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BMC Pregnancy and Childbirth Nov 2023Given the physiological changes during pregnancy, pregnant women are likely to develop recurrent urinary tract infections (UTIs) and pyelonephritis, which may result in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Given the physiological changes during pregnancy, pregnant women are likely to develop recurrent urinary tract infections (UTIs) and pyelonephritis, which may result in adverse obstetric outcomes, including prematurity and low birth weight preeclampsia. However, data on UTI prevalence and bacterial profile in Latin American pregnant women remain scarce, necessitating the present systematic review to address this issue.
METHODS
To identify eligible observational studies published up to September 2022, keywords were systematically searched in Medline/PubMed, Cochrane Library, Embase, Web of Science, and Bireme/Lilacs electronic databases and Google Scholar. The systematic review with meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the quality of studies was classified according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. The meta-analysis employed a random-effects method with double-arcsine transformation in the R software.
RESULTS
Database and manual searches identified 253,550 citations published until September 2022. Among the identified citations, 67 met the inclusion criteria and were included in the systematic review, corresponding to a sample of 111,249 pregnant women from nine Latin American countries. Among Latin American pregnant women, the prevalence rates of asymptomatic bacteriuria, lower UTI, and pyelonephritis were estimated at 18.45% (95% confidence interval [CI]: 15.45-21.53), 7.54% (95% CI: 4.76-10.87), and 2.34% (95% CI: 0.68-4.85), respectively. Some regional differences were also detected. Among the included studies, Escherichia coli (70%) was identified as the most frequently isolated bacterial species, followed by Klebsiella sp. (6.8%).
CONCLUSION
Pregnant women in Latin America exhibit a higher prevalence of bacteriuria, UTI, and pyelonephritis than pregnant women globally. This scenario reinforces the importance of universal screening with urine culture during early prenatal care to ensure improved outcomes. Future investigations should assess the microbial susceptibility profiles of uropathogens isolated from pregnant women in Latin America.
TRIAL REGISTRATION
This research was registered at PROSPERO (No. CRD42020212601).
Topics: Infant, Newborn; Pregnancy; Female; Humans; Bacteriuria; Latin America; Pregnant Women; Pregnancy Complications, Infectious; Prevalence; Urinary Tract Infections; Pyelonephritis; Anti-Bacterial Agents
PubMed: 37940852
DOI: 10.1186/s12884-023-06060-z -
Pediatric Nephrology (Berlin, Germany) Dec 2023Acute pyelonephritis (APN) in pediatric patients may lead to kidney scarring and is one of the main causes of permanent kidney damage. The incidence of kidney scarring... (Meta-Analysis)
Meta-Analysis Review
The efficacy and safety of corticosteroids in pediatric kidney scar prevention after urinary tract infection: a systematic review and meta-analysis of randomized clinical trials.
BACKGROUND
Acute pyelonephritis (APN) in pediatric patients may lead to kidney scarring and is one of the main causes of permanent kidney damage. The incidence of kidney scarring after one febrile urinary tract infection (UTI) is reported to range from 2.8 to 15%, with the percentage rising to 28.6% after ≥ 3 febrile UTIs. Corticosteroids may have a role in the reduction of kidney scar formation and urine cytokine levels. The possible benefit of adjuvant corticosteroid administration in the reduction of kidney scar formation in children with APN has been recently examined in randomized controlled trials (RCTs).
OBJECTIVES
The aim of this meta-analysis was to provide a summary of the current literature about the efficacy and safety of adjuvant corticosteroid administration in the reduction of kidney scar formation in children with APN.
DATA SOURCES
An extensive literature search through major databases (PubMed/MEDLINE and Scopus) was carried out for RCTs from inception until October 12, 2022, investigating the efficacy and safety of adjuvant corticosteroids in preventing kidney scarring in children with APN. A risk ratio with 95% CI was used for dichotomous outcomes.
RESULTS
In total, 5 RCTs with 918 pediatric patients with APN were included in the study. Adjuvant corticosteroid treatment revealed a statistically significant reduction in kidney scarring (95% CI 0.42-0.95, p = 0.03), without increasing the risk of adverse events like bacteremia, prolonged hospitalization, or recurrence of UTI.
LIMITATIONS
There were limitations regarding sample size (n = 498 children), different classes of corticosteroids (methylprednisolone or dexamethasone), different routes of corticosteroid administration (intravenous or oral), and different day courses (3-day or 4-day course).
CONCLUSIONS
Adjuvant corticosteroid administration seems to have a beneficial effect on kidney scar reduction in children with APN. Future studies should focus on the evaluation of the efficacy and safety of corticosteroids in kidney scarring reduction after APN to strengthen the results of our study. A higher resolution version of the Graphical abstract is available as Supplementary information.
