Abstract
Background
In the Netherlands and Germany, most antibiotics are prescribed in primary care, with urinary tract infections (UTIs) being the most common reason. The resistance rates of pathogens causing UTIs are rising in Europe. Differences in clinical practice guidelines may play a role and influence the prevalence of antibiotic resistance and treatment options. Therefore, we aim to explore the reality of general practices, including the diagnosis and management of uncomplicated UTIs in the Northern Dutch–German cross-border region.
Methods
From January 2023 to April 2024, a qualitative study was performed using semi-structured interviews with German and Dutch general practitioners (GPs). The number of interviews was determined when data saturation was reached. The interviews were recorded, transcribed, translated and anonymised. MAXQDA (Version 24.1.0.) was utilised to code the interviews. The analysis was done using structured qualitative content analysis.
Results
We recruited 13 GPs in Germany and 10 GPs in the Netherlands. Four main themes were identified: diagnosis, treatment options, decision making and guidelines. Dutch GPs delegated most diagnosis and treatment tasks to practice assistants, which is facilitated by the more stringent use of guidelines. More variety was seen in the types of antibiotics and herbal remedies used by German GPs.
Conclusions
This study provides valuable insights into GPs’ decision making regarding the diagnosis and treatment of UTI. Increasing awareness of UTI diagnosis and treatment can help GPs assess their own practices and think more critically of their antibiotic use. Further research is needed to explore the effects on antibiotic resistance in the cross-border region.
Keywords: Uncomplicated urinary tract infection, antimicrobial resistance, primary care, guidelines, antibiotics, public health
KEY MESSAGES
Both German and Dutch GPs reported using dipsticks and medical history to diagnose UTI and using cultures in uncertain cases.
Dutch GPs perceived following guidelines more than German GPs and delegated diagnosis and treatment tasks to assistants.
German GPs reported more variety in antibiotics and herbal remedies.
Introduction
The global rise in antibiotic resistance (ABR) poses a significant threat to public health, diminishing the efficacy of common antibiotics against widespread bacterial infections. A high antibiotic consumption through overuse or misuse of antibiotics ultimately increases ABR [1]. In Germany and the Netherlands, most antibiotics are prescribed in primary care, with regional differences in antibiotic prescribing and consumption in the outpatient sector [2–4]. Antibiotic consumption in the primary care sector of the Netherlands was among the lowest in Europe (8.3 DDD/1,000 inhabitants/day), whereas in Germany, it was 10.0 DDD/1,000 inhabitants/day [5].
One of the most common indications for antibiotic prescriptions are urinary tract infection (UTIs). This can be explained by the high occurrence of UTIs, especially among women [6]. In the Netherlands, UTIs are the most reported reason to contact a general practitioner (GP). In 2021, 3.6% of all GP contacts by female patients were for UTIs [7]. In Germany, patients can choose to visit specialists; GPs treat the majority of UTIs, with urologists and gynaecologists also providing care [7]. According to health insurance data, incidence rates lie between 5.8% and 7.3% [7,8].
Non-antibiotic measures can be utilised to manage uncomplicated UTIs. While this approach can mitigate ABR, using antibiotics often considerably shortens the duration of symptoms [9]. Clinical practice guidelines for UTIs are similar for German and Dutch GPs, but differ slightly in their recommendations regarding antibiotic use (see Box 1) [10,11]. Both advocate for shared decision-making regarding treatment options, including antibiotics. Nevertheless, the rationale behind choosing an approach for managing UTIs may differ depending on several factors, such as the region where the GP works.
Box 1.
