The Diagnosis, Treatment, and Prevention of Recurrent Urinary Tract Infection.

BACKGROUND: Urinary tract infection has a one-year prevalence of 11% in women and ranges among the most common reasons for consulting a primary care physician and for receiving a prescription for antibiotics. In the case of recurrent urinary tract infection (rUTI), there are questions about the further work-up, treatment, and preventive measures. METHODS: The systematic literature search performed for the update of the German clinical practice guideline on uncomplicated urinary tract infection (043-044) (up to February 2022) was supplemented with a selective search for clinical trials (up to August 2023). RESULTS: Urine culture and ultrasonography are reasonable steps in the diagnostic evaluation of rUTI. Further invasive testing is suggested for men but is not routinely indicated for women. Antibiotics are among the most effective preventive measures (risk ratio [RR] 0.15, 95% confidence interval [0.1; 0.3]) but carry a high risk of side effects. Non-antibiotic preparations such as cranberry juice (RR 0.74 [0.5; 0.99]), mannose (RR 0.23 [0.14; 0.37]), and vaginal estrogen (RR, 0.42 [0.30; 0.59]) can also reduce the infection rate, with a low risk of side effects. Increased daily fluid intake has been shown to lower infection rates in the short term (odds ratio [OR] 0.13 [0.07; 0.25]); the use of hygienically advisable wiping techniques after passing stool or urine has been little studied but can be implemented with no risk. CONCLUSION: rUTI poses a challenge for the treating physician. The measures to be taken must be considered on an individual basis. Vulnerable groups, such as older patients, need special attention.

Dipsticks and point-of-care Microscopy to reduce antibiotic use in women with an uncomplicated Urinary Tract Infection (MicUTI): protocol of a randomised controlled pilot trial in primary care.

INTRODUCTION: Uncomplicated urinary tract infections (uUTIs) in women are common infections encountered in primary care. Evidence suggests that rapid point-of-care tests (POCTs) to detect bacteria and erythrocytes in urine at presentation may help primary care clinicians to identify women with uUTIs in whom antibiotics can be withheld without influencing clinical outcomes. This pilot study aims to provide preliminary evidence on whether a POCT informed management of uUTI in women can safely reduce antibiotic use. METHODS AND ANALYSIS: This is an open-label two-arm parallel cluster-randomised controlled pilot trial. 20 general practices affiliated with the Bavarian Practice-Based Research Network (BayFoNet) in Germany were randomly assigned to deliver patient management based on POCTs or to provide usual care. POCTs consist of phase-contrast microscopy to detect bacteria and urinary dipsticks to detect erythrocytes in urine samples. In both arms, urine samples will be obtained at presentation for POCTs (intervention arm only) and microbiological analysis. Women will be followed-up for 28 days from enrolment using self-reported symptom diaries, telephone follow-up and a review of the electronic medical record. Primary outcomes are feasibility of patient enrolment and retention rates per site, which will be summarised by means and SDs, with corresponding confidence and prediction intervals. Secondary outcomes include antibiotic use for UTI at day 28, time to symptom resolution, symptom burden, number of recurrent and upper UTIs and re-consultations and diagnostic accuracy of POCTs versus urine culture as the reference standard. These outcomes will be explored at cluster-levels and individual-levels using descriptive statistics, two-sample hypothesis tests and mixed effects models or generalised estimation equations. ETHICS AND DISSEMINATION: The University of Würzburg institutional review board approved MicUTI on 16 December 2022 (protocol n. 109/22-sc). Study findings will be disseminated through peer-reviewed publications, conferences, reports addressed to clinicians and the local citizen's forums. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT05667207.

The Percentage of Antibiotic Resistance in Uncomplicated Community-Acquired Urinary Tract Infections.