Topics: Child; Humans; Cicatrix; Randomized Controlled Trials as Topic; Urinary Tract Infections; Pyelonephritis; Adrenal Cortex Hormones; Kidney; Glomerulonephritis
PubMed: 36943468
DOI: 10.1007/s00467-023-05922-0 -
Journal of Nephrology Jul 2023Acute pyelonephritis is a common infection in children that may cause renal scarring. The aim of this systematic review and meta-analysis was to analyse the use of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute pyelonephritis is a common infection in children that may cause renal scarring. The aim of this systematic review and meta-analysis was to analyse the use of corticosteroid treatment to prevent renal scarring.
METHODS
We searched the PubMED, SCOPUS, Cochrane CENTRAL and Web of Science databases in June 2022 for (corticosteroid* or dexamethasone or prednisolone* or prednisone* or hydrocortisone*) AND pyelonephritis. Randomised controlled trials focusing on children were included. The intervention was corticosteroid treatment with antibiotics compared to antibiotics with or without a placebo. The main outcome was the presence of renal scars on dimercaptosuccinic acid scanning at follow-up. The evidence quality was assessed using the GRADE methodology and risk of bias 2.0 tool. We calculated the risk ratio (RR), absolute risk difference (RD) with 95% confidence intervals (CI) and the number needed to treat (NNT). We applied a fixed effects model due to low heterogeneity.
RESULTS
We screened 872 abstracts and included five full texts. Renal scarring at follow-up was found in 31/220 (14.1%) patients in the corticosteroid groups and 76/278 (27.3%) in the control groups (RR 0.65, CI 0.44-0.96, RD - 13.2%, NNT 8). The evidence quality was moderate. Two studies reported adverse events with no differences between the groups. The risk of bias analysis showed some concerns in four studies.
CONCLUSION
We found moderate quality evidence that adjuvant corticosteroid treatment could prevent renal scarring. Adverse events were insufficiently reported, and more research on their effectiveness and harm is therefore needed before using corticosteroids in clinical settings.
Topics: Child; Humans; Cicatrix; Adrenal Cortex Hormones; Prednisolone; Anti-Bacterial Agents; Pyelonephritis; Randomized Controlled Trials as Topic
PubMed: 36692666
DOI: 10.1007/s40620-022-01552-1 -
Clinical Microbiology and Infection :... Dec 2022Randomised controlled trials (RCTs) investigated analgesics, herbal formulations, delayed prescription of antibiotics, and placebo to prevent overprescription of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Randomised controlled trials (RCTs) investigated analgesics, herbal formulations, delayed prescription of antibiotics, and placebo to prevent overprescription of antibiotics in women with uncomplicated urinary tract infections (uUTI).
OBJECTIVES
To estimate the effect of these strategies and to identify symptoms, signs, or other factors that indicate a benefit from these strategies.
DATA SOURCES
MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Database of Systematic Reviews and of Controlled Trials, and ClinicalTrials.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS
RCTs investigating any strategies to reduce antibiotics vs. immediate antibiotics in adult women with uUTI in primary care.
METHODS
We extracted individual participant data (IPD) if available, otherwise aggregate data (AD). Bayesian random-effects meta-analysis of the AD was used for pairwise comparisons. Candidate moderators and prognostic indicators of treatment effects were investigated using generalised linear mixed models based on IPD.
RESULTS
We analysed IPD of 3524 patients from eight RCTs and AD of 78 patients. Non-antibiotic strategies increased the rates of incomplete recovery (OR 3.0; 95% credible interval (CrI), 1.7-5.5; Bayesian p-value (p) = 0.0017; τ = 0.6), subsequent antibiotic treatment (OR 3.5; 95% CrI, 2.1-5.8; p = 0.0003) and pyelonephritis (OR 5.6; 95% CrI, 2.3-13.9; p = 0.0003). Conversely, they decreased overall antibiotic use by 63%. Patients positive for urinary erythrocytes and urine culture were at increased risk for incomplete recovery (OR 4.7; 95% CrI, 2.1-10.8; p = 0.0010), but no difference was apparent where both were negative (OR 0.8; 95% CrI, 0.3-2.0; p = 0.667). In patients treated using non-antibiotic strategies, urinary erythrocytes and positive urine culture were independent prognostic indicators for subsequent antibiotic treatment and pyelonephritis.
CONCLUSIONS
Compared to immediate antibiotics, non-antibiotic strategies reduce overall antibiotic use but result in poorer clinical outcomes. The presence of erythrocytes and tests to confirm bacteria in urine could be used to target antibiotic prescribing.
Topics: Female; Adult; Humans; Anti-Bacterial Agents; Urinary Tract Infections; Pyelonephritis
PubMed: 35788049
DOI: 10.1016/j.cmi.2022.06.017 -
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 -
The Cochrane Database of Systematic... Sep 2020In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive biomarkers could accurately differentiate children with cystitis from children with pyelonephritis, treatment and follow-up could potentially be individualized. This is an update of a review first published in 2015.
OBJECTIVES
The objectives of this review were to 1) determine whether procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) can replace the acute DMSA scan in the diagnostic evaluation of children with UTI; 2) assess the influence of patient and study characteristics on the diagnostic accuracy of these tests, and 3) compare the performance of the three tests to each other.
