The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1

Objectives: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Materials and Methods: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, ­EMBASE, and the Cochrane Library to identify literature published in 2010–2015. Results: We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed. Conclusion: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention

Background: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. Materials and Methods: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010–2015. Results: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. Conclusion: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients

Klimasensible Verordnung von Inhalativa

The health care system is responsible for about 5 % of carbon dioxide (CO2) emis- sions. The biggest contributor to the carbon footprint caused by ambulatory primary care is the prescription of medications, followed by emissions from transportation (of patients and staff) and heating. Medication for chronic obstructive airway diseases (inhalers) is of special importance regarding the carbon footprint of the health care sector. The extent to which these inhalers contribute to climate changes varies depending on their method of functioning. The two main categories of inhalers are dry powder inhalers and metered-dose inhalers. Dry powder inhalers (DPIs) contain an active substance in powder form. The active ingre- dient is released and distributed by inhalation, requiring a sufficiently strong inhale to ensure effective therapy. In contrast, metered dose inhalers (MDIs) use propellants to transport the active substance into the deep sections of the lungs. The chlorofluorocarbons (CFCs) that were used as propellants for MDIs in the past have been largely banned due to their impact on the ozone layer and have been replaced by hydrofluoroalkanes (fluranes). While these do not damage the ozone layer, they are pow - erful greenhouse gases. Compared with DPIs, MDIs therefore have more potential to damage the atmosphere (global warming potential - GWP). This guideline aims to support a shift in prescribing patterns of inhalers to reduce the carbon footprint of the health care system. It addresses those involved in prescribing inhalers and counselling patients with asthma/COPD. This includes doctors and their practice teams as well as pharmacists and other health professionals. The guideline supports climate-conscious prescription of inhalers by n summarising existing evidence on the decision between DPIs and MDIs and explicitly addressing the climate damage caused by propellants.n/a11

Decision aid for patients

Die REGATTA Studie untersuchte die Wirksamkeit des pflanzlichen Mittels Bärentraubenblätterextrakt im Vergleich mit dem Antibiotikum Fosfomycin bei Frauen mit einem unkomplizierten Harnwegsinfekt. In diesem Flyer stellen wir Ihnen die wesentlichen Ergebnisse der Studie zusammenfassend dar.1

Versorgung älterer Patienten durch Gemeindenotfallsanitäter

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 G‑NFS 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 G‑NFS were counselling (79.4%), aid in self-medication (16.7%) and administration of medication (23.2%). Of the G‑NFS 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 G‑NFS enabled the majority of patients to be treated on-site, thus saving resources of emergency services and hospitals; however, the G‑NFS 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

Manual therapy applied by general practitioners for nonspecific low back pain: results of the ManRück pilot-study

Abstract Background Nonspecific acute low back pain (LBP) is a common reason for accessing primary care. German guidelines recommend non-steroidal anti-inflammatory drugs and physical activity as evidence-based treatments. Manual Therapy (MT) remains controversial. To increase evidence-based treatment options for general practitioners (GPs), a Pilot-Study was set up to gather information about the required conditions and setting for an RCT. Methods The open pilot-study assesses recruitment methods for GPs and patients, timelines, data collection and outcomes of treatment immediately (T0) and 1, 6 and 12 weeks after consultation (T1, T2, T3). Inclusion criteria for GPs were: no experience of MT; for patients: adults between 18 and 50 suffering from LBP for less than 14 days. Study process: Patients’ control-group (CG) was consecutively recruited first and received standard care. After GPs received a single training session in MT lasting two and a half hours, they consecutively recruited patients with LBP to the intervention group (IG). These patients received add-on MT. Primary outcomes: (A): timelines and recruitment success, (B): assessment tools and sample size evaluation, (C) clinical findings: pain intensity change from baseline to day 3 and time till (a) analgesic use stopped and (b) 2-point pain reduction on an 11-point scale occurred. Secondary outcomes: functional capacity, referral rate, use of other therapies, sick leave, patient satisfaction. Results 14 GPs participated, recruiting 42 patients for the CG and 45 for the IG; 49% (56%) of patients were women. Average baseline pain was 5.98 points, SD: ±2.3 (5.98, SD ±1.8). For an RCT an extended timeline and enhanced recruitment procedures are required. The assessment tools seem appropriate and provided relevant findings: additional MT led to faster pain reduction. IG showed reduced analgesic use and reduced pain at T1 and improved functional capacity by T2. Conclusions Before verifying the encouraging findings that additional MT may lead to faster pain reduction and reduced analgesic use via an RCT, the setting, patients’ structure, and inclusion criteria should be considered more closely. Trial registration Number: DRKS00003240 Registry: German Clinical Trials Registry (DRKS) URL: https://www.drks.de/drks_web/. Registration date: 14.11.2011. First patient: March 2012. Funding: the Rut and Klaus Bahlsen Stiftung, Hannover

Resistance profiles of urinary tract infections in general practice - an observational study

Abstract Background 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. Methods 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. Results 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. Conclusions 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.</p

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 responsibility in the climate crisis-the investment strategies of German Doctors’ pension funds: a conflict between ethics and monetisation

Energy production from fossil resources is a major contributor to the anthropogenic climate crisis. Many international medical organisations have therefore called for divestment, i.e., the withdrawal of capital from these industries. The capital investments of the physicians’ pension funds in Germany amount to approximately 110 billion euros. Due to a lack of transparency, it is unclear to what extent environmental, social and governance criteria are applied to the allocation of investments. To protect human health, the climate impact of investments must be measured regularly and quantitatively (climate impact analysis). In addition, climate-related risks with respect to the returns on investment should be considered (climate risk analysis), when entire industrial sectors have to be re-organised. To ecologically and economically track the pathway to a zero-emission-portfolio, the outcome must be transparent for both the members and the public. This article summarises controversial issues discussed in this context with a focus on the situation and recent developments in Germany