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Pediatric Nephrology (Berlin, Germany) Jun 2021The sensitivity and specificity of the leukocyte esterase test are relatively low for a screening test for urinary tract infection (UTI). More accurate tests could...
BACKGROUND
The sensitivity and specificity of the leukocyte esterase test are relatively low for a screening test for urinary tract infection (UTI). More accurate tests could reduce both overtreatment and missed cases. This study aimed to determine whether neutrophil gelatinase-associated lipocalin (NGAL) can replace leukocyte esterase in the diagnosis of UTI and/or whether NGAL accurately identifies children with acute pyelonephritis.
METHODS
Data sources-MEDLINE and EMBASE. We only considered published studies that evaluated the results of an index test (NGAL) against the results of urine culture (for UTI) or against the results of dimercaptosuccinic acid (for acute pyelonephritis) in children aged 0 to 18 years. Two authors independently applied the selection criteria to all citations and independently extracted the data.
RESULTS
A total of 12 studies met our inclusion criteria. Four studies (920 children) included data on NGAL for UTI; eight studies (580 children) included data on NGAL for pyelonephritis. We did not pool accuracy values because the included studies used different cutoff values. For the diagnosis of UTI, urinary NGAL appeared to have better accuracy than the leukocyte esterase test in all included studies. For the diagnosis of pyelonephritis, neither plasma NGAL nor urinary NGAL had high sensitivity and/or specificity. The number of studies was the main limitation of this systematic review.
CONCLUSIONS
Urinary NGAL appears promising for the diagnosis of UTI; however, larger studies are needed to validate this marker as a replacement for leukocyte esterase. The use of NGAL for diagnosing acute pyelonephritis requires further study.
Topics: Biomarkers; Child; Humans; Lipocalin-2; Overtreatment; Pyelonephritis; Urinary Tract Infections
PubMed: 33389090
DOI: 10.1007/s00467-020-04854-3 -
BMC Family Practice Sep 2021Accurate diagnosis of urinary tract infection is essential as children left untreated may suffer permanent renal injury. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Accurate diagnosis of urinary tract infection is essential as children left untreated may suffer permanent renal injury.
AIM
To compare the diagnostic values of biomarkers or clinical prediction rules for urinary tract infections in children presenting to ambulatory care.
DESIGN AND SETTING
Systematic review and meta-analysis of ambulatory care studies.
METHODS
Medline, Embase, WOS, CINAHL, Cochrane library, HTA and DARE were searched until 21 May 2021. We included diagnostic studies on urine or blood biomarkers for cystitis or pyelonephritis in children below 18 years of age. We calculated sensitivity, specificity and likelihood ratios. Data were pooled using a bivariate random effects model and a Hierarchical Summary Receiver Operating Characteristic analysis.
RESULTS
Seventy-five moderate to high quality studies were included in this review and 54 articles in the meta-analyses. The area under the receiver-operating-characteristics curve to diagnose cystitis was 0.75 (95%CI 0.62 to 0.83, n = 9) for C-reactive protein, 0.71 (95% CI 0.62 to 0.80, n = 4) for procalcitonin, 0.93 (95% CI 0.91 to 0.96, n = 22) for the dipstick test (nitrite or leukocyte esterase ≥trace), 0.94 (95% CI 0.58 to 0.98, n = 9) for urine white blood cells and 0.98 (95% CI 0.92 to 0.99, n = 12) for Gram-stained bacteria. For pyelonephritis, C-reactive protein < 20 mg/l had LR- of 0.10 (95%CI 0.04-0.30) to 0.22 (95%CI 0.09-0.54) in children with signs suggestive of urinary tract infection.
CONCLUSIONS
Clinical prediction rules including the dipstick test biomarkers can support family physicians while awaiting urine culture results. CRP and PCT have low accuracy for cystitis, but might be useful for pyelonephritis.
Topics: Biomarkers; C-Reactive Protein; Child; Humans; Primary Health Care; Pyelonephritis; Sensitivity and Specificity; Urinary Tract Infections
PubMed: 34565335
DOI: 10.1186/s12875-021-01530-9 -
Internal and Emergency Medicine Mar 2021The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies.
MATERIALS AND METHODS
We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence.
RESULTS
We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53-0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75-1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs.
CONCLUSIONS
Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.