BACKGROUND: Uncomplicated bacterial urinary tract infections(uUTIs) are commonly seen in outpatient practice. They are usuallytreated empirically with antibiotics. The pertinent German ClinicalPractice Guideline contains recommendations on antibiotic selection,with the additional advice that the local resistance situationshould be considered as well. However, up-to-date information onlocal resistance is often unavailable, because microbiological testingis mainly recommended for complicated UTIs. Resistance ratesare often higher in recurrent uUTIs than in single episodes. In thisstudy, we aimed to determine the resistance rates of Escherichiacoli (E. coli) in patients with community-acquired uUTIs and tomake these data available to the treating physicians. METHODS: In a nationwide cross-sectional study in Germany (DRKS00019059), we determined the percentages of resistance to antibioticsrecommended for uUTIs (first choice: fosfomycin, nitro -xoline, mecillinam, nitrofurantoin, trimethoprim; second choice:cefpodoxime, ciprofloxacin, cotrimoxazole, levofloxacin, norfloxacin,ofloxacin) over the period 2019-2021. The data were stratified bysingle episodes vs. recurrent UTIs (rUTIs). RESULTS: Data from 2390 subjects were analyzed. E. coli was foundin 75.4% of the samples with positive urine cultures (1082 out of1435). The resistance rate of E. coli in single episodes (n = 725)was less than 15% for all antibiotics tested. In rUTIs(n = 357), resistance rates were also less than 15%for the most part; the only exceptions were trimethoprim(21.4%) and cotrimoxazole (19.3%). CONCLUSION: For single episodes of uUTI, all of theantibiotics studied can be recommended, at least asfar as their resistance profiles are concerned. Forrecurrent UTI, all but trimethoprim and cotrimoxazolecan be recommended. The second-choice antibioticsexamined do not have a more favorable resistanceprofile than the first-choice antibiotics.

[Frequency and characteristics of interventions by community paramedics on people in need of care : Analysis of 2,410 deployment protocols for people aged 65+ years]. / Häufigkeit und Charakteristika von Einsätzen der Gemeindenotfallsanitäter bei Pflegebedürftigen : Analyse von 2410 Einsatzprotokollen bei Personen im Alter von 65+ Jahren.

BACKGROUND: The aim of this study was to obtain a differentiated view of interventions delivered by community paramedics (Gemeindenotfallsanitäter, G­NFS) in older people in need of care living in nursing homes and at home. MATERIALS AND METHODS: A retrospective analysis of G­NFS documentation from 2021 with a focus on patients aged ≥65 years was performed. Data were grouped into callouts to nursing homes or private homes. Interventions, urgency, transport, and further recommendations were analyzed descriptively. RESULTS: Of 5,900 G-NFS protocols, 43.0% (n = 2,410) were related to elderly people (mean age 80.8 years, 49.7% female). A total of 20.6% of these callouts involved nursing home residents, 38.4% (n = 926) were homecare patients, and 41% (n = 988) of callouts were to persons who did not rely on care. No specific interventions except advice were given to 48.4% of nursing home residents, and to even 82.1% of those in homecare and 83.7% of those without care needs. About 60% of the G­NFS interventions were classified as non-urgent. Transport was waived for 63.1% of nursing home residents, for 58.1% in homecare, and for 60.6% of persons without care needs. A visit to the emergency department was recommended to 29.4% of nursing home residents, 37.6% of homecare patients, and 33.6% of persons without need of care. Measures related to urine catheters were documented much more often in nursing homes (38.5%) than in patients in homecare (15.1%) or without need of care (9.3%). CONCLUSION: Community paramedics perform primary care tasks and can contribute to a reduction in unnecessary transport. It should be discussed whether the emergency medical service is responsible for such interventions and how older people in need of care can be cared for according to their needs in the future.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial.

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial.

OBJECTIVES: To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women. DESIGN: Parallel, cluster randomised, controlled trial. SETTING: General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022. PARTICIPANTS: General practitioners from 128 randomly assigned practices. INTERVENTIONS: Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention. MAIN OUTCOME MEASURES: Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes. RESULTS: 110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups. CONCLUSIONS: The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS00020389.

Prevalence of indwelling urinary catheters in nursing home residents: Systematic review.

