Women with symptoms of a urinary tract infection but a negative urine culture: PCR-based quantification of Escherichia coli suggests infection in most cases.

OBJECTIVES: Our objective was to examine whether or not women with symptoms of a urinary tract infection but with a negative culture (20%-30%) do have an infection. METHODS: We performed quantitative PCR (qPCR) for Escherichia coli and Staphylococcus saprophyticus, on top of a standard culture, in urine samples from 220 women with dysuria and/or frequency and/or urgency and from 86 women without symptoms. For symptomatic women, qPCR was also carried out for four sexually transmitted agents. RESULTS: In the symptomatic group, 80.9% (178/220) of the urine cultures were positive for any uropathogen and 95.9% (211/220) were E. coli qPCR-positive. For the control group, cultures for E. coli and E. coli qPCR were positive in, respectively, 10.5% (9/86) and 11.6% (10/86). In the symptomatic group, qPCR yielded 19 positive samples for S. saprophyticus qPCR, one positive sample for Mycoplasma genitalium and one for Trichomonas vaginalis. CONCLUSIONS: These findings suggest that almost all women with typical urinary complaints and a negative culture still have an infection with E. coli.

Uropathogen distribution and antimicrobial susceptibility in uncomplicated cystitis in Belgium, a high antibiotics prescribing country: 20-year surveillance.

Treatment of cystitis in primary care is usually empirical, guided by the prior probability of causal pathogens and their susceptibility. To re-evaluate empirical treatment guidelines, the actual distribution and susceptibility of uropathogens was examined and compared with two previous surveys in Belgium over the past 20 years. Because of the alarming increase in carriage of extended-spectrum ß-lactamase (ESBL)- and carbapenemase-producing Escherichia coli, this specific resistance was explored. From May 2014 to December 2015, 120 general practitioners collected midstream urine specimens from adult pre- and postmenopausal female patients with suspected cystitis. A dipslide was inoculated and sent for microbiological analysis. Anal swabs were collected for ESBL and carbapenemase detection. Of 265 enrolled patients, 203 (79.3 %) had a positive culture. Escherichia coli (81.6 %) was the most frequently isolated uropathogen, followed by Staphylococcus saprophyticus (8 %), confirming the results of the 1995 and 2005 surveys. The susceptibility of E. coli remained nearly 100 % for nitrofurantoin and fosfomycin, decreased from nearly 100 % in 1995 to 94.2 % for quinolones, from 73.2 to 55.5 % for ampicillin, and from 83.3 to 76.3 % for trimethoprim-sulfamethoxazole (TMP-SMX). In E. coli present in positive urine cultures, ESBLs were found in 2.5 % and carbapenemases were absent. In fecal specimens, ESBL-producing E. coli were found in 7.9 % and carbapenemases were not detected. Over a 20-year period, the distribution of uropathogens in women with cystitis remained unchanged. Susceptibility remained excellent for nitrofurantoin and fosfomycin. For TMP-SMX, ampicillin, and quinolones, there was a decrease.

The resident microflora of voided midstream urine of healthy controls: standard versus expanded urine culture protocols.

The workup and interpretation of urine cultures is not always clear-cut, especially for midstream samples contaminated with commensals. Standard urine culture (SUC) protocols are designed in favor of growth of uropathogens at the expense of commensals. In selected clinical situations, however, it is essential to trace fastidious or new uropathogens by expanding the urine culture conditions (EUC). The aim of our study was to map the microflora in midstream urine specimens from healthy controls by means of EUC, in view of the interpretation of bacterial culture results in symptomatic patients. Midstream urine specimens from 101 healthy controls (86 females and 15 males) were examined using both SUC and EUC. Whilst 73 % of samples examined by SUC showed no growth at 103 colony-forming units (CFU)/mL, 91 % of samples examined by EUC grew bacterial species in large numbers (≥104 CFU/mL). Asymptomatic bacteriuria, as defined by the European guidelines for urinalysis, was detected in six samples with both protocols. EUC revealed 98 different species, mostly Lactobacillus, Staphylococcus, Streptococcus, and Corynebacterium. None of the samples grew Staphylococcus saprophyticus, Corynebacterium urealyticum, or Aerococcus urinae. Samples from females contained higher bacterial loads and showed higher bacterial diversity compared to males. Midstream urine of healthy controls contains large communities of living bacteria that comprise a resident microflora, only revealed by EUC. Hence, the use of EUC instead of SUC in a routine setting would result in more sensitive but less specific results, requiring critical interpretation. In our view, EUC should be reserved for limited indications.

