Prediction scores or gastroenterologists' Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding

INTRODUCTION

Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists' Gut Feeling in patients with a suspected upper GI bleeding.

METHODS

WE PROSPECTIVELY EVALUATED GUT FEELING OF SENIOR GASTROENTEROLOGISTS AND ASKED THEM TO ESTIMATE: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists' Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes.

RESULTS

We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively).

CONCLUSIONS

Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.

Diabetes mellitus in itself is not a risk factor for antibiotic resistance in Escherichia coli isolated from patients with bacteriuria

AIM

To investigate whether diabetes mellitus is a risk factor for resistance in Escherichia coli isolated from patients with bacteriuria.

METHODS

Data were obtained from a multicentre study. A clean-voided midstream urine culture was collected from 636 women with diabetes, who were between 18 and 75-years-old, attended an out-patient department and had no symptoms of a urinary tract infection. The resistance of E. coli was determined for different antimicrobials. The results were compared with resistance data from routine isolates of E. coli, obtained from women in the same age category, time period and location.

RESULTS

A total of 135 E. coli were isolated from women with diabetes mellitus (mean age 57 +/- 14 years) and compared with 5907 routine isolates of E. coli obtained from female patients visiting an out-patient department (mean age 52 +/- 17 years). The resistance rates of E. coli isolated from diabetic patients and the routine isolates of E. coli to trimethoprim-sulfamethoxazole were 19% and 23%, respectively, to amoxicillin 16% and 32%, to nitrofurantoin 1% and 3%, to ciprofloxacin 0% and 4%, to ofloxacin 0% and 5%, and to norfloxacin 1% and 4%.

CONCLUSION

The resistance of uropathogenic E. coli in non-hospitalized women with diabetes mellitus is not higher than that seen in routine isolates of E. coli. This suggests that diabetes in itself is not a risk factor for resistance.

[Asymptomatic bacteriuria; management choices in different patient groups]

Asymptomatic bacteriuria is a common medical condition, especially in women and elderly people. It is generally considered to be a benign condition, which does not require screening or antibiotic treatment. However, there are a few exceptions for which screening is possibly worthwhile. For children it is unclear whether the early detection of ASB can result in better clinical outcomes. Screening is therefore not advised, except for young children during the first few months after a symptomatic urinary tract infection. For pregnant women the use of screening for ASB is also unclear and in general not indicated. Research is necessary into the possible transition from ASB to pyelonephritis and the possible connection with low birth weight and premature births. There are indications that ASB in women with type I diabetes mellitus can lead to a deterioration in the renal function, yet these are insufficient to recommend screening as a routine procedure.

[Urinary tract infections in women with diabetes mellitus]

Women with diabetes mellitus (DM) have asymptomatic bacteriuria (ASB) and urinary tract infections (UTIs) more frequently than women without DM. For type 1 diabetes mellitus, risk factors for asymptomatic bacteriuria include a longer duration of diabetes, peripheral neuropathy and macroalbuminuria. For type 2 diabetes, the risk factors are higher age, macroalbuminuria and a recent symptomatic UTI. Poorly-controlled diabetes and residual urine after urination are no risk factors. The most important risk factor for a UTI in type 1 diabetes patients is sexual intercourse. In type 2 diabetes patients the major risk factor is the presence of asymptomatic bacteriuria. This higher prevalence does not appear to be based on a difference in virulence of the causative microorganism. Differences in host response may explain this higher prevalence: E. coli with type 1 fimbriae adhere better to uroepithelial cells in women with DM than to those in women without DM; women with DM and ASB have lower urinary cytokine concentrations and leukocyte counts compared to women without DM and ASB; in vitro studies show that E. coli grow better when glucose is present in urine. There is no consensus on whether ASB should be treated in these patients. There are indications that UTIs in diabetes patients should be treated as complicated UTIs.

[Candidate vaccine against urinary tract infections]

Urinary tract infections (UTIs) are an important medical problem for women. The most common uropathogen is Escherichia coli. The adherence of E. coli to the uroepithelium is mediated by the FimH adhesin, a minor component of type-1 fimbriae. This is the initial step in the pathogenesis of UTIs. Recently, a candidate vaccine has been developed, based on this FimH adhesin. In animal studies and in a phase 1 study, this vaccine has proven to be both immunogenic and safe. In this era of increasing resistance to antibiotics, such a method of prevention is of high importance.