Topics: Anti-Bacterial Agents; Humans; Practice Guidelines as Topic; Pyelonephritis
PubMed: 32566969
DOI: 10.1007/s11739-020-02401-4 -
JAMA Sep 2019Screening for asymptomatic bacteriuria can identify patients for whom treatment might be beneficial for preventing symptomatic infection and other health outcomes.
IMPORTANCE
Screening for asymptomatic bacteriuria can identify patients for whom treatment might be beneficial for preventing symptomatic infection and other health outcomes.
OBJECTIVE
To systematically review benefits and harms of asymptomatic bacteriuria screening and treatment in adults, including during pregnancy, to inform the US Preventive Services Task Force.
DATA SOURCES
MEDLINE, PubMed (publisher-supplied records), and Cochrane Collaboration Central Registry of Controlled Trials; surveillance through May 24, 2019.
STUDY SELECTION
Randomized clinical trials (RCTs) and observational studies on benefits and harms of screening for asymptomatic bacteriuria; RCTs on benefits and harms of asymptomatic bacteriuria treatment. Eligible populations included unselected, asymptomatic individuals without known urinary tract conditions.
DATA EXTRACTION AND SYNTHESIS
Independent critical appraisal and data abstraction by 2 reviewers. Random-effects meta-analysis was conducted to estimate benefits of the interventions.
MAIN OUTCOMES AND MEASURES
Symptomatic infection; function, morbidity, mortality; pregnancy complications and birth outcomes.
RESULTS
Nineteen studies (N = 8443) meeting inclusion criteria were identified. Two cohort studies (n = 5289) found fewer cases of pyelonephritis in the cohorts of screened pregnant women (0.5%) than within retrospective comparisons of unscreened cohorts (2.2% and 1.8%); the larger study estimated a statistically significant relative risk of 0.30 (95% CI, 0.15-0.60). No studies examined screening in nonpregnant populations. Among 12 trials of asymptomatic bacteriuria screening and treatment during pregnancy (n = 2377; 1 conducted within past 30 years), there were reduced rates of pyelonephritis (range, 0%-16.5% for the intervention group and 2.2%-36.4% for the control group; pooled risk ratio [RR], 0.24 [95% CI, 0.14-0.40]; 12 trials) and low birth weight (range, 2.5%-14.8% for the intervention group and 6.7%-21.4% for the control group; pooled RR, 0.64 [95% CI, 0.46-0.90]; 7 trials). There was no significant difference in infant mortality (pooled RR, 0.98 [95% CI, 0.29-3.26]; 6 trials). Five RCTs of asymptomatic bacteriuria treatment in nonpregnant adults (n = 777) did not report any significant differences in risk of infection, mobility, or mortality. Limited evidence on harms of screening or treatment was available, and no statistically significant differences were identified.
CONCLUSIONS AND RELEVANCE
Screening and treatment for asymptomatic bacteriuria during pregnancy was associated with reduced rates of pyelonephritis and low birth weights, but the available evidence was not current, with only 1 study conducted in the past 30 years. Benefits of asymptomatic bacteriuria treatment in nonpregnant adult populations were not found. Trial evidence on harms of asymptomatic bacteriuria antibiotic treatment was limited.
Topics: Adult; Anti-Bacterial Agents; Bacteriuria; Female; Humans; Infant, Low Birth Weight; Male; Mass Screening; Microbiota; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications, Infectious; Pyelonephritis; Risk Factors; Urinary Tract Infections
PubMed: 31550037
DOI: 10.1001/jama.2019.10060 -
European Journal of Clinical... Dec 2018There is increasing resistance to the oral antibiotics currently recommended for the treatment of pyelonephritis, and increased healthcare costs are associated with the...
