Optimalisation of the antibiotic policy in The Netherlands. XI. The national electronic antibiotic guide'SWAB-ID' for use in hospitals

The 'Stichting Werkgroep Antibioticabeleid' (Dutch Working Party on Antibiotic Policy) has developed an electronic national antibiotic guide for the antibiotic treatment and prophylaxis of common infectious diseases in hospitals. This guide also contains information on the most important characteristics of antimicrobial drugs. Advice on antibiotic treatment is based on existing national evidence-based guidelines, where available. Where no guideline is available, the advice is based on an inventory of the antibiotic policies of the 12 Dutch centres with an infectious disease or medical microbiology training programme. The national antibiotic guide can be accessed through the SWAB website (www.swab.nl) and can also be downloaded on PDA/PocketPC, free of charge. Every hospital antibiotic formulary committee in the Netherlands will be offered the opportunity to edit The national version for local use.     

The practice guideline 'Allergic and non-allergic rhinitis' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The Dutch guideline 'Allergic and nonallergic rhinitis' of the Dutch College of General Practitioners has been revised. The use of intranasal corticosteroids (INCS) is now advocated in cases with persistent complaints and there is more evidence to prescribe intranasal antihistamines for intermittent allergic rhinitis. The effect of dust-proof bedding covers is questioned and only advocated in persons showing both allergic rhinitis and asthma. Attention is given to the relationship between allergic rhinitis and asthma. Although the efficacy of INCS on asthma outcome has not been assessed, the guideline suggests that INCS could improve asthma symptoms and perhaps could diminish the dose of inhalation corticosteroids for persons with concomitant asthma.     

Summary of the practice guideline 'Atopic dermatitis' (first revision) from the Dutch College of General Practitioners

The 1996 practice guideline on atopic dermatitis from the Dutch College of General Practitioners has been updated. For diagnosing atopic dermatitis, the use of Williams' criteria is recommended. Testing for food allergy is only useful in case of children under the age of 2 who have other food-related allergic complaints together with dermatitis. In the treatment of atopic dermatitis, keeping the skin in good condition with emollients is essential; furthermore, topical corticosteroids are the therapy of first choice. In case of a severe exacerbation of atopic dermatitis, starting with a class 3 corticosteroid is preferred. In case of frequent recurrences, 'pulse-therapy' is indicated: topical corticosteroids on 2-4 consecutive days per week as maintenance therapy. The role of preparations from tar is marginal. The use of the topical immunomodulators tacrolimus and pimecrolimus in general practice is discouraged.     

Guideline 'Precautionary measures for contrast media containing iodine'

Annually, 0.5-1 million injections of contrast media containing iodine are administered in the Netherlands. Almost all contrast media nowadays are low-osmolar and nonionic. Nevertheless, the development ofcontrast-induced nephropathy is still a relevant clinical problem. Through an initiative by the Radiological Society of the Netherlands and with aid of the Dutch Institute for Healthcare Improvement (CBO), a guideline was conceived for the intravascular use of iodine-containing contrast media, based on recent scientific literature. The guideline defines the risk factors for contrast-induced nephropathy. One of the major risk factors is an impaired renal function. It is important to measure the glomerular filtration rate (GFR) in patients with a possible impaired kidney function, preferably by using the 'Modification of diet in renal disease' (MDRD)-study formula. The key measures for avoidance of contrast nephropathy are: limiting the amount of contrast agent used and to assure good hydration, by infusion of sodium chloride 0.9% 12-16 ml/kg body weight, both prior to and after contrast infusion. If time is limited, intravenous administration of sodium bicarbonate is an option. The guideline recommends discontinuation of metformin use from the day of contrast injection, if the GFR < 60 ml/min/1.73 m2, and to restart metformin 2 days following contrast infusion providing the GFR has not significantly deteriorated. Only in the case of previous moderate or severe adverse reactions to contrast media, prophylaxis with corticosteroids and antihistamines is recommended. Iodine allergy or an atopic condition is not a contraindication for the use of iodine-containing contrast media, and no prophylaxis is required. No specific measures are indicated in case of hyperthyroidism, acute pancreatitis, or phaeochromocytoma. Injection of contrast media is not contraindicated in case of pregnancy or lactation.     

