotic prophylaxis is promoted because of the link between vesicoureteral reflux, recurrent UTIs, and renal scarring and hypertension. We generally provide prophylaxis until children are 3 or 4 years, when risk of damage from reflux is lessened and timely urine samples are easier to obtain for prompt therapy. Surgical opinion is sought only when medical management has failed. Failure is defined as either recurrent infections and pyelonephritis or poor renal growth. CONCLUSION: To diagnose UTIs in children, physicians must suspect them, obtain proper urine samples, order appropriate investigations to rule out underlying anatomic abnormalities, and treat with appropriate antibiotics considering both organism sensitivities and length of therapy.
PMCID: PMC2018548  PMID: 11561337

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