Doubts and Questions Remain

It is vitally necessary, as well as commendable, to observe the development of resistance patterns in uncomplicated urinary tract infections and to develop recommendations and treatment strategies on that basis. The publication of the S3 guideline, however, still leaves doubts and questions. A key message of this guideline is the classification of three antibiotic substances as first-line treatments for uncomplicated cystitis: fosfomycin trometamol, nitrofurantoin, and pivmecillinam.

Fosfomycin trometamol is currently available commercially only in the form of one preparation. This preparation is licensed only for women in a restricted age range. If this preparation were to be prescribed to a 67-year-old woman, for example, this would constitute off-label use. This would mean that the treating physician is at risk of penalties from the health insurers. The guidelines do not include a warning in this respect.

The two other preparations do not offer an alternative.

How can a guideline for first-line treatment recommend a substance whose use should be restricted, according to product information? Nitrofurantoin must be given only if more effective and lower-risk antibiotics cannot be used. In my experience, resistance in longer-term therapy or after multiple administrations is clearly above 20%. In my opinion, this rules out nitrofurantoin too.

Pivmecillinam is the third recommended option, but this preparation is not available in Germany.

Some of the guideline’s recommendations are thus not practical. The lack of guideline implementation in routine clinical practice has been the subject of much criticism. Perhaps better implementation would be possible if, when developing guidelines, attention is given to whether these are applicable for basic care such as is provided by general practices.

DOI: 10.3238/arztebl.2012.0079a

Dr. med. Joachim Liebendörfer

Ostelsheim

Liebendoerfer.Ostelsheim@t-online.de

Conflict of interest statement
Dr Liebendörfer holds shares in Sanofi-Aventis and GSK.