There is increasing resistance to the oral antibiotics currently recommended for the treatment of pyelonephritis, and increased healthcare costs are associated with the reliance on alternative intravenous agents. We, therefore, performed a systematic review of randomised controlled trials to determine the clinical efficacy and safety of oral antibiotics for the treatment of pyelonephritis in adults. A search of four major medical databases (MEDLINE, Embase+ Embase classic, CENTRAL and Cochrane Database for Systematic Reviews) in addition to manual reference searching of relevant reviews was conducted. Clinical cure and adverse event rates were reported, and trial quality and bias were assessed. A total of 277 studies were reviewed; five studies matched all eligibility criteria and were included. Antibiotics included were cefaclor, ciprofloxacin, gatifloxacin, levofloxacin, lomefloxacin, loracarbef, norfloxacin, rufloxacin and trimethoprim-sulfamethoxazole. In included studies, the clinical success of the outpatient treatment of pyelonephritis by cefaclor, ciprofloxacin and norfloxacin at 4 to 6 weeks was comparable at between 83 to 95%. Relatively high rates of adverse events were noted in a trial of ciprofloxacin (24%) and trimethoprim-sulfamethoxazole (33%). Significant heterogeneity between all aspects of the trial designs was identified, with all studies having a potential for bias. This review demonstrates a need for high-quality clinical trials into the oral antibiotic treatment of pyelonephritis, with more consistent designs and reporting of outcomes. There are data to support further research into oral norfloxacin and cefaclor for the outpatient treatment of pyelonephritis in adults.
Topics: Acute Disease; Administration, Oral; Anti-Bacterial Agents; Cephalosporins; Ciprofloxacin; Drug Combinations; Humans; Norfloxacin; Pyelonephritis; Randomized Controlled Trials as Topic; Sulfamethizole; Trimethoprim
PubMed: 30191339
DOI: 10.1007/s10096-018-3371-y -
Expert Opinion on Pharmacotherapy Apr 2020Urinary tract infections (UTIs) are among the most common causes of sepsis presenting to hospitals. Treating complicated UTIs is extremely important due to their...
INTRODUCTION
Urinary tract infections (UTIs) are among the most common causes of sepsis presenting to hospitals. Treating complicated UTIs is extremely important due to their potential mortality. Levofloxacin is a fluoroquinolone antibacterial that has become one of the cornerstones of antibiotic therapy of complicated UTIs and pyelonephritis since its introduction in the 1990s because of its exceptional pharmacokinetic (PK) and pharmacodynamic (PD) profile. However, the emergence of widespread fluoroquinolone resistance over the past decade has prompted investigators to reexamine its place in the treatment of UTI.
AREAS COVERED
This literature review summarizes data about the efficacy and the tolerability of levofloxacin in treating complicated UTIs and pyelonephritis.
EXPERT OPINION
In the early 2000s, fluoroquinolones became the most commonly prescribed antibiotic in the US. Since then, the resistance rate of to fluoroquinolones has increased, largely hampering the use of this class of drugs. These data, in association with emerging data about inappropriate prescription and toxicity, have limited its clinical use. For these reasons, a judicious use of levofloxacin and other fluoroquinolones and a careful implementation of infection control procedures are the main available tools for the management of UTIs and pyelonephritis.
Topics: Anti-Bacterial Agents; Drug Resistance, Bacterial; Female; Humans; Infection Control; Levofloxacin; Pyelonephritis; Sepsis; Urinary Tract Infections
PubMed: 32004097
DOI: 10.1080/14656566.2020.1720647 -
Journal of Obstetrics and Gynaecology :... Aug 2020We performed a comprehensive systematic review of acute pyelonephritis in pregnancy using PubMed, SCOPUS, ClinicalTrials.gov, and Ovid from inception to April 2018....
We performed a comprehensive systematic review of acute pyelonephritis in pregnancy using PubMed, SCOPUS, ClinicalTrials.gov, and Ovid from inception to April 2018. About 7796 references were screened for inclusion, and 52 references from 1908 to 2017 were included. One hundred seven cases of acute pyelonephritis in pregnant women were reviewed. Gestational age at diagnosis was reported as 2 (2%), 43 (40%), and 51 (52%) during the first, second, and third trimesters, respectively. Maternal complications included sepsis (49%), acute respiratory distress syndrome (47%), anaemia (33%), acute kidney injury (10%), renal abscess (6%), and death (6%). 25 preterm deliveries (23%), 6 intrauterine foetal demises (6%), 4 spontaneous abortions (4%), and 8 neonatal intensive care unit admissions (7%) were reported. Microorganisms cultured included (51%), (8%), (5%), (5%), (4%), and (3%). Early diagnosis and management led to fewer complications.Impact statement Acute pyelonephritis during pregnancy can lead to adverse pregnancy outcomes and in this article, we highlight the most common outcomes previously reported. Previous studies have reported maternal adverse outcomes and only very few stressed on fetal/neonatal outcomes. The results add that not only is maternal morbidity/mortality is increased, but also increases adverse outcomes for the fetus/neonate, such as preterm delivery and fetal/neonatal demise. The implications from this article serve to increase a medical providers knowledge on how to appropriately counsel pregnant women with acute pyelonephritis. In addition, future research can aim to understand why pregnant women are more prone to morbidity and mortality compared to nonpregnant women.