Weight and weight gain at 4 months (The Netherlands 1998): influences of nutritional practices,socio-economic and ethnic factors

We describe the determinants of weight gain in the first 4 months of life in a cohort of 3256 infants. The study was designed as a survey with follow-up. In the period 1 April to 1 July 1998, all infants, usually 4 weeks old but not older than 4 months, brought to a well-baby clinic for the first time were included. Nutritional practices, demographic data on mother and child, birthweight and a second weight measured between days 118 and 147 were recorded. Simple and multiple linear regression analyses were performed. The average weight gain over 4 months was 27.7 g/day for boys and 24.5 g/day for girls. Weight gain was lower with high parity and if the mother was a native Dutch speaker. Nutritional practices affected weight gain only slightly: exclusive breast feeding for 4 months lowered the weight gain by 0.06 g/day. However, because of their higher birthweight, breast-fed infants weighed a little more than formula-fed infants at 4 months. In addition, we compared the median weight at the age of 4 months with the median weight at the same age in previous Dutch growth studies. The median weight, adjusted to day 133, was higher in 1998 than in 1965, 1980 and 1997 (boys 7.15 vs. 6.85, 6.77 and 6.95 kg; girls 6.59 vs. 6.49, 6.39 and 6.45 kg respectively).     

Treatment of overweight and obesity in adults: proposal for a guideline

Overweight and obesity are rapidly increasing health problems, leading to considerable co-morbidity and increased mortality. In this article a Dutch guideline is proposed for the management of overweight and obesity, which in part is based on North American and European treatment proposals. After having assessed the degree of overweight and associated health risks, based on medical history, physical examination and laboratory investigations, a decision to start treatment can be made. First, consensus with regard to treatment goals has to be reached between doctor and patient, who has to be motivated to change his or her lifestyle. A modest (5-15% of pre-treatment weight) weight loss, which has to be sustained in the long term, is a desirable, realistic and achievable treatment goal for the majority of patients. Dietary management, an increased level of physical activity and behavioural advice are the most important basic treatment options in obesity. This advice is best provided as a multidisciplinary approach. In selected patients pharmacotherapy and in severe obesity bariatric surgery can be a useful addition to basic obesity management.     

The new CBO-guideline 'Osteoporosis' is a broadly supported standard for clinical practice

The Dutch Institute for Health Care Improvement (CBO) has published new (revised) guidelines for the screening and case-finding of osteoporosis and for its prevention and treatment. During the last few years, two other guidelines have been published by the Dutch College of General Practitioners and the Dutch Health Council, respectively. The CBO guideline would seem to reflect the current views on clinical practice the best and is supported by all the relevant medical specialist communities. Screening of the general population is discouraged, whilst case-finding is recommended with selected patients. Compared to the 1999 standard of the Dutch College of General Practitioners, this new consensus offers more possibilities for the preventive treatment of patients with possible osteoporosis and the treatment of patients with the disease. In the first years after menopause, treatment with oestrogens (combined if necessary with progestagens), tibolone and selective oestrogen receptor modulators may be considered. Treatment with bisphosphonates is advised in persons who are being or will be treated with corticosteroids, postmenopausal women with one or more osteoporotic fractures, or men and women with an increased risk and a T-score below -2.5. The CBO guideline constitutes the current standard for clinical practice with regard to osteoporosis. There would appear to be no need for a revision of the other guidelines.     

The practice guideline 'Asthma in adults' (second revision) from the Dutch College of General Practitioners; a response from the perspective of pulmonology

The second revised guideline 'Asthma in adults' from the Dutch College of General Practitioners describes the current approach to the diagnosis and treatment of patients with asthma. An interesting change to the guideline is the recommended use of combination medications. The guideline includes new insights into the relationship between peripheral airway inflammation and the clinical severity of asthma. Inhaled corticosteroids with smaller particles are thought to be more effective than traditional corticosteroids. The revised guideline contains recommendations for reducing the local side-effects associated with inhaled corticosteroids. For patients with persistent symptoms despite inhaled medication, a new algorithm can help to determine why symptoms persist before adjusting the medication.     