Key recommendations of Dutch and German clinical practice guidelines for primary care for healthy non-pregnant women with uncomplicated urinary tract infections (UTI)*.
| Netherlands1 | Germany2 | |
|---|---|---|
| Diagnosis | After taking medical history, dipsticks are always needed to confirm UTI diagnosis. | After taking medical history, UTI can be diagnosed based only on symptoms. In uncertain cases, dipstick can be used |
| Dipstick: A UTI can be confirmed if nitrite is positive. |
Dipstick: An uncertain case of UTI can be confirmed if: 1) nitrite and leucocytes are both positive,2) only nitrite is positive or only nitrite and haemoglobin are positive, 3) leucocytes and haemoglobin are positive. |
|
| If nitrite test is negative and leucocytes test is positive, then dipslide or urine sediment test can be used to confirm UTI. | If nitrite test is negative, bacterial culture with susceptibility testing and calculated therapy (targeted treatment after identification) but it is not generally recommended to do microbiological testing in the case of uncomplicated UTI. | |
| Physical examination: recommended in case of recurrent UTI or signs of tissue invasion e.g. fever. | Physical examination: recommended for patients with limited communication, patients with complicating factors or flank pain/fever. | |
| Treatment | In healthy, non-pregnant women with uncomplicated UTI who have not previously experienced pyelonephritis, guideline recommends to consider a wait-and-see policy. If necessary, analgesia can be recommended. Antibiotic treatment is recommended in all other patient groups and in the presence of signs of tissue invasion. Antibiotic prescription can be started empirically. |
Antibiotics are recommended to treat acute UTI after critically evaluating the necessity. Indication for antibiotic treatment in case of pyelonephritis. Non-antibiotic, symptomatic treatment can be considered in patients with mild/moderate symptoms. Antibiotic prescription can be started empirically. |
| Phytotherapeutic treatment could be considered as prophylaxis for recurrent UTI. | Phytotherapeutic treatment could be considered as prophylaxis for recurrent UTI. | |
| Participatory decision-making with patient is recommended. | Participatory decision-making with patient is necessary. | |
| Recommended antibiotic therapy3 |
|
Guideline recommends short-term therapy (duration of 1–3 days), if possible. First-line antibiotics5:
Not recommended as 1st choice for uncomplicated UTI in non-pregnant women: fluoroquinolones and cephalosporins. |
* At the time of data collection for this study (2023–2024).
1. Nederlands Huisartsen Genootschap-werkgroep (2020). NHG-Standaard Urineweginfecties (M05). Retrieved from https://richtlijnen.nhg.org/standaarden/urineweginfecties.
2. The German Society for General and Family Medicine (2018). Brennen beim Wasserlassen: S3-Leitlinie und Anwenderversion der S3-Leitlinie Harnwegsinfektionen. DEGAM-Leitlinie Nr. 1.
3. The doses and durations of antibiotics are underlined when there is a difference between the recommendations.
4. dd = daily dose.
5. The antibiotics are ranked in alphabetical order.
Since ABR cannot be contained within a country’s borders, it is important to conduct cross-country comparisons to learn from each other, adopt best practices and potentially improve patient care. In this study, a qualitative methodology is employed to comprehensively understand GPs’ preferences and opinions regarding diagnosing and treating women with uncomplicated UTIs in the Northern Dutch–German cross-border region. We aim to determine the underlying reasons for routine decisions made in practice and analyse how they are influenced by medical guidelines.
Methods
Study design
We conducted a qualitative study using semi-structured interviews with GPs.
Study participants
GPs from the cross-border Ems-Dollart region were recruited using convenience sampling through the networks of the divisions of general practice in the University of Oldenburg (UOL) and the University Medical Centre Groningen (UMCG) using email and subsequent snowball sampling. Unless otherwise specified, the term ‘GPs’ refers to both German and Dutch GPs.
During recruitment, the purposive sampling of GPs reflected different experience levels, genders, locations and sizes of the practices, and number of working hours.
Data collection and management
An interview guide (See Box 2 and Supplement 2) was developed based on the guideline recommendations on uncomplicated UTIs [10,11] and expert input from the research team. The interview guide was initially drafted in German and then translated into Dutch. Subsequently, the German interview guide was pilot tested with two GPs and wording was adjusted for clarity. Participants were allowed to freely disclose their experiences, thoughts, and feelings regarding their decisions on antibiotic prescriptions. The interview guide was structured into three key topics: diagnosis, treatment, and extent of prescribing antibiotics. We omitted questions regarding guidelines in the interview guide to reduce potential social desirability bias and to minimise the GPs’ perception of being evaluated.
