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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 -
Progres En Urologie : Journal de... Nov 2021The aim of this article was to cite rare but sometimes serious emergencies that may be encountered by any urologist during their practice, and to outline the main...
INTRODUCTION
The aim of this article was to cite rare but sometimes serious emergencies that may be encountered by any urologist during their practice, and to outline the main principles of their management.
MATERIAL AND METHOD
A systematic review of the literature using PubMed, Embase and Google Scholar was carried out between January 2000 and June 2021. The articles obtained were selected according to their age and type. The original articles, meta-analyses, recommendations and the most recent journal articles published in French and English have been retained. A total of 312 articles were identified and 58 selected from their abstracts. The articles were then analysed exhaustively by the authors, and 24 references were finally selected.
RESULTS
Several rare emergencies of an infectious nature (xanthogranulomatous pyelonephritis, emphysematous cystitis and pyelonephritis, malacoplasia, hydatiduria), ischemic nature (Fournier's gangrene, penile calciphylaxis), or hemorrhagic nature (hemospermia, hemorrhages of the upper urinary tract or adrenal gland spontaneous hematoma), or at the origin of painful manifestations (spermatic colic, venous thrombosis of the penis), can pose diagnostic and therapeutic difficulties, in the absence of consensus concerning their management.
CONCLUSION
These pathologies, rare but sometimes serious, must be recognized in order to not delay the treatment and to be able to reduce their morbidity and mortality. Combined with the constant improvement of our diagnostic and therapeutic arsenal, a better knowledge of these rare emergencies will help to preserve the functional and vital prognosis of patients.
Topics: Cystitis; Emergencies; Fournier Gangrene; Humans; Male; Pyelonephritis; Urology
PubMed: 34419373
DOI: 10.1016/j.purol.2021.08.002 -
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 -
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 -
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 -
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 -
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 -
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 -
The Annals of Pharmacotherapy Aug 2020Gaps and inconsistencies in published information about optimal antibiotic treatment duration for uncomplicated urinary tract infection (UTI) in pediatric patients pose... (Meta-Analysis)
Meta-Analysis
Gaps and inconsistencies in published information about optimal antibiotic treatment duration for uncomplicated urinary tract infection (UTI) in pediatric patients pose a dilemma for antibiotic stewardship. Evaluate the association of antibiotic treatment duration with recurrence rates in children with new-onset cystitis or pyelonephritis. Retrospective cohort analysis of patients aged 2 to 17 years with new-onset cystitis or pyelonephritis and without renal/anatomical abnormality was conducted using Truven Health MarketScan Database for 2013-2015. Of 7698 patients, 85.5% had cystitis, 14.3% pyelonephritis. Duration of antibiotic treatment was as follows: 3 to 5 days for cystitis (20.4%) or 7 (33.6%), 10 (44.2%), or 14 (1.8%) days for any UTI. Recurrence occurred in 5.5% of patients. Covariates associated with increased recurrence risk included pretreatment antibiotic exposure (odds ratio [OR] = 1.29; 95% CI = 1.06-1.57), pyelonephritis on diagnosis date (OR = 1.44; 95% CI = 1.03-2.00), follow-up visit during antibiotic treatment (OR = 3.21; 95% CI = 2.20-4.68), parenteral antibiotic (OR = 1.89; 95% CI = 1.33-2.69), and interaction of pyelonephritis diagnosis with nitrofurantoin monotherapy (OR = 3.68; 95% CI = 1.20-11.29). After adjustment for covariates, the association between duration of antibiotic treatment and recurrence was not significant (compared with 7 days: 10 days: OR = 1.07, 95% CI = 0.85-1.33; 14 days: OR = 0.89, 95% CI = 0.45-1.78). Antibiotic treatment duration was not significantly associated with recurrence of uncomplicated UTI in a national pediatric cohort. Results provide support for shorter-course treatment, consistent with antimicrobial stewardship efforts.
Topics: Adolescent; Anti-Bacterial Agents; Antimicrobial Stewardship; Child; Child, Preschool; Cystitis; Duration of Therapy; Female; Humans; Male; Pyelonephritis; Recurrence; Retrospective Studies; Urinary Tract Infections
PubMed: 31958969
DOI: 10.1177/1060028019900650 -
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