Monocrotophos induced dysfunction on estrous cycle and follicular development in mice

Monocrotophos a organophosphate pesticide was administered orally at doses of 1.6, 3.3, 6.6, 10 and 13 mg/kg body weight/day to normal virgin Swiss albino mice for 30 days. The vaginal smear and body weight of the mice were recorded daily and mice were sacrificed on 31st day. The ovaries from each animal was serially sectioned and stained for follicular studies. Estrous cycle was affected by showing a significant decrease in the number of estrous cycle and duration of proestrus, estrus and metestrus with concomitant significant increase in the duration of diestrus in all the treated groups, except with 1.6 mg/kg body weight/day monocrotophos treated group. There were significant decrease in the small, medium, large and total number of healthy follicles and increase in the medium, large and total number of atretic follicles with 6.6, 10 and 13 mg/kg body weight/day monocrotophos treatment. However, there were no significant change in the number of healthy and atretic follicles with 1.6 and 3.3 mg/kg/bodyweight/day monocrotophos treatment. There was no change organs weight except for a significant decrease in weight of the ovary with 3.3, 6.6, 10 and 13 mg/kg body weight/day and uterus and body weight with 10 and 13 mg/kg body weight/day monocrotophos treatment. Interruption in estrous cycle, decrease in healthy follicles and increase in atretic follicles may be due to harmonal imbalance or toxic effects of monocrotophos, which adversely effects reproductive function, as it has also analgesic and sedative action.     

The practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The first revision of the practice guideline 'Otitis externa' from the Dutch College of General Practitioners has been published. Data from a clinical trial in primary care clearly show that acid eardrops containing corticosteroids are superior to acid eardrops without corticosteroids. Other minor changes have been made. A KOH test is no longer necessary in general practice. Aluminium acetotartrate eardrops 1.2% are reserved for otitis externa with tympanic membrane perforation.     

Summary of the practice guideline 'The Prevention Visit' from the Dutch College of General Practitioners

The aim of the practice guideline 'The Prevention Visit' is the prevention of cardiovascular diseases, type 2 diabetes and chronic kidney injury in adults not previously diagnosed with hypertension, hypercholesterolaemia, or the above-mentioned cardiometabolic disorders. This is done by actively offering risk assessment combined with relevant treatment and advice (if indicated), integrated into primary health care. A self-report questionnaire is used to identify persons at high risk of developing cardiometabolic disease. Individuals with a risk score above the established threshold are advised to visit their general practitioner for measurement of height, weight, waist circumference, blood pressure, fasting glucose, cholesterol, and HDL cholesterol. At a subsequent practice visit, a risk assessment is performed according to the Dutch College of General Practitioners' practice guideline 'Cardiovascular Risk Management', at which time the patient's lifestyle is evaluated. If indicated, the general practitioner will initiate support and treatment according to relevant practice guidelines established by the Dutch College of General Practitioners.     

The practice guideline 'Bacterial skin infections' (first revision) from the Dutch College of General Practitioners; a response from the perspective of dermatology

We reviewed the first revision of the clinical practice guidelines on the management of bacterial skin infections developed by the Dutch College of General Practitioners. Bacterial skin infections are subdivided into superficial and deep infections; the former are often treated locally while the latter may require systemic antibiotics or surgical intervention. The rate of infection with methicillin-resistant Staphylococcus aureus (MRSA) in the community is relatively low in The Netherlands, but the guideline provides recommendations, such as the restricted use of mupirocin ointment, to facilitate future MRSA control measures. Clinical distinction between erysipelas and cellulitis is often impossible; therefore, the term cellulitis is used throughout the guideline and refers to both Staphylococcus aureus and Streptococcus pyogenes infections of the skin and subcutaneous tissue. The first line of therapy for cellulitis remains a small spectrum, beta-lactamase resistant penicillin, such as flucloxacillin for 10 days. There are no conclusive studies on the prevention of recurrent cellulitis, so recommendations are based on expert opinion and pathophysiological considerations. The lack of rigorous and controlled studies often precludes making clear evidence-based recommendations. However, this guideline succeeds remarkably well in combining the available evidence and formulating sound practical management advice for bacterial skin infections in primary care in The Netherlands. It deserves widespread implementation among general practitioners.     

The practice guideline 'Atopic dermatitis' (first revision) from the Dutch College of General Practitioners; a response from the perspective of dermatology

The practice guideline on atopic dermatitis from the Dutch College of General Practitioners has recently been revised. The main differences from the previous edition (1996) concern the lack of value of allergy tests in the absence of immediate symptoms, the use of the stepdown approach when starting therapy with topical corticosteroids, the absence of topical or systemic side effects if topical corticosteroids are used in a controlled way, the restriction of topical calcineurin inhibitors to second-line treatment, and the lack of effect of non-sedative antihistamines.     