Box 2.
Translated interview guide
Due to the time constraint of the GPs, 20- to 30-minute interviews were carried out via video conference, telephone or face-to-face (either at GPs’ practices or the University) between January 2023 and April 2024. Field notes were made after the interview.
Interviews were conducted in Dutch and German. The interviews were audio-recorded and transcribed verbatim. The transcripts were anonymised and stored in files accessible only to the coders, and translated into English; using DeepL for German and Open AI for Dutch interviews. Research team members reviewed translated transcripts for accuracy, before coding was done using MAXQDA Version 2022.0.0. Transcripts of the interviews were not returned to participants for comment or correction. Interviews were conducted until data saturation was reached, when no relevant additional insights were gained from subsequent interviews that were not already covered in prior interviews.
Data analysis
Interviews were analysed using structured qualitative content analysis according to the methodology described by Kuckartz and Rädiker [12], which began with reading transcripts and taking notes. The contents of the interviews were categorised into main codes deriving from the key topics covered in the interview guide. Sub-codes were then built inductively from the study material and main codes. Subsequently, the data were coded using both main and sub-codes.
The coding was done independently by two researchers (AB, VMJ). A consensus about discrepancies was reached after discussions among the coders. More information on the research team and reflexivity can be found in Supplement 1.
Ethics approval
The study was approved by the Medical Ethics Committee of both UOL (2022-070) and UMCG (2022/574). Informed consent was obtained according to existing regulations in the two countries; the German participants signed a written informed consent, while Dutch participants verbally consented to participation, which was recorded. The information presented to participants was identical in both countries. The data were anonymised and stored in files accessible only to the coders.
Results
The characteristics of the 23 GPs participating from Germany (n = 13) and the Netherlands (n = 10) are shown in Table 1. More German GPs were male and worked full time or more hours compared to Dutch GPs. Participating German GPs reported more work experience (median 19 years) compared to Dutch GPs (10.5 years). More information on the GPs’ characteristics can be found in Supplement 3.
Table 1.
Characteristics of the participants in the semi-structured interviews.
| Characteristic | German GPs (n = 13) | Dutch GPs (n = 10) |
|---|---|---|
| Gender, n | ||
| Male:Female | 8:5 | 3:7 |
| Completion year of GP Traininga, n (%) | ||
| 1980–1989 | 1 (8) | – |
| 1990–1999 | 2 (15) | 3 (30) |
| 2000–2009 | 7 (54) | 1 (10) |
| 2010–present | 3 (23) | 6 (60) |
| Number of years as a GP, n (%) | ||
| <10 years | 1 (8) | 5 (50) |
| 10–20 years | 6 (46) | 2 (20) |
| >20 years | 6 (46) | 3 (30) |
| Work hours per week, n (%) | ||
| <20 | – | 1 (10) |
| 20–30 | 2 (15) | 4 (40) |
| 31–40 | 7 (54) | 4 (40) |
| >40 | 4 (31) | 1 (10) |
| Number of GPs in practiceb,c, n (%) | ||
| 1 | 1 (8) | 2 (20) |
| 2–3 | 5 (38) | 5 (50) |
| ≥4 | 7 (54) | 2 (20) |
| Location of practiced, n (%) | ||
| City | 5 (38) | 6 (60) |
| Town | 4 (31) | 1 (10) |
| Village | 4 (31) | 3 (30) |
| Mode of conducting interviews, n (%) | ||
| Online | 4 (31) | 9 (90) |
| Telephone | 5 (38) | 1 (10) |
| Face-to-face | 4 (31) | – |
For physicians working in general practices without having a specific GP training (e.g. internists working as GPs), the year of their specialist examination was considered.
