A rapid diagnostic test have has investigated in a clinical trial in Rwanda with which urinary tract infections (UTIs) can be treated earlier and in a more targeted manner. According to researcher Janneke van de Wijgert (Julius Center), rapid testing for infections can also achieve a great deal of health gain in the Netherlands. Especially in the vulnerable elderly.

Whoever goes to the doctor in the Netherlands with complaints that may indicate an infection, for example an airway infection or a bladder infection, often does not undergo testing to determine whether there is actually an infection and, if so, which infection. Sometimes a doctor will take a sample and send it to a laboratory, but then it takes a few days before the result is known. The doctor usually bases his opinion during the consultation on the complaints of a patient and a physical examination: he has a strong suspicion and makes a "best guess".

In developing countries, urinary tract infections are usually treated according to the WHO-guidelines in a non-targeted manner. These guidelines were originally intended to simplify the work of doctors who do not have access to laboratories.

Stunning evidence
"There is now overwhelming evidence that a ‘best guess’ and the WHO approach have shortcomings," says Janneke van de Wijgert. As Professor of Epidemiology of Immunological Diseases at UMC Utrecht, she focuses primarily on microbiological pathogens and infections. Janneke: “The consequences can be either under-treatment or over-treatment. So: some people do not get what they need and others receive treatment that they do not need. In addition, people with an infection but without complaints are actually always overlooked, while we know that infections without complaints can cause medical complications in some risk groups.

Rapid diagnostic tests
In the so-called WISH study, published in Lancet Infectious Diseases, Janneke investigated whether rapid testing for UTIs yielded better results than the WHO approach. Moreover, she compared the results of the rapid tests with those of "ideal tests", the so-called Gold Standard tests in which all circumstances are optimal: sufficient money, time and lab facilities. The study took place in Rwanda, with 705 women. The point-of-care tests focused on infections due to Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis (a lesser known sexually transmitted disease) and bacterial vaginosis (a common disturbance of the bacterial balance in the vagina).

Effectiveness
Some results: the POC-tests for chlamydia, gonorrhoeae and trichomonas were almost as good as the Gold Standard tests, and led to drastically less over-treatment than with the WHO approach. Janneke: “Studies with these tests had already been done in practice, but never such extensive comparative research with Gold Standard tests. That comparison really says something about the effectiveness of the POC-tests.

Point-of-care testing for rapid diagnosis of UTIs

In Africa, the infections investigated are common and can take on epidemic forms. The importance of cheap and simple diagnostic POC-testing, which can also be taken by people who are not highly educated, is high. "With these tests, women with complaints, but also women without complaints who are at risk of complications, such as pregnant women, can be diagnosed on a large scale," Janneke says. "Only the costs are still relatively high for developing countries." The WHO sees the further development of POC-tests to be able to identify pathogens within 30 minutes as a priority and has set up a network of clinical posts to evaluate new rapid tests.

Health gain
Many POC diagnostics recognize bacterial and virological pathogens by their DNA or RNA. These techniques have improved over the past 20 years, but the vast majority of research into microbiological pathogens is still done - also in the Netherlands - through culture. Janneke: “Many bacteria are difficult to grow - they are often missed - and this must be done in a lab and takes a few days, while a patient can be very ill. A doctor must still start taking antibiotics, so quick tests can also help.”

According to Janneke, POC tests can also achieve a lot of health gains in the Netherlands. “It often happens that vulnerable elderly people with an infection develop a delirium or even sepsis. It is a major problem in our aging population: elderly people with a common infection, that develop a life-threatening condition. With a rapid test you can start adequate treatment much sooner so that people do not get seriously ill or worse.”

Increased risk
Janneke also wants to show doctors that urinary tract infections are less harmless than many think, especially in pregnant women. “For example, pregnant women are tested for fever and usually only for one bacterium. If someone has no complaints, we don't have to deal with it, is the idea. But even if there are no complaints, there can be an increased risk of miscarriage or premature birth or a bacterium can be transmitted to the baby. I experienced that once. The baby was born healthy, but died 24 hours later by a bacterial infection. That could have been prevented by screening with a POC test.”

CF is a hereditary disease that is incurable. Patients with this condition are therefore 'ill' throughout their lives and depend on specialized healthcare. With approximately 500 of the 1,600 Dutch patients with CF under treatment, the CF center of the UMC Utrecht is by far the largest in the Netherlands. Thanks to the increasing improvement in life expectancy, the majority of patients are now older than 18 years and there is an increasing number of people reaching 50 years. “How different was this when I first came in contact with this disease in 1986. Then most patients died within a few years of their 18^th birthday."

More CF doctor than lung doctor
Almost all patients with CF have a chronic sinusitis and nasal polyps. Approximately 80 percent of these are born with pancreatic abnormalities, resulting in a disturbed fat and protein metabolism which often leads to diabetes. The intestine also has to do with a disturbed water transport which can cause serious intestinal congestion. It may also lead to a disturbed bile flow which can result in serious liver failure. And then there are other complications: consider the choice for education and work, relationships, family planning and pregnancy. "Although I am a lung doctor, I see myself and my colleagues more as CF doctors and GPs for this specific patient group."

Evening consultation
The transition from child to the adult care is something that many patients struggle with. “Whole transition programs are being devised for that, often without adequately consulting the parents and children involved. In particular, because with reaching the 18^th year of life the disease will not change. So it seems that the patient has to adapt to the hospital system and not the other way around. More cooperation between pediatricians and doctors should eliminate this nuisance to a large extend. For that reason, the pediatrician involved at the Wilhelmina Children's Hospital and I have been holding evening consultations for two years now, which facilitates that we can see each other's patients. Interim evaluations show that patients and their parents greatly appreciate this. The transition process from the pediatrician to the pulmonologist is then performed in a natural way, you don't have to develop any protocol for that.”

E-health
Harry explains it's wonderful to see and talk to patients at the hospital, but wonders if that is always the best approach for patients. “Our patients with CF often have to travel significant distances to get to the hospital. For them, an outpatient visit is often a full-day program if they have to come from places like Helmond or Winterswijk. With an improvement in prognosis, many patients also have a full-time job and/or a normal family life. Then such a day is cumbersome, especially if you actually feel pretty good. Nowadays, lung functions can also be tested at home; you can also send a sputum culture by mail to the hospital ten days in advance; everyone can weigh themselves. Measuring vitality/activity is also easy and can go unnoticed via mobile phone. We just have to arrange this. Naturally, this requires IT support and financial resources for the equipment that patients must use at home, but I cannot imagine that this can not be solved. My intention is to hold an E-health consultation hour once every two weeks by 2020. That is also possible in the evening from home. In short, the patient and the doctor at home has a lot of advantages. Without the hassle of beepers and other crowds. I already look forward to that."