'Decubitus' guideline of the Dutch College of Family Practitioners: response from internal medicine

The guideline on pressure ulcers by the Dutch College of General Practitioners is good in the aspects of simplicity and giving very practical advice. It can be used as a guideline for prevention as well as treatment of pressure ulcers. Some aspects, however, are insufficiently dealt with. There is no summing up of the differences in anti-pressure ulcer devices such as mattresses and cushions. Use is made of the international classification of pressure ulcers in 4 stages, but also of a kind of rating in three colours (red-yellow-black), of which it is known that it underestimates the severity of pressure ulcers. There is an advice to use the knowledge of surgeons, dermatologists and nursing home doctors in difficult cases in the home care, where training and deployment of nurses specialised in this specific field might be preferable. Nevertheless, the guideline is well documented and useful in general practice.     

Summary of the practice guideline 'Thyroid disorders' (first revision) from the Dutch College of General Practitioners

--The practice guideline 'Thyroid disorders' developed by the Dutch College of General Practitioners replaces the practice guideline 'Functional thyroid disorders' from 1996. Recommendations for palpable thyroid disorders have been added. --Hypothyroidism can often be treated by the general practitioner. The guideline offers specific recommendations for substitution therapy based on the 'start low, go slow'-principle. --Pharmacological treatment of hyperthyroidism is described as an optional activity for general practitioners. --A conservative approach is taken to the treatment of subclinical thyroid dysfunction. The development of symptoms may justify treatment initiation. --Cooperation has improved harmonisation of this practice guideline with the Netherlands Association for Internal Medicine's practice guideline 'Functional thyroid disorders' and the Dutch Institute for Healthcare Improvement's practice guideline 'Thyroid carcinomas'.     

Revised practice guideline 'Management of patients with mild traumatic head/brain injury'

Recently the out-of-date Dutch guideline 'Mild traumatic head/brain injury' dating from 2001 was revised under the supervision of the Dutch Institute for Healthcare Improvement (CBO). The revised guideline gives underpinned decision rules for the referral of patients to hospital, carrying out diagnostic imaging investigations, and formulating indications for admission. Mild head-brain injury is no longer an indication for a conventional skull radiograph. Adults and children aged 6 years and older no longer have to be woken regularly if they are allowed home. The guideline can be used in both primary care and on the Emergency Departments of hospitals and is applicable to both adults and children. The guideline does not address the rehabilitation or long-term care of patients with mild traumatic head/brain injury, but it does give advice on reducing the risk of long-term symptoms. Regional implementation of the guideline in primary and secondary care is recommended.     

The Dutch College of General Practitioners' practice guideline "Dizziness"; reaction from a general practitioner's perspective

The Dutch College of General Practitioners' practice guideline entitled 'Dizziness' concerns a complaint experienced by many people, yet it provides few scientific data to support the recommendations. The standard does, however, provide the general practitioner with some concrete advice: the diagnostic work-up should, in the first instance, aim to differentiate vertigo from other forms of dizziness, and medicinal treatment is not indicated as it has not been proven to be effective. However, when it comes to further diagnostic procedures and non-medicinal therapy, the standard tends to list options and give less direction.     

The practice guideline 'Asthma in children' (second revision) from the Dutch College of General Practitioners; a response from the perspective of paediatric pulmonology

The second revised guideline 'Asthma in children' from the Dutch College of General Practitioners provides a well-documented and useful overview. Diagnostic recommendations depend heavily on the symptom 'wheezing', which may be difficult to detect in young children. A uniform therapeutic approach for the various asthma phenotypes is recommended, including a therapeutic trial with inhaled corticosteroids for persistent symptoms. Pitfalls include the fact that inhalation of corticosteroids is sometimes difficult in young children, and that the use of corticosteroids in children with transient virus-induced wheeze is not evidence-based. The guideline no longer recommends the use of cromoglycate. Children who are refractory to inhaled steroids should be referred to a paediatrician before trying long-acting beta2-sympathomimetics or leukotriene antagonists. The current challenge is to effectively incorporate this new guideline into a coherent system of care for the asthmatic child in cooperation with paediatricians, asthma nurses and others involved in the diagnosis and treatment of childhood asthma.