In cases where GPs worked at several practices, the practice where they worked the most amount of time was considered.
Includes postgraduate physicians training in the practice, does not include medical students.
For the German side, the description of the GP was used to classify the location of the practice. For the Dutch side, researchers classified the location.
We identified four main codes: (i) diagnosis, (ii) treatment options, (iii) decision-making, and (iv) guidelines. A total of 47 sub-codes were used (See Supplement 4).
Theme 1: Diagnosis
In the Netherlands, practice assistants were more involved in diagnosis, using standardised structured questionnaires, based on the Dutch guidelines, to assess patients’ medical history. Recognising if the patient has recurring symptoms and determining severity is an essential first step mentioned in both countries. German GPs usually stated that they had a face-to-face consultation with patients, whereas this task is delegated to assistants in the Netherlands, illustrated in the following quotes:
G11 (German GP): ‘The patients usually already report at the reception and say that they have problems with urination and pain, then the urine sample is usually automatically handed out, so to speak, and that is ‘dip-sticked’, and then she comes in to the consultation […].’
N4 (Dutch GP): ‘[…] that [diagnosis] is mainly taken care of by the assistants either via phone or a questionnaire available in the practice. Some patients who are already familiar with it fill out a questionnaire, a symptom checklist, deliver it to the assistants, and provide a urine sample. The assistants examine the urine with a stick. They inform the GP about the results.’
GPs from both countries reported that assistants analysed urine samples using dipsticks, specifically for nitrites, leucocytes and erythrocytes. Other parameters like protein and glucose usually played a peripheral role in ruling out other comorbidities. In unclear cases, the practices either sent urine samples to be cultured in a laboratory and/or utilised an additional test, a dipslide. GPs rarely mentioned performing microscopic analysis of the sediment in the practice. GPs stated recurrent symptoms typically lead them to send a culture to the laboratory to investigate the causes further or rule out resistance, as illustrated in the next quote:
G4: ‘So, tests, in that sense, is the rapid urine test, the test strip. If this test strip is positive and the woman has already had multiple UTIs in the past, or if there has been an accumulation of infections in the last 12 months, or if there are antibiotic intolerances, then the urine is subsequently sent in. […] We do not do further examinations, unless there are preventable dangerous indication[s].’
In the Netherlands, direct GP contact usually occurred when UTI severity was too great to be managed solely by the assistant. A physical examination would be conducted in case there was a consultation with the GP. In Germany, some GPs conducted physical examinations as part of the routine procedure, while others only did so if there were suspicions of a more serious illness.
N4: ‘Yes, if a patient comes to my office, always. If they come with lower abdominal complaints or with a fever or feeling unwell. But if it’s just a typical story of a UTI, I don’t see those patients in my office, except if they have recurrent UTIs. Then we have more questions about prophylaxis, what’s the cause? Is there an underlying issue?’
Theme 2: Treatment options
The main difference in treatment procedures reported is that the Dutch GPs usually delegated this task to practice assistants. Depending on the patient’s symptoms and the guidelines, the assistant would suggest treatment, including antibiotic prescription; the GP would then authorise it. Dutch GPs reported they were not directly involved in the process unless it was a complicated UTI.
N1: ‘And sometimes it’s clear that it’s uncomplicated, and then the assistants can also give prescriptions directly. And I approve it later.’
N9: ‘[…] the assistants already have a lot on their plate of course. Yes, and adding that is difficult. And what I also do is, if I see a patient who keeps coming back with multiple urinary tract infections per year. Then I say maybe it’s handy to come to my consultation hour.’
GPs on both sides emphasised the importance of patient education in preventing recurrence and alleviating symptoms, a role typically carried out by assistants in the Netherlands. German GPs were mostly actively involved in consulting and treating their patients. Two Dutch GPs additionally mentioned directing patients to the website ‘thuisarts.nl’ (the patient website of the Dutch College of GPs) as an important resource for patient information. Two German GPs mentioned that they did not always have consultations but delegated advising patients to assistants after inspecting diagnostic results on the practice computer system. Subsequently, assistants informed patients of the GP’s decision, gave and documented their advice.
