Dutch Working Party on Antibiotic Policy

Stichting Werkgroep Antibiotica Beleid (SWAB)

Guideline: Antimicrobial treatment of complicated urinary tract infections

Suzanne Geerlings, MD PhD

Dutch Working Party on Antibiotic Policy: Surveillance system

• Use of antimicrobial agents

• Resistance patterns of medically important bacteria

• Collection of resistance data from 15 laboratories for Medical Microbiology: GPs and hospitals

• All parts of the Netherlands

• These data represent 30% of Dutch population

• Most recent resistance percentages are used for guidelines etc.

Escherichia coli - Community

-10

10

30

50

1988 1992 1997 2000 2001 2003/2004

Res

ista

nce

(%)

amox icillin co-amox iclav trimethoprim

nitrofurantoin norflox acin co-trimox azole

0

10

20

30

40

50

Res

ista

nce

(%)

amox icillin co-

amox iclav

trimethoprim co-

trimox azole

nitrofurantoinnorflox acin

Escherichia coli - Community

East West South Total

Dutch Working Party on Antibiotic Policy: Guidelines

• To develop evidence-based guidelines for the use of antimicrobial agents in (hospitalized) adult patients for common infections

• Most recent Dutch resistance percentages of causative microorganisms are used

• Optimalisation antimicrobial treatment procedures to lower the costs and to limit and prevent resistance development

• Final purpose: Contribution to proper care of patients in the Netherlands

• Financial support by Ministry of Health, Welfare and Sport

Problems with guideline development

• Several parties are developing guidelines

• No uniform recommendations

• Increasing quality demands

SWAB-UTI guideline: Authors from all professions

• Suzanne Geerlings, infectious disease specialist (Dutch Working Party on Antibiotic Policy)

• Peter Hans van den Broek, infectious disease specialist (Netherlands Society for Infectious Diseases)

• Ernst van Haarst, urologist (Netherlands Society for Urology)• Louis-Jean Vleming, nephrologist (Dutch Federation Nephrologists) • Karin van Haaren, general practitioner (Dutch College of General

Practitioners)• Rob Janknegt, hospital pharmacist (Netherlands Society of Hospital

Pharmacists) • G-J Platenkamp, medical microbiologist (Netherlands Society for

Medical Microbiologiy) • JM Prins, infectious disease specialist (Dutch Working Party on

Antibiotic Policy)

Collaboration with other Dutch UTI guidelines

• Earlier (1999) National guideline UTI: Peter Hans van den Broek (main author)

• Guideline UTI GPs (2005): Karin van Haaren and Suzanne Geerlings members working group, also SWAB resistance data used for nonhospitalized patients

• Guideline UTI Urologists (2006/07): Ernst van Haarst main author and Suzanne Geerlings member working group

Scope and purpose guideline UTI

• Empirical antibiotic treatment (before culture results)

• Hospitalized adult patient (> 12 years)• With a complicated UTI • Choice of treatment based on recent Dutch

resistance percentages of uropathogens • Collaboration with (development of) guidelines

GPs, gynaecologists and urologists

Definitions

• Uncomplicated UTI: cystitis nonpregnant woman, non-immunocompromised, without anatomical or functional abnormalities urinary tract, without signs tissue invasion or systemic infection

• All UTIs which are uncomplicated are considered complicated UTIs

• Therefore, pyelonephritis/urosepsis are complicated UTIs

Following patient catagories are discussed separately

• General part: UTIs with systemic symptoms • Men • Pregnant women • Patients with a urinary catheter• Patients with urine retention (neurological or

obstructive cause) • Patients with diabetes mellitus • Patients with renal diseases: congenital

polycystic kidney disease and pyocystis

Not were discussed

• How to diagnose a UTI

• Childeren

• (Peri-operative) prophylaxis

• Epididymitis, orchitis

• Genital Infections, as Sexual Transmitted Diseases

Writing the guideline

• Systematic methods to search evidence

• Link between recommendations and supporting evidence

• External review by experts before publication (internet access for all members of professional societies of all target users)

www.swabeditline.nl

How to start: scope and purpose

• Formation of working group with representatives from all professional societies

• To formulate who are the target users• To formulate which patient categories have to be

discussed, but also which patient categories have NOT to be discussed

• To formulate the purpose: - Contribution to proper care of patients or - also optimalisation antimicrobial treatment procedures to lower the costs and to limit and prevent the resistance development?

Check AGREE before you start

Next steps• To review existing national and international

UTI guidelines (EAU 2006, SWAB 2006)• To analyze the resistance patterns of

uropathogens in this country• To decide whether these other guidelines

can be adapt to the local situation• To decide which additional steps have to be

done (literature search, writing, etc.)• To divide the work