BACKGROUND: This systematic review examines the prevalence of indwelling urinary catheters in nursing home residents. METHODS: MEDLINE via PubMed, CINAHL, and EMBASE were searched from inception to 9 August 2022. Cross-sectional studies and longitudinal studies with cross-sectional analyses reporting catheter prevalence in nursing home residents were identified and summarized descriptively. Study quality was assessed using the Joanna Briggs Institute's tool. RESULTS: Sixty-seven studies (92.5 % cross-sectional) were included. The reported number of included residents ranged from 73 to 110,656. The median catheter prevalence was 7.3 % (interquartile range 4.3-10.1 %; n = 65 studies). It was higher in Germany (10.2 % [9.7-12.8 %]; n = 15) than in the United States of America (9.3 % [6.3-11.9 %]; n = 9), United Kingdom (6.9 % [4.8-8.5 %]; n = 7), and Sweden (7.3 % [6.4-7.9 %]; n = 6). Furthermore, it was higher among men (17.0 % [16.0-26.0 %]) than among women (5.3 % [4.0-9.5 %]) (n = 9). Only one study investigated differences by age. The prevalence was higher for transurethral (5.7 % [5.6-7.2 %]; n = 12) than for suprapubic (1.2 % [0.6-2.5 %]; n = 13) catheters. Most catheterized residents were long-term catheterized (n = 6) and had their catheter changed within 3 months (n = 2). Symptomatic urinary tract infections were more common among catheterized than among non-catheterized residents (n = 4). DISCUSSION: Catheter prevalence in nursing home residents varies between studies and countries. Prevalence differences by sex, age, and catheter type as well as duration of catheterization, catheter change intervals, and catheter-associated urinary tract infections are rarely reported because most studies do not primarily focus on catheters. Future studies should focus on the circumstances of urinary catheter use and care in nursing home residents. REGISTRATION AND FUNDING: PROSPERO (29 August 2022; CRD42022354358); no funding.

Point-of-care laboratory testing in primary care: utilization, limitations and perspectives of general practitioners in Germany.

BACKGROUND: Due to their fast turnaround time and user-friendliness, point-of-care tests (POCTs) possess a great potential in primary care. The purpose of the study was to assess general practitioners' (GPs) perspectives on POCT use in German primary care, including utilization, limitations and requirements. METHODS: We conducted a cross-sectional survey study among GPs in Germany (federal states of Thuringia, Bremen and Bavaria (Lower Franconia), study period: 04/22-06/2022). RESULTS: From 2,014 GPs reached, 292 participated in our study (response rate: 14.5%). The median number of POCTs used per GP was 7.0 (IQR: 5.0-8.0). Six POCTs are used by the majority of surveyed GPs (> 50%): urine dipstick tests (99%), glucose (urine [91%] and plasma [69%]), SARS-CoV-2 (80%), urine microalbumin (77%), troponin I/T (74%) and prothrombin time / international normalized ratio (65%). The number of utilized POCTs did not differ between GP practice type (p = 0.307) and population size of GP practice location (p = 0.099). The great majority of participating German GPs (93%) rated POCTs as useful diagnostic tools in the GP practice. GPs ranked immediate decisions on patient management and the increase in diagnostic certainty as the most important reasons for performing POCTs. The most frequently reported limitations of POCT use in the GP practice were economic aspects (high costs and inadequate reimbursement), concerns regarding diagnostic accuracy, and difficulties to integrate POCT-testing into practice routines (e.g. time and personnel expenses). CONCLUSION: Although participating German GPs generally perceive POCTs as useful diagnostic tools and numerous POCTs are available, several test-related and contextual factors contribute to the relatively low utilization of POCTs in primary care.

Patterns and trends of antibacterial treatment in patients with urinary tract infections, 2015-2019: an analysis of health insurance data.

BACKGROUND: Urinary tract infections are among the most common reason for encounter and subsequent antibiotic prescriptions. Due to the risk of collateral damage and increasing resistance rates, explicit recommendations against the use of fluoroquinolones like ciprofloxacin in uncomplicated urinary tract infections have been issued. However, to what extent these recommendations were followed and if there are relevant differences between the disciplines involved (general practitioners, urologists, paediatricians and gynaecologists) are unknown. METHODS: We used anonymized data from a local statutory health insurance (SHI) company, which covered about 38% of all SHI-insured persons in the federal state of Bremen, Germany between 2015-2019. Data included demographics, outpatient diagnoses and filled prescriptions on an individual level. RESULTS: One-year prevalence of urinary tract infections was 5.8% in 2015 (females: 9.2%, males: 2.5%). Of all 102,715 UTI cases, 78.6% referred to females and 21.4% to males, 6.0% of cases were younger than 18 years. In females, general practitioners were the most common diagnosing speciality (52.2%), followed by urologists (20.0%) and gynaecologists (16.1%). Overall, fluoroquinolones were most often prescribed (26.3%), followed by fosfomycin (16.1%) and the combination of sulfamethoxazole and trimethoprim (14.2%). Fluoroquinolones were most often prescribed by urologists and general practitioners, while gynaecologists preferred fosfomycin. During the study period, shares of fluoroquinolones decreased from 29.4% to 8.7% in females and from 45.9% to 22.3% in males. CONCLUSIONS: Despite a clear trend toward a more guideline adherent prescription pattern, there is still room for improvement regarding the use of second-line antibiotics especially fluoroquinolones. The choice of antibiotics prescribed differs between specialities with higher uptake of guideline-recommended antibiotics by gynaecologists, mainly because of higher prescription shares of fosfomycin.