The most frequently cited treatment options were (1) Wait-and-see approach, and (2) Antibiotics.
Wait-and-see
Six German GPs stated they first attempted to employ a wait-and-see approach if the likelihood of ascending UTI was low, with three of them preferring the use of naturopathic remedies over antibiotic prescriptions. Conversely, two Dutch GPs stated they preferred the wait-and-see approach, and three emphasised shared decision-making, guided by patients’ preferences after providing information on available options.
Reasons mentioned by GPs who suggested wait-and-see approach were: unclear diagnostics (e.g. UTI symptoms without positive dipstick results), short symptom duration, bridging time until the urine culture results are available and reducing side-effects and preventing resistance.
N6: ‘Do you know the joke about Dutch GPs, just wait two weeks and use paracetamol for this and that reason. And it’s really true. That’s also my introduction speech and then they also know what to expect from me.’
The wait-and-see approach is similar on both sides. While waiting, the GPs provided otherwise healthy young female patients with advice, including drinking a lot, using pain relief and reassuring patients that uncomplicated UTIs can resolve on their own.
German GPs indicated that patients can be dissatisfied with their care when they are told to wait and see, because the patient may have waited before coming to the practice. Occasionally, patients may present with predefined preferences and independently propose delaying treatment. Therefore, most German GPs indicated that they also recommend herbal remedies either by their own choice or at the patient’s request.
G8: ‘[…] If the symptoms are recent and do not recur […] a wait-and-see attitude is recommended with, if necessary, anti-inflammatory pain therapy or analgesia, so mostly ibuprofen, if the patients tolerate that, but paracetamol or aspirin […] if the patients are very eager for pills, then it can be that one gives them- or supportively we then also recommend herbal remedies […]drinking a lot, hot water bottle, hygiene measures[…]. ‘
Delayed antibiotic prescribing was mentioned as another way to reduce prescribing. Patients would be given the prescription and told to take it if symptoms worsen. Three German GPs cited delayed prescribing to prevent symptoms from worsening on upcoming weekends or holidays and to avoid emergency visits. Three Dutch GPs primarily used this approach as a way to encourage patients to wait and see, advising antibiotics only if symptoms worsened or remained the same, leaving the decision to the patient.
Antibiotic prescribing
On both sides, antibiotics were only prescribed if the dipstick or symptoms indicated a UTI.
N6: ‘[…] we try to be cautious about that. A few years ago, it used to be in the NHG [Nederlands Huisartsen Genootschap] standard that if a woman recognises the symptoms of a UTI, you could just give antibiotics. We try to move away from that, but because it used to be like that, many people with a UTI want antibiotics. They really want antibiotics, so it takes a lot of time and patience from the assistants and doctors to educate the population again.’
There was more variation in antibiotic choice among the German GPs, reporting fosfomycin, trimethoprim, pivmecillinam and nitrofurantoin, with trimethoprim, quinolones, or cotrimoxazole used in case of ABR or allergies as exceptions. Cefpodoxime was rarely mentioned, aside from one GP stating using it on elderly patients with diabetes. Some German GPs reported using nitrofurantoin as a reserve or for older patients (G6, G10). GPs reported their preference for an antibiotic depended on their own former education or expertise, and the patient’s age and recurrence of their symptoms. Some German GPs said they had an antibiotic they always preferred using, and others chose freely from the recommended antibiotics by the local resistance reports.