Mutual perception of communication between general practitioners and hospital-based specialists.

BACKGROUND: Communication between general practitioners (GPs) and specialists is an important aspect of qualitative care. Efficient communication exchange is essential and key in guaranteeing continuity of care. Inefficient communication is related to several negative outcomes, including patient harm. This study aimed to investigate the perception of GPs and hospital-based specialists in Belgium of the quality of their mutual communication. METHODS: A cross-sectional study was conducted among GPs and specialists. Participants were asked to complete a validated questionnaire on several aspects of their mutual communication. RESULTS: Response rates of 17.9% (343/1.912) for GPs and 17.3% (392/2.263) for specialists were obtained. Both specialists and GPs qualify their mutual telephone accessibility as suboptimal. Specialists think poorly of the GP referral letter, in contrast to GP perception. Eighty per cent of the GPs feel that specialists address their questions appropriately; specialists have a similar perception of their own performance. According to 16.7% of the specialists, GPs not always follow their recommendations. Contrarily, GPs rate their compliance much higher (90.7%). Less than half of the GPs feel that the specialists' letter arrives on time, whereas specialists have a different and a more positive perception. CONCLUSIONS: GPs and specialists disagree on several aspects of their mutual communication. These include the perception of accessibility, in both directions, and of the timeliness of written communication. Feedback is positively appreciated, again in both directions. Nevertheless, specialists feel that uptake of their recommendations is insufficient. Hence, there may remain significant room for improvement, which could contribute significantly to continuity of care and patient safety.

A multidisciplinary network for the care of abnormal fatigue and chronic fatigue syndrome in the provinces of East and West Flanders in Belgium.

The organization of care for patients with the chronic fatigue syndrome (CFS) in tertiary care referral centres from 2002 onwards, was negatively evaluated by the Belgian Health Care Knowledge Centre on the endpoint of socio-professional reintegration. Subsequently, the federal health authorities asked for the elaboration of a new and innovative model of stepped care, aiming at improved integration of diagnosis and treatment into primary care and between levels of health care for patients with CFS. The reference centre of the University Hospital Ghent took the initiative of recruiting partners in the Belgian provinces of East and West Flanders to guarantee the care for patients with medically unexplained symptoms, in particular abnormal fatigue and CFS. A new and innovative care model, in which general practitioners play a central role, emphasizes the importance of early recognition of the patient 'at risk', correct diagnosis and timely referral. Early detection and intervention is essential in order to avoid or minimize illness progression towards chronicity, to safeguard opportunities for significant health improvement as well as to enhance successful socio-professional reintegration. This approach covers both the large sample of patients developing somatic complaints without obvious disease in an early phase as well as the more limited group of patients with chronic illness, including CFS. Cognitive behavioural therapy and graded exposure/exercise therapy are the evidence based main components of therapy in the latter. A biopsychosocial model underlies the proposed path of care.

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

Which bacteria are found in Belgian women with uncomplicated urinary tract infections in primary health care, and what is their susceptibility pattern anno 95-96?

Dysuria is a frequent reason for encounter in general practice and also gynaecologists and urologists will be frequently confronted with it. In female patients 1/2 to 2/3 of dysuric episodes are due to urinary tract infections. In nearly all cases therapy is started before the results of a culture is available. Therefore it is very important to know which bacteria are most prevalent in the treated population, and what their susceptibility pattern is . Because most available information is based on retrospective data issued from very mixed populations, we performed a prospective study including the most frequently involved population: symptomatic adult women without any symptom of complicated UTI. Among 279 urine specimens collected in general practices, 164 were positive (59%). The most frequent micro-organism found was E. coli (78%), followed by S. saprophyticus (9%) and Proteus spp. (4%). In the 15 remaining specimens, 8 different bacterial species were found. Overall resistance to ampicillin was 30%, to cotrimoxazole 14%, to nitrofurantoin 7%, to fluoroquinolones 1%. The E.coli resistance to ampicillin was 27%, to co-trimoxazole 17%, to nitrofurantoin 1% and to fluoroquinolones 1%. In this population the same bacteria, in the same proportion, are found as in earlier studies in other countries. The susceptibility pattern confirms a substantial resistance level to ampicillin and co-trimoxazole. On the contrary, resistance to nitrofurantoin and fluoroquinolones is negligible. Resistance data from Belgian regional laboratories in their outpatient population were significantly different from ours.