Comment on: urinary tract infections in general practice patients: diagnostic tests versus bacteriological culture.

OBJECTIVES Urinary tract infections (UTIs) are common bacterial infections encountered in general practice. For the optimal treatment the general practitioner (GP) should rely on the results of diagnostic tests and recent antimicrobial susceptibility of uropathogens. PATIENTS AND METHODS In total 1993 female patients (11-70 years) with complaints of an acute uncomplicated UTI were included. The performance characteristics of the diagnostic tests used were determined and compared with the antibiotic prescription rate. The antibiotic therapy (agent and duration), the uropathogens and the antibiotic susceptibility of Escherichia coli were determined for each age group. RESULTS The positive predictive value (PPV) (96%) and the specificity (94%) of the nitrite test were high for all samples. A negative nitrite with a positive leucocyte-esterase (LE) test showed a high PPV (79%) and sensitivity (82%). When both nitrite and LE tests were negative approximately 50% of the samples were culture positive. Of the patients, 94% of those with a positive nitrite test and 71% of those with a negative nitrite and positive LE test were prescribed antibiotics, mostly nitrofurantoin and trimethoprim. Nitrofurantoin prescriptions decreased and those of fluoroquinolones increased with increasing age. Nitrofurantoin was equally prescribed for 3-7 days in all patients. Trimethoprim was mostly prescribed for 3 days in patients aged 21-50 years and for 5 days in the other patients. E. coli, the uropathogen mostly isolated, decreased in frequency with increasing age. Proteus mirabilis was found more in the oldest patients and Staphylococcus saprophyticus in the younger patients. The antimicrobial susceptibility of E. coli was not age related. The lowest percentages were found for amoxicillin (67%) and trimethoprim (77%). Fluoroquinolone resistance was emerging in the older patients. CONCLUSIONS For female patients with symptoms of an acute uncomplicated UTI a positive nitrite test or a negative nitrite test with a positive LE test confirmed UTI whereas a negative nitrite together with a negative LE test did not rule out infection. For empirical treatment GPs should take into account the changing aetiology with increasing age. Prudent use of antibiotics in general and more specifically fluoroquinolones remains recommended. As trimethoprim resistance reached 20% it might be advisable to no longer use it as therapy of first choice for acute uncomplicated UTIs in The Netherlands.