G11 : ‘There is actually a cooperation with the [laboratory] for the region here, [practice district], and they have a person sitting in there who works supra-regionally, also together with the Dutch and always analyses all these germ spectra, and there is a (…) booklet especially for [practice district] where we are recommended which antibiotics are the best right now, for which illness, UTIs are also listed. […]’
Most Dutch GPs reported using nitrofurantoin and fosfomycin in the Netherlands. Dutch GPs mentioned basing their choice of antibiotics on the NHG guideline. On both sides, most GPs remarked being inclined to prescribe single-dose antibiotics as it is easiest for patients to take. Patient recognition plays a role, if they said they had a bad reaction to a previous course, GPs mentioned that they would be reluctant to prescribe the antibiotic again.
N4: ‘[…] we really follow the guidelines in that regard. Sometimes, the patient has a partial say in it. […]’
Some GPs on both sides found it easier for the practice and the patient to give antibiotics instead of the wait-and-see approach because the patient would not return to the practice again. Another advantage mentioned was quick alleviation of suffering and preventing complications of ascending UTI. Disadvantages mentioned were side effects such as damaging intestinal and/or vaginal flora, allergies and developing resistance to antibiotics. One GP also stated that patients will often expect antibiotics if they receive them for minor complaints.
German GPs reported using the patients’ level of suffering as an important indication for prescribing antibiotics. Usually, they were inclined to prescribe antibiotics as it provides quicker relief for the patient.
Other types of treatment
Most Dutch GPs recommended cranberry pills instead of juice to prevent recurrent UTI. Some have also suggested D-mannose as a supportive supplement, with one GP mentioning vitamin C.
N9: ‘Yes, cranberry, yes. That’s mentioned in the guideline, but it’s a bit faded out. But cranberry plus D-mannose. But what’s difficult is that many people say oh, I’ll buy cranberry juice.[…] I never recommend juice, I recommend tablets, cranberry, plus D-mannose. And it’s also for people who keep coming back every time.’
In contrast, there were a variety of other herbal and naturopathic remedies mentioned by German GPs compared to Dutch GPs. German GPs recommended D-mannose and cranberries but also included herbal teas and remedies. The remedies mentioned included goldenrod, bearberry leaf, etc., with one German GP mentioning using homeopathic and anthroposophical treatment remedies.
G4: ‘However, if the urine results are more harmless, I always try to treat them with herbal remedies, meaning they are recommended to drink a lot, take painkillers and an herbal remedy. Then we take a preparation, the Canephron Uno, which is also antibiotically effective and also well tested against antibiotics […]. Otherwise we recommend Solidago, goldenrod, and of course a recurrence prophylaxis, which means the recommendation to work with cranberries […]’
G5: ‘Once the UTI is diagnosed, then, and depending on what is in the urine sediment, […] I treat it with Cystinol, an herbal therapeutic.’
Some German GPs only offered herbal remedies if the patient specifically requested it.
G9: ‘[…] either with ibuprofen, just painkillers and drinking enough. There are also herbal preparations, Canephron, right? So some patients who don’t like to take antibiotics or something like that, who say ‘I’d like something herbal’, then there are also attempts to offer them something like that.’
Theme 3: Decision making
Diagnosis and treatment decisions were influenced by a dynamic interplay of patient-, GP-, and practice-related factors (Supplement 5). Patients’ symptom profiles signalled infection severity, while demographic characteristics (e.g. age, cultural background), health literacy, and prior antibiotic experiences shaped treatment expectations.
G8: ‘[…] With the older patients, it’s rather a little bit more effort for the practice maybe[…]’
GPs on both sides reported that familiarity with long-term patients enabled more efficient decision-making.
N1: ‘[…] After 25 years, you know the patient, and occasionally you make a mistake, but generally not. […]’
Clinician preferences, prior education, and experience – particularly in interpreting guidelines – guided therapeutic approaches. Meanwhile, practice-level constraints, including time pressure, cost of diagnostics, and logistical convenience, influenced whether tests were conducted or antibiotics were prescribed.