The emotional impact of urinary tract infections in women: a qualitative analysis.

BACKGROUND: While many studies address the clinical management of participants with uncomplicated urinary tract infection (uUTI), the emotional impact of uUTIs has been investigated less often. The aim of this qualitative study was to understand the emotional experience of women with uUTIs. METHODS: This was a qualitative, exploratory, in-depth interview-based study conducted among women in the United States (US) and Germany. Women aged ≥ 18 years with at least one uUTI treated with antibiotics in the past year were recruited through a patient community panel and physician referrals. Participants were recruited using purposive sampling to include an equal split of those with 1 or ≥ 2 antibiotics, and an equal split of those treated for a single or recurrent uUTIs (≥ 2 uUTIs in the past year). A structured telephone interview included questions about symptoms, diagnosis, treatment, and retreatment (if any). Each participant was queried about her emotions and the impact of the uUTI on life activities. Thematic analysis of responses was carried out to identify common themes. RESULTS: A total of 65 participants completed the interview, 40 (61.5%) from the US and 25 (38.5%) from Germany. Major themes that emerged from the analyses included (1) a wide range of negative emotions were experienced due to uUTI symptoms, interference with activities of daily life, and effects on relationships and sleep; (2) varied emotions and understanding related to uUTI treatment and management approaches; (3) treatment failure caused frustration, worry, and anger; and (4) the prospect of recurrent uUTIs provoked dread and helplessness. CONCLUSION: Our research uncovered emotions of helplessness and dread experienced by women in the context of uUTI clinical treatment failure and recurrent uUTIs. Knowing patients' perspectives on UTI management will help guide the development of patient education and improve shared decision-making.

[Is it feasible to conduct drug studies in general practice? - Results of a survey among investigating physicians and medical staff]. / Sind Arzneimittelstudien in der Hausarztpraxis durchführbar? ­ Ergebnisse einer Befragung von Prüfärzt*innen und Medizinischen Fachangestellten.

BACKGROUND: Pragmatic randomized controlled trials are able to make an essential contribution to the further development of evidence-based treatment recommendations for primary care patients. However, drug trials are regulated by specific guidelines and have not yet become a routine task in GP practices. Within the scope of a multi-center, double-blind, randomized controlled trial on treating urinary tract infections in women with and without antibiotics (REGATTA), the feasibility of pharmaceutical studies in GP practices was evaluated by means of a questionnaire sent out to participating physicians and practice nurses. METHODS: Using a self-designed, non-validated questionnaire, the perspectives, attitudes and experiences of participating physicians and practice nurses were assessed anonymously. In this way, we identified both hindering and beneficial factors affecting the conduct of drug trials in German GP practices. RESULTS: 39 physicians and 48 practice nurses participated in the survey. 95 % of the physicians and 88 % of the practice nurses indicated that the implementation of drug trials with all their regulatory requirements is, in principle, possible in GP practices. In particular, the high amount of time and documentation necessary were identified as barriers. The implementation can be facilitated by formulating a research question that is relevant to practice and patients and by support from the study center. CONCLUSION: Although participation in a drug trial is an additional burden in everyday practice, it is considered feasible and worthwhile by the GPs and practice nurses involved. Due to an assumed selection bias, the predominantly positive experiences of the respondents may be overestimated and transferable only to a limited extent.

Contacts with general practitioners, dentists, and medical specialists among nursing home residents: a cross-sectional study in 44 German nursing homes.