SEARCH METHODS
We searched MEDLINE, EMBASE, DARE, Web of Science, and BIOSIS Previews through to 17th December 2019 for this review. The reference lists of all included articles and relevant systematic reviews were searched to identify additional studies not found through the electronic search.
SELECTION CRITERIA
We only considered published studies that evaluated the results of an index test (PCT, CRP, ESR) against the results of an acute-phase Tc-dimercaptosuccinic acid (DMSA) scan (conducted within 30 days of the UTI) in children aged 0 to 18 years with a culture-confirmed episode of UTI. The following cut-off values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/hour for ESR.
DATA COLLECTION AND ANALYSIS
Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate pooled random-effects pooled sensitivity and specificity values.
MAIN RESULTS
A total of 36 studies met our inclusion criteria. Twenty-five studies provided data for the primary analysis: 12 studies (1000 children) included data on PCT, 16 studies (1895 children) included data on CRP, and eight studies (1910 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the PCT, CRP, ESR tests at the aforementioned cut-offs were 0.81 (0.67 to 0.90), 0.93 (0.86 to 0.96), and 0.83 (0.71 to 0.91), respectively. The summary specificity values for PCT, CRP, and ESR tests at these cut-offs were 0.76 (0.66 to 0.84), 0.37 (0.24 to 0.53), and 0.57 (0.41 to 0.72), respectively.
AUTHORS' CONCLUSIONS
The ESR test does not appear to be sufficiently accurate to be helpful in differentiating children with cystitis from children with pyelonephritis. A low CRP value (< 20 mg/L) appears to be somewhat useful in ruling out pyelonephritis (decreasing the probability of pyelonephritis to < 20%), but unexplained heterogeneity in the data prevents us from making recommendations at this time. The procalcitonin test seems better suited for ruling in pyelonephritis, but the limited number of studies and the marked heterogeneity between studies prevents us from reaching definitive conclusions. Thus, at present, we do not find any compelling evidence to recommend the routine use of any of these tests in clinical practice.
Topics: Acute Disease; Biomarkers; Blood Sedimentation; C-Reactive Protein; Calcitonin; Child; Cystitis; Diagnosis, Differential; Humans; Procalcitonin; Pyelonephritis; Randomized Controlled Trials as Topic; Sensitivity and Specificity; Urinary Tract Infections
PubMed: 32911567
DOI: 10.1002/14651858.CD009185.pub3 -
The Cochrane Database of Systematic... Nov 2019Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15%... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15% of pregnancies. If left untreated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth. This is an update of a review last published in 2015.
OBJECTIVES
To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth.
SEARCH METHODS
For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 4 November 2018, and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised controlled trials (RCT) comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. Trials using a cluster-RCT design and quasi-RCTs were eligible for inclusion, as were trials published in abstract or letter form, but cross-over studies were not.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.
MAIN RESULTS
We included 15 studies, involving over 2000 women. Antibiotic treatment compared with placebo or no treatment may reduce the incidence of pyelonephritis (average risk ratio (RR) 0.24, 95% confidence interval (CI) 0.13 to 0.41; 12 studies, 2017 women; low-certainty evidence). Antibiotic treatment may be associated with a reduction in the incidence of preterm birth (RR 0.34, 95% CI 0.13 to 0.88; 3 studies, 327 women; low-certainty evidence), and low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; 6 studies, 1437 babies; low-certainty evidence). There may be a reduction in persistent bacteriuria at the time of delivery (average RR 0.30, 95% CI 0.18 to 0.53; 4 studies; 596 women), but the results were inconclusive for serious adverse neonatal outcomes (average RR 0.64, 95% CI 0.23 to 1.79, 3 studies; 549 babies). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes, and maternal adverse effects were rarely described. Overall, we judged only one trial at low risk of bias across all domains; the other 14 studies were assessed as high or unclear risk of bias. Many studies lacked an adequate description of methods, and we could only judge the risk of bias as unclear, but in most studies, we assessed at least one domain at high risk of bias. We assessed the quality of the evidence for the three primary outcomes with GRADE software, and found low-certainty evidence for pyelonephritis, preterm birth, and birthweight less than 2500 g.
AUTHORS' CONCLUSIONS
Antibiotic treatment may be effective in reducing the risk of pyelonephritis in pregnancy, but our confidence in the effect estimate is limited given the low certainty of the evidence. There may be a reduction in preterm birth and low birthweight with antibiotic treatment, consistent with theories about the role of infection in adverse pregnancy outcomes, but again, the confidence in the effect is limited given the low certainty of the evidence. Research implications identified in this review include the need for an up-to-date cost-effectiveness evaluation of diagnostic algorithms, and more evidence to learn whether there is a low-risk group of women who are unlikely to benefit from treatment of asymptomatic bacteriuria.
Topics: Anti-Bacterial Agents; Asymptomatic Infections; Bacteriuria; Female; Humans; Infant, Low Birth Weight; Infant, Newborn; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Premature Birth; Pyelonephritis; Randomized Controlled Trials as Topic
PubMed: 31765489
DOI: 10.1002/14651858.CD000490.pub4