N2: ‘[…] a culture is expensive and that sometimes holds me back from doing it. […]’
G1: ‘Well, from the perspective of the therapist, of course it’s easier, the moment I give the antibiotic. […]’
Theme 4: Guidelines
Dutch GPs were specifically asked which guideline they utilised and only the NHG guideline was mentioned. Deviations from the guideline were perceived as rare and only occurred in exceptional cases depending on the situation of the patient.
N3: ‘[…] there are more things in the [guideline] that I’m not happy with. I actually never see good results from an old man with […] UTI who only gets nitrofurantoin. […]’
German GPs often relied on their experience and were not explicitly asked about the type of guideline they used but they mentioned implementing them; some specifically mentioned the guideline for GPs while others relied more on the local resistance reports.
G6: ‘We always get information here from health offices […], for example […] from the Lower Saxony State Health Office […] how the resistance situation is right now, as far as certain bacterial diseases are concerned […]’
G4: ‘[…]We try to consider the resistance situation in [district], which the laboratories send us every year, and select the narrowest possible antibiotic with a low resistance rate […].’
G8: ‘[…] I wasn’t aware of that, that in our guideline the dipstick is not in there […]. I think, would guess that every family doctor here does a dipstick. […] Actually, from my point of view, it is a really a part of it […]’
Discussion
This study explored GPs’ diagnosis and treatment decisions in the Northern Dutch–German cross-border region. Our findings indicate that both German and Dutch GPs diagnosed UTI based on the patient’s medical history and a positive dipstick result. In case of unclear symptoms and/or inconclusive dipstick results, some GPs advised patients to await urine culture results before initiating treatment. Dutch GPs reported delegating most diagnosis and treatment tasks of UTI to practice assistants, who utilised the NHG guidelines. Treatment decisions were more varied on the German side, with more types of antibiotics and herbal remedies mentioned. Most GPs in both countries remarked they tended to prescribe antibiotics due to the ease of treatment and preventing ascending UTI.
We found that Dutch GPs perceived a closer adherence to national guidelines for UTI management compared to their German counterparts, consistent with previous research [13–15]. Several reasons may explain the differences in guideline adherence, such as the varying role of guidelines and health systems in each country. It is also possible that this may be due to the interviewed German GPs having more work experience. Evidence-based medical education was established around 20 years ago and younger GPs may have had more exposure to guideline utilisation during their education. Older GPs may prefer using their experience more than guidelines compared to younger GPs [16,17]. Another reason can be further mandatory professional training and recertification of Dutch GPs every five years, where they are updated on latest developments, including guidelines. This process does not exist in Germany. Dutch GPs also register patient data in IT systems with integrated guideline recommendations.
Working closely to guidelines can facilitate the delegation of responsibilities to assistants. The role of the assistants differs due to variations in educational backgrounds and their respective health care systems. In Germany, ‘medizinische Fachangestellte’ are skilled medical workers who assist practices in organisational tasks as well as diagnostic and therapeutic procedures, including laboratory work and vaccinations. Delegation of tasks to non-GP personnel is more strictly regulated in Germany, with certain tasks performed only under physician supervision [18]. In the Netherlands, ‘doktersassistenten’ are well-trained personnel with increased independence who can handle more delegated tasks according to various guidelines and protocols [19]. They are allowed to be more involved in treatment and counselling in practices, including suggesting antibiotic prescriptions, for patients with more common conditions [20]. Although this saves time and increases efficiency, due to less direct patient contact in the Netherlands, shared decision making may not take place as often, as the physician assistants may not be as highly trained in this area compared to GPs [21].
Another finding was that German GPs cited a greater variety of antibiotics compared to their Dutch counterparts, a pattern also reflected in the national guidelines for GPs and national ABR. At the time of the study, the German guideline recommended five antibiotics for UTI: fosfomycin, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim, with the latter included based on local resistance pattern [10]. In contrast, the Dutch guideline provided a ranked list, with nitrofurantoin as the first-line choice, followed by fosfomycin and trimethoprim [11]. A nationwide German study in general practices, excluding North-western Germany, found 14.5% of uropathogens were resistant to trimethoprim, with other first-line antibiotics below 10% resistance [22]. Similarly, resistance levels for E. coli isolated from uncomplicated UTI in the Dutch outpatient practices were around 21% for trimethoprim and 2% for both nitrofurantoin and fosfomycin [4]. Impact on ABR in this cross-border region is not yet known and needs to be further researched.