BACKGROUND: Nursing home residents have high medical care needs. Their medical care utilization is, however, lower compared to community-dwelling elderly and varies widely among nursing homes. This study quantified the utilization of general practitioners (GPs), dentists, and medical specialists among nursing homes and residents, and investigated whether dentist utilization is associated with individual and nursing home characteristics. METHODS: Forty-four nursing homes invited 2124 residents to participate in a cross-sectional study. For 10 medical specialties, data on contacts in nursing homes, practices, and by telephone in the last 12 months were assessed at individual and nursing home level. The proportion of nursing homes and residents with any form of contact, and the median number and interquartile range (IQR) of contacts among individuals with contact were determined. Using multilevel logistic regression, associations between the probability of individual dental care utilization and sex, age, LTC grade, years of residence, sponsorship, number of nursing home beds, and transport and medical escort services for consultations at a practice were investigated. RESULTS: The proportion of nursing homes with any form of contact with physicians ranged from 100% for GPs, dentists, and urologists to 76.7% for gynecologists and orthopedists. Among the nursing homes, 442 residents participated (20.8% response). The proportion of residents with any contact varied from 97.8% for GPs, 38.5% for neurologists/psychiatrists, and 32.3% for dentists to 3.0% for gynecologists. Only for GPs, neurologists/psychiatrists, dentists, otorhinolaryngologists, urologists, and dermatologists, the proportion was higher for nursing home contacts than for practice and telephone contacts. Among residents with any contact, the median number of contacts was highest for GPs (11.0 [IQR 7.0-16.0]), urologists (4.0 [IQR 2.0-7.0]), and neurologists/psychiatrists (3.0 [IQR 2.0-5.0]). Dentist utilization varied widely among nursing homes (median odds ratio 2.5) and was associated with higher age. CONCLUSIONS: Almost all residents had regular contact to GPs, but only one third had contact with dentists. Lower proportions with contact were found for medical specialists, except for neurologists/psychiatrists. Reasons for the large variations in dental care utilization among nursing homes should be identified. TRIAL REGISTRATION: DRKS00012383 [2017/12/06].

[Care of older patients by community emergency paramedics : Comparison of community-dwellers and nursing home residents]. / Versorgung älterer Patienten durch Gemeindenotfallsanitäter : Vergleich der Einsätze im Pflegeheim und in der Häuslichkeit.

BACKGROUND: Emergency departments and emergency services are increasingly burdened by non-emergency patients. A substantial proportion of these is represented by older people. The project "community emergency paramedic" ("Gemeindenotfallsanitäter" [G-NFS]) was initiated to prevent unnecessary use of emergency services. OBJECTIVE: To identify specific utilizations of the G­NFS services by older people at home and in nursing homes. MATERIAL AND METHODS: Retrospective analysis of the assignment protocols from July 2019 through June 2020. Only data from patients aged ≥ 65 years were included. Data were grouped into whether patients lived on their own or in nursing homes. RESULTS: A total of 2358 protocols of older patients (mean age 80.8 years; 52.9% female) were evaluated and 55% of patients were treated on-site. The most frequently used measures by G­NFS were counselling (79.4%), aid in self-medication (16.7%) and administration of medication (23.2%). Of the G­NFS assignments 329 (14.0%) were carried out for nursing home residents. Measures related to urine catheter complications were more frequently performed in nursing home residents than in patients who lived at home (32.2% vs. 5.7%). Compared to other emergency cases, patients with catheter-related complications were most often treated at the scene (84.3% vs. 52.2%). CONCLUSION: The G­NFS enabled the majority of patients to be treated on-site, thus saving resources of emergency services and hospitals; however, the G­NFS also performed measures that were normally the responsibility of general practitioners. This possibly highlights structural deficits in the medical and nursing care of older people.

[Presentation of an innovative interdisciplinary and cross-sector therapeutic concept for pain patients as part of a regional selective contract]. / Vorstellung eines innovativen interdisziplinären, sektoren-übergreifenden und gestuften Behandlungskonzepts für Schmerzpatient*innen im Rahmen eines regionalen Selektivvertrages nach §140a SGB V.