Topics: Acute Disease; Adult; Female; Fetal Death; Gestational Age; Humans; Infant, Newborn; Maternal Mortality; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Pyelonephritis
PubMed: 32648533
DOI: 10.1080/01443615.2019.1647524 -
Urologia Internationalis 2018We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in...
The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention.
BACKGROUND
We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs.
MATERIALS AND METHODS
An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015.
RESULTS
For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection.
CONCLUSION
In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Bacteriuria; Cystitis; Female; Germany; Humans; Interdisciplinary Communication; Male; Practice Guidelines as Topic; Pregnancy; Premenopause; Pyelonephritis; Societies, Medical; Urinary Tract Infections; Urology
PubMed: 29539622
DOI: 10.1159/000487645 -
Archives of Disease in Childhood Nov 2021Acute pyelonephritis in children may result in permanent kidney scarring that is primarily caused by inflammation during acute infection. Antibiotic therapy alone is not... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Acute pyelonephritis in children may result in permanent kidney scarring that is primarily caused by inflammation during acute infection. Antibiotic therapy alone is not enough to significantly reduce kidney scarring, and adjuvant corticosteroid therapy has shown a significant reduction in inflammatory cytokines in urine prompting its evaluation in randomised controlled trials. A few clinical trials showed a trend towards a reduction in renal scarring but did not have an adequate sample size to show a significant effect. Therefore, we planned to synthesise the available evidence on the role of corticosteroids as adjuvant therapy in reducing kidney scarring.
OBJECTIVE
To assess the efficacy and safety of adjuvant corticosteroid therapy for the prevention of kidney scarring in children with acute pyelonephritis.
DESIGN
Systematic review and meta-analysis.
SETTING
Community-acquired febrile urinary tract infections.
PATIENTS
Children (less than 18 years) with acute pyelonephritis.
INTERVENTION
Adjuvant corticosteroid therapy (along with antibiotic treatment).
MAIN OUTCOME MEASURES
Primary: efficacy in preventing kidney scarring; secondary: serious adverse events associated with corticosteroid therapy.
RESULTS
Three randomised trials (529 children) were included. Corticosteroids are effective in lowering the risk of kidney scarring as compared with placebo (risk ratio (RR): 0.57; 95% CI 0.36 to 0.90). No significant increase risk of bacteraemia (RR: 1.38; 95% CI 0.23 to 8.23) and hospitalisation (RR: 0.87; 95% CI 0.3 to 2.55) was observed in corticosteroid group.
CONCLUSION
Moderate quality evidence suggests that short duration 'adjuvant corticosteroid therapy' along with routine antibiotic therapy in acute febrile urinary tract infection significantly reduces the risk of kidney scarring without any significant adverse effects.
Topics: Acute Disease; Adolescent; Adrenal Cortex Hormones; Anti-Bacterial Agents; Case-Control Studies; Chemotherapy, Adjuvant; Child; Community-Acquired Infections; Cytokines; Drug Therapy, Combination; Female; Glomerulonephritis; Humans; Inflammation; Kidney; Male; Placebos; Pyelonephritis; Randomized Controlled Trials as Topic; Risk Reduction Behavior; Safety; Treatment Outcome; Urinary Tract Infections
PubMed: 33632785
DOI: 10.1136/archdischild-2020-320591 -
Urologia Internationalis 2018We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in...
The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1.
OBJECTIVES
We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients.
MATERIALS AND METHODS
An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, -EMBASE, and the Cochrane Library to identify literature published in 2010-2015.
RESULTS
We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed.
CONCLUSION
In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Bacteriuria; Cystitis; Female; Germany; Humans; Interdisciplinary Communication; Male; Practice Guidelines as Topic; Pregnancy; Premenopause; Pyelonephritis; Societies, Medical; Urinary Tract Infections; Urology
PubMed: 29342469
DOI: 10.1159/000486138