We also found that German GPs prescribed more herbal remedies. The use of natural remedies can help increase the patients’ acceptance of delaying antibiotics [22]. Studies show that more than half of general practitioners in Germany incorporate naturopathy or alternative therapies into their practice [23,24]. This can be attributed to a high demand in Germany, which can also increase the economic competitiveness of a practice. Complementary and integrative medicine is also incorporated into the German undergraduate medical curriculum, with GPs being able to have additional postgraduate qualifications in naturopathy [25]. Alternative medicine is not part of Dutch GPs’ education and is rarely practised.
Several factors influenced decision-making. Empiric treatment of UTI was often initiated after diagnosis based on patients’ symptoms and dipstick results, which is in line with findings in Ireland, Sweden and the US [26–28] and the European guideline [29]. Patients with severe symptoms are more likely to request antibiotics, and GPs may prioritise patient satisfaction over evidence-based guidelines, as supported by international literature [22,27]. Having a consistent, easily accessible guideline can help decrease unnecessary prescribing [27]. GPs who were hesitant to prescribe antibiotics often gave pain medication or herbal prescriptions to increase patient satisfaction and reduce the burden. Good communication between patients and physicians is essential for improving antibiotic use, but it requires additional time and resources [30].
The strength of our qualitative approach is that it enables an in-depth exploration of the reasons for decision-making. Data saturation was achieved at both sides of the border. GPs interviewed were from a cross-border region, which provides novel insights into the impact of different national health systems on healthcare decision-making.
A notable limitation is social desirability bias. Some GPs may have reviewed clinical guidelines to refresh their knowledge before the interview. Certain German GPs were aware of the guidelines because they attended a presentation related to the project. We recruited GPs through the university networks and their colleagues, which may not ensure a representative sample. Expanding the study scope by additionally interviewing patients and/or practice assistants would increase the diversity of perspectives and improve validity. Our study focussed on non-recurrent UTI, as such, future research can expand to investigate recurrent UTI.
The implementation of a cross-border healthcare collaboration model between GPs and health offices can facilitate the exchange of knowledge and expertise. GPs can better identify the strengths and weaknesses of their own practices by increasing awareness of how UTIs are diagnosed and treated in the neighbouring country, encouraging more critical reflection, and potentially contributing to improving patient care. Taking time for consultations is a necessary aspect to improving antibiotic stewardship, which can also be conducted with physician assistants to reduce the time constraints in the practice. Our findings underscore the need for further quantitative research to investigate the application of UTI clinical guidelines. Future research should focus on investigating the prevalence of ABR in UTI in this cross-border region to inform public health policy and practice.
Conclusion
This study highlighted differences in the diagnosis and management of UTI within primary care settings in the Northern Dutch–German cross-border region. Specifically, Dutch GPs delegated more responsibilities to their practice assistants, while German GPs demonstrated a greater tendency to prescribe a wider variety of antibiotics and herbal remedies.
Supplementary Material
Acknowledgements
We thank all GPs who participated in the interviews. This study was conducted in partnership with the Cross-Border Institute of Healthcare System and Prevention (CBI), a joint initiative of the Carl von Ossietzky University of Oldenburg, University of Groningen and University Medical Centre Groningen (UMCG). We want to acknowledge the cooperation and support within the CHARE-GD subgroup.
Funding Statement
This project was funded by the Ministry of Science and Culture of Lower Saxony (MWK) as part of the ‘Niedersächsisches Vorab’ Program. (Grant Agreement No. ZN3730).
Disclosure statement
No potential conflict of interest was reported by the authors.
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