BACKGROUND: A graded therapeutic concept for the treatment of chronic pain patients in Germany is only available to a limited extent. Following the onset of coronavirus disease (COVID-19), care for these patients has become even worse. AIM: To develop and establish a cross-sector therapeutic concept for chronic pain patients as part of a selective contract. METHODS: Embedded in existing therapeutic procedures, we define seven clinical pathways (CPs) into which patients are directed, after an interdisciplinary assessment according to refined criteria. ORGANIZATION: In CP I, patients remain in standard therapy. In CP II, patients have the opportunity to participate in an additional inter-profession education program. In CP III, patients get a specialized outpatient treatment. CP IV is a partial inpatient treatment, where multiple inpatient attendance days are replaced by tele-medical treatment, via a rehabilitation app. CP V and VI are inpatient treatments over 8 and 15 days each. If patients need further psychotherapeutic support after an inpatient treatment, they can be treated by clinical psychotherapists for another six months in CP VII. EVALUATION: The evaluation takes place 3, 6 and 12 months after initial assessment and includes the German Pain Questionnaire with different psychometric tests.

REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care.

BACKGROUND: Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine. METHODS/DESIGN: In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention. DISCUSSION: If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care.  Trial registration DRKS, DRKS00020389, Registered 30 January 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020389 .

Herbal treatment with uva ursi extract versus fosfomycin in women with uncomplicated urinary tract infection in primary care: a randomized controlled trial.

OBJECTIVE: We explored whether initial treatment with the herbal drug uva ursi (UU) reduces antibiotic use in women with uncomplicated urinary tract infection (UTI) without increasing symptom burden and complication frequency compared with antibiotic treatment. METHODS: A double-blind randomized controlled trial was conducted in 42 family practices in Germany. The participants were adult women with suspected uncomplicated UTIs receiving either UU 105 mg 3 × 2 tablets for 5 days (intervention) or fosfomycin a 3-g single dose (control), and their respective placebos. Participants and investigators were blinded. The primary outcome included (1) antibiotic courses day 0-28 as superiority, and (2) symptom burden (sum of daily symptom scores) day 0-7, as non-inferiority outcome (margin 125%). Clinicaltrials.gov: NCT03151603. RESULTS: Overall, 398 patients were randomly allocated to groups receiving UU (n = 207) and fosfomycin (n = 191). The number of antibiotic courses was 63.6% lower (95% CI 53.6%-71.4%; p < 0.0001) in the UU group than in the fosfomycin group. The ratio of total symptom burden in the UU group compared with control was 136.5% (95% CI 122.7-151.9; p 0.95), failing non-inferiority. Eight women developed pyelonephritis in the UU group compared with two in the fosfomycin group (mean difference 2.8; 95% CI 0.2-5.9; p 0.067). Adverse events were similar between the groups. DISCUSSION: In women with uncomplicated UTIs, initial treatment with UU reduced antibiotic use but led to a higher symptom burden and more safety concerns than fosfomycin.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters.

BACKGROUND: Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits. AIMS: We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR. METHODS: We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED. RESULTS: A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%). DISCUSSION: Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary. CONCLUSION: Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

[Medical specialist undertreatment in nursing home residents-Prevalence and extrapolation]. / Fachärztliche Unterversorgung bei Heimbewohnern ­ Prävalenzstudie und Hochrechnung.

BACKGROUND: Nursing home residents tend to have lower medical specialist utilization than other groups of older people; however, as yet there is little evidence whether nursing home residents obtain adequate medical specialist care. This study investigated whether nursing home residents receive adequate oral health care, ophthalmological care, otorhinolaryngologist care and neurological care. The unmet needs of the nursing home population in Germany was extrapolated. MATERIAL AND METHODS: Audiometry, eye examinations and oral visual inspection were performed in 409 residents from 44 nursing homes. Medical care in the previous 12 months as well as existing diagnoses were retrieved from the nursing documentation. Teams of physicians evaluated for each resident based on all collected data if the resident obtained specialist care that was adequate to the needs. RESULTS: Between 15% and 45% of the residents with need for medical specialist care did not receive adequate specialist care. Of all residents 27% had unmet need of specialist care in at least one of the investigated medical specialties. It is projected that up to 205,000 nursing home residents in Germany do not receive adequate medical specialist care. CONCLUSION: Given a considerable proportion of nursing home residents with unmet need of specialist care, interventions should be developed that help reduce the level of unmet needs.

Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study.

BACKGROUND: Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce. AIMS: The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer. METHODS: We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively. RESULTS: Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3-83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%). DISCUSSION: Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences. CONCLUSION: Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.