A valuable lesson in ‘less is more’ from a Dutch patient

A few weeks ago one of my patients, Eva, asked about the treatment of urinary tract infections. In the course of our conversation I mentioned that in Australia antibiotics are recommended.

Eva had symptoms of a bladder infection and was after a diagnosis, but preferred not to take antibiotics. She was Dutch and said that cystitis in the Netherlands is often initially managed without antibiotics.

We decided to look it up (it has been a while since I practised in my birth country) and I googled the website of the Dutch College of General Practitioners. I had a feeling Eva was correct, as it was Dutch research that concluded middle ear infections can often be treated without antibiotics. The Netherlands, Norway and Iceland also top the charts when it comes to lowest rates of resistance to antibiotics.

Since 1989 the Dutch GP College has developed about one hundred independent, evidence-based guidelines for conditions managed in primary care. It didn’t take long to find the guideline on urinary tract infections, published in 2013.

Indeed, the document stated (freely translated from Dutch):

“Cystitis in healthy, non-pregnant women can be self-limiting. Leaving cystitis untreated seldom leads to bacterial tissue invasion.

But what is the risk of complications, like a kidney infection, I wanted to know after reading the advice to Eva (who didn’t look surprised at all).

“Apparently it is not very high, doctor,” she answered.

In the endnotes of the guideline I found a reference to two studies, indicating that pyelonephritis in non-immunocompromised, healthy women is rare, with no statistically significant difference in the occurrence of pyelonephritis between antibiotic treatment groups (0 tot 0,15%) and placebo groups (0,4 tot 2,6%).

The document further contained instructions about what to discuss with patients:

“The GP discusses the option of watchful waiting (drinking plenty of fluids and painkillers if needed) and delayed prescribing. The patient can then decide to start antibiotics if symptoms persist or worsen.

Some evidence indicates that, without treatment, 25–42% of uncomplicated urinary tract infections in women resolve spontaneously.

Eva was right about the Dutch approach. In healthy people with uncomplicated infections the Dutch College of GPs recommends consideration of no antibiotics.

Are the Dutch unhappy about a health system that often advises against antibiotics? My patient certainly didn’t seem to be. She was relieved when we decided not to treat her urinary tract infection with antibiotics.

The answer appears to be no. For years the Netherlands has led the Euro Health Consumer Index, which measures patient satisfaction with healthcare systems in Europe – including outcomes, access to healthcare and medications.

On the Choosing Wisely Australia website I found one sentence on the topic: “The management of urinary tract infections (UTIs) is changing, although it can still include antibiotics.” Lack of systematically reviewed placebo randomised trials seems to be a key factor for Australia.

Eva’s urinary tract infection cleared up without antibiotics.

I recommend sensible use of local clinical practice guidelines and treatment recommendations. Always seek timely advice from your doctor regarding any medical condition you may have, including urinary tract infections. For privacy reasons the name and details of the patient have been altered.

6 thoughts on “A valuable lesson in ‘less is more’ from a Dutch patient

  • HI
    Edwin, nice blog. I’m from the Netherlands too and totally agree that these college guidelines are so good. They have helped me and patients so often and usually so well aligned to Australian GP too. Why there are only a couple translated in
    English ? Nobody knows.

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  • Australia should invest money in something like AGPS ( Australian General Practitioner Society), an equivalent to NHG.
    It would save money as the GP’s would change their prescribing habits and order less tests.

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    • Thanks Felix, hope all is well. I think Australia has several equivalents to the Dutch College (NHG) 🙂 but no GP led guidelines equivalent to the NHG Standaarden.

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  • A little bit North of Holland: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447293/ Am J Public Health. 2002 October; 92(10): 1609–1611. PMCID: PMC1447293 PMID: 12356607
    Acupuncture Treatment in the Prevention of Uncomplicated Recurrent Lower Urinary Tract Infections in Adult Women
    Terje Alraek, BAc, Liv Inger Fosli Soedal, Siri Urnes Fagerheim, Asbjørn Digranes, MD, and Anders Baerheim, MD, PhD
    It is only a large, statistically significant RCT, so you will ignore it and continue to prescribe analgesics, when you don’t prescribe antibiotics.
    And nobody will do a meta-analysis because there is no money in it.
    I can sense Semmelweis’ disseminated molecules doing some interesting “spins”.
    Until Australia trains about 20,000 medical acupuncturists ($176 million outlay, currently totally funded by the doctors concerned with no government or industry subsidy) and raises the MBS rebate for medical acupuncture to appropriate levels, to recognise the extra work done in the medical acupuncture consultation (about $4.70 differential to a Level B for the Part 1 level, mainly GP’s, and $14.70 differential to a Level B for Fellowship Level, mix of GP’s and Specialists) , the Australian public will be largely denied Level 1 and 2 evidence based treatment that will conservatively save $2.5 billion per year, based on the Kooreman and Baars study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3482459/, extrapolated to Australian conditions.
    COI I am the ex-President of the Australian Medical Acupuncture College. My patients, who are twice as sick as the national average for inner regional patients (according to BEACH), eg, about the same as a Remote area -(how many of your 3 month olds died of Salmonella?) tend to live, in their own homes, into their mid 90’s, unless malignancy, dementia, cardiovascular or cerebrovascular disease, or COPD pre-empt (+ the odd trauma, or suicide or infectious disease).

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