Collateral damage from oral ciprofloxacin versus nitrofurantoin in outpatients with urinary tract infections: a culture-free analysis of gut microbiota.

Recent treatment guidelines for uncomplicated urinary tract infections (UTIs) discourage fluoroquinolone prescription because of collateral damage to commensal microbiota, but the ecologic impact of alternative agents has not been evaluated by culture-free techniques. We prospectively collected faecal samples at three time points from ambulatory patients with UTIs treated with ciprofloxacin or nitrofurantoin, patients not requiring antibiotics and household contacts of ciprofloxacin-treated patients. We described changes in gut microbiota using a culture-independent approach based on pyrosequencing of the V3-V4 region of the bacterial 16S rRNA gene. All groups were similar at baseline. Ciprofloxacin had a significant global impact on the gut microbiota whereas nitrofurantoin did not. The end of ciprofloxacin treatment correlated with a reduced proportion of Bifidobacterium (Actinobacteria), Alistipes (Bacteroidetes) and four genera from the phylum Firmicutes (Faecalibacterium, Oscillospira, Ruminococcus and Dialister) and an increased relative abundance of Bacteroides (Bacteroidetes) and the Firmicutes genera Blautia, Eubacterium and Roseburia. Substantial recovery had occurred 4 weeks later. Nitrofurantoin treatment correlated with a reduced relative proportion of the genus Clostridium and an increased proportion of the genus Faecalibacterium. This study supports use of nitrofurantoin over fluoroquinolones for treatment of uncomplicated UTIs to minimize perturbation of intestinal microbiota.

[Imaging in the evaluation of headaches]. / Céphalées: quelle imagerie?

Headache is a common complaint in primary care medicine. Most of the time, they are primary and benign headaches, with no need for further investigations; nevertheless, in the presence of red flags, a brain imaging is warranted. The diagnostic approach depends upon the most likely suspected cause and the degree of emergency. In those situations, a head CT scan without and with contrast is the exam of choice in most patients, because it is helpful for identifying intracranial lesions or bleeding. The MRI, more sensible, is preferred in the ambulatory setting for investigation and follow-up of intracranial tumoral or infectious diseases.

[What is new in ambulatory internal medicine in 2012?]. / Nouveautés 2012 en médecine interne générale ambulatoire.

Ten articles published in 2012 and of interest for the practice of ambulatory general internal medicine are reviewed in this paper. Topics of public health issues, such as the association between sleep disorders and prediabetes, the association between prediabetes and stroke, and the harmful effects of prolonged sitting are tackled. Other focuses include hepatitis C screening, abdominal aortic aneurysm screening and prostatic cancer screening. Therapeutic aspects are reviewed, such as the management of nongonococcal urethritis, the treatment of iron deficiency without anemia and the substitution of subclinical hypothyroidism. Finally a new study about aspirin and cancer prevention is discussed.

[What to do with a normal urinary strip in case of lower urinary tract symptoms?]. / Symptômes urinaires bas et bandelette normale: à quoi penser?

Patients very often consult for lower urinary tract symptoms, that do not necessarily equate to common cystitis. When urinary leucocytes and nitrites are absent, the urinary strip has a very good negative predictive value and makes the diagnosis of a lower urinary tract infection very unlikely. One then has to search for other diagnoses and to clarify the nature of the symptoms, irritating or obstructive ones, their duration and to correlate them to the patient's age and gender. In sexually active young patients, infectious diseases predominate, such as uretritis or vaginitis, while, with age, the prevalence of dysfunction of vesical emptying, benign prostatic hyperplasia or atrophic vaginitis increase.

[Emergency department point of care testing: what are the benefits and for which patients?]. / Laboratoire délocalisé aux urgences: quels bénéfices pour quels patients?

Laboratory tests contribute to patient length of stay in the emergency department. Therefore, rapid tests performed at the bedside (POCT or point of care testing) are attractive because they allow the emergency physician to obtain immediate biological, diagnostic and/or prognostic data. Userfriendly and with validated analytical performance, POCT have the potential to reduce laboratory time, patient length of stay and time to treatment or disposition. The expected benefit from POCT implementation will depend on the type of patients involved (inpatient or outpatient), their clinical condition and their overall care. Furthermore, logistical and economic implications should also be taken into account.

[Vertigo: it all revolves around the physical exam]. / Vertiges: tout tourne-t-il autour de la clinique?

Dizziness is a common complaint in an emergency department. True vertigo, characterized by subjective sensation of rotation of the subject or of objects around the subject, may be peripheral (85%) or central (15%). Patient's history and physical exam identify the etiology of vertigo in more than 70% of patients. Hallpike test is easily performed and crucial for the diagnosis of benign paroxysmal peripheral vertigo. Central vertigo should be suspected and brain imaging performed in the presence of neurological symptoms, in older patients, or when several risk factors for cerebrovascular disease are present.