Correspondence (letter to the editor): The Reality of Healthcare in Germany Was Partially Ignored

I welcome guidelines based on high-level evidence. However, this article seems to me to be problematic in parts. The German recommendations ultimately reflect part of the current guideline from the European Association of Urology (EAU), “Urological Infections” (www.uroweb.org). The German recommendations for empirical treatment of uncomplicated cystitis replicate this guideline without modifications, which results in substantial compatibility problems within Germany’s healthcare services.

In addition to fosfomycin trometamol, the substances recommended as first-line treatments are nitrofurantoin and pivmecillinam. In Germany nitrofurantoin is indicated only in cases in which other antibiotics or chemotherapeutic drugs that are more effective or with a lower risk-profile, cannot be used (Rote Liste [Germany’s national formulary] 2011). The risk of severe pulmonary complications is probably rather low—in the Anglo-American healthcare systems, the risk seems to be estimated less seriously than in Germany. Still, it is amazing that the substance ranges among the “top 3” recommendations.

The recommendation for pivmecillinam is entirely unreasonable as this substance is not available in Germany.

There was obviously disagreement regarding the recommendation of cotrimoxazole/trimethoprim. This recommendation, in a setting where local resistance patterns are known, is also part of the EAU guideline, but it seems that in Germany, general practitioners had to ensureits inclusion into the guideline. Was a consensus not possible? The substances are mostly well tolerated and not expensive, and if the clinical symptoms do not improve after initial treatment, patients could still be switched to a different substance. Some 75% of cases of cystitis due to E coli would be “caught” by using cotrimoxazole/trimethoprim, and it is likely that a proportion of the cystitis cases due to E coli strains with resistance to cotrimoxazole would be self limiting, with a spontaneous cure rate of 30–50%. In spite of these problems I wish to thank the authors for setting out their guideline. They have prompted me to think/read up on a subject in more detail, which will certainly influence my routine prescribing behavior.