-
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 -
Antimicrobial Agents and Chemotherapy Jan 2019Increasing bacterial resistance and poor patient adherence rates limit the effectiveness of conventional antibiotic therapies for urinary tract infection (UTI). The...
Increasing bacterial resistance and poor patient adherence rates limit the effectiveness of conventional antibiotic therapies for urinary tract infection (UTI). The objective of this study was to investigate whether a single aminoglycoside dose adequately treated UTI. A systematic search of PubMed/MEDLINE and Google Scholar databases was performed through September 2018 for English language original research articles assessing the efficacy of one-time parenteral aminoglycoside as UTI monotherapy. Of 252 potentially relevant studies, 13 studies met the inclusion criteria, representing 13,804 patients. Patient ages ranged from 2 weeks to >70 years; both inpatient and outpatient settings were represented. Cystitis was more common than pyelonephritis, and more females were represented than males. was the most commonly isolated uropathogen. The pooled microbiologic cure rate with single-dose aminoglycoside therapy was 94.5% ± 4.3%. Cure was sustained (no recurrence) for 73.4% ± 9.6% of patients at day 30. Lower cure rates were observed among patients with radiographic urinary tract abnormality (chi-square < 0.01). Across all studies, 63/13,804 (0.5%) cases of nephrotoxicity, vestibular toxicity, or injection site reaction were reported; no hearing loss was observed. Single-dose aminoglycoside therapy appears to be an effective treatment option for lower UTI in nonseptic patients, with minimal toxicity. Additional studies would be beneficial to confirm efficacy for pyelonephritis. When resistance to first-line UTI agents is endemic, aminoglycosides may serve as β-lactam- and fluoroquinolone-sparing options.
Topics: Adolescent; Adult; Aged; Aminoglycosides; Anti-Bacterial Agents; Antimicrobial Stewardship; Child; Child, Preschool; Cystitis; Drug Administration Schedule; Drug Resistance, Multiple, Bacterial; Escherichia coli; Escherichia coli Infections; Female; Humans; Infant; Infant, Newborn; Male; Middle Aged; Pyelonephritis; Treatment Outcome
PubMed: 30397061
DOI: 10.1128/AAC.02165-18 -
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 -
Pharmacotherapy Jun 2018Commonly prescribed durations of therapy for many, if not most, bacterial infections are not evidence-based. Misunderstandings by clinicians and patients alike influence... (Meta-Analysis)
Meta-Analysis
Commonly prescribed durations of therapy for many, if not most, bacterial infections are not evidence-based. Misunderstandings by clinicians and patients alike influence perspectives on antibiotic use, including duration of therapy and its role in antibiotic resistance. To demonstrate that shorter durations of antibiotic therapy are as efficacious as longer durations for many infections, a systematic review was undertaken of English-language articles by using PubMed to identify articles for inclusion. Additionally, infection-specific guidelines were identified for review of recommendations. Search terms included specific infection types, randomized controlled trial (RCT), duration of therapy, treatment duration, short course, and long course. Only RCTs of single-agent antibiotic therapy for the treatment of bacterial infections in adults were included. Independent data extraction of articles was conducted by two authors by using predefined guidance for article inclusion. In total, 23 RCTs met our criteria for inclusion. All trials compared single-agent antibiotics for a short and long antibiotic course in six common infections: community-acquired pneumonia, ventilator-associated pneumonia, intraabdominal infections, skin and soft tissue infections, uncomplicated cystitis, and complicated cystitis or pyelonephritis. Clinicians can decrease net antibiotic use by recommending shorter courses where evidence supports them. Antimicrobial stewardship programs that systematically address treatment duration may significantly affect institutional antibiotic use without negatively affecting patient care.
Topics: Anti-Bacterial Agents; Bacterial Infections; Community-Acquired Infections; Cystitis; Humans; Pneumonia; Pneumonia, Ventilator-Associated; Pyelonephritis; Randomized Controlled Trials as Topic; Soft Tissue Infections; Time Factors
PubMed: 29679383
DOI: 10.1002/phar.2118 -
Nephrology (Carlton, Vic.) Apr 2019The aim of this study was to determine whether a correlation exists between interleukin-8 receptor polymorphisms and urinary tract infection (UTI) susceptibility. (Meta-Analysis)
Meta-Analysis
AIM
The aim of this study was to determine whether a correlation exists between interleukin-8 receptor polymorphisms and urinary tract infection (UTI) susceptibility.
METHODS
We systematically searched electronic databases including PubMed, Embase, China National Knowledge Infrastructure, and Web of Science up to 5 November 2017 to select appropriate studies that focused on C-X-C chemokine receptor type 1 and/or 2 (CXCR1, CXCR2) polymorphisms with susceptibility to UTI. Eight case-control studies including 2085 patients with UTI and 2012 controls were enrolled in this study. Seven studies of CXCR1 rs2234671 and two studies of rs3138086 were included in the meta-analyses. Pooled odds ratio (OR) and corresponding 95% confidence interval (CI) were synthesized using fixed-effects or random-effects model according to heterogeneity.
RESULTS
No significant correlations were found between CXCR1 rs2234671 and rs3138086 polymorphisms and UTI susceptibility. However, subgroup analysis showed that rs2234671 was associated with an increased risk of UTI under allelic comparisons (C vs. G, OR = 1.95, 95% CI = 1.07-3.55), heterozygous model (GC vs. GG, OR = 1.93, 95% CI = 1.06-3.50), and dominant model (GC + CC vs. GG, OR = 1.98, 95% CI = 1.07-3.69) in children, especially in paediatric patients with acute pyelonephritis (allelic, OR = 2.43, 95% CI = 1.28-4.60; heterozygous, OR = 2.40, 95% CI = 1.24-4.62; dominant, OR = 2.48, 95% CI = 1.26-4.88). Furthermore, these results remained the same after eliminating paediatric patients with vesicoureteral reflux.
CONCLUSION
CXCR1 rs2234671 polymorphism might be associated with an increased risk of UTI in children.
Topics: Age Factors; Case-Control Studies; Gene Frequency; Genetic Association Studies; Genetic Predisposition to Disease; Heterozygote; Homozygote; Humans; Phenotype; Polymorphism, Single Nucleotide; Protective Factors; Pyelonephritis; Receptors, Interleukin-8A; Receptors, Interleukin-8B; Risk Factors; Urinary Tract Infections
PubMed: 29577511
DOI: 10.1111/nep.13260 -
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 -
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 -
Pediatrics May 2017Acute pyelonephritis may result in renal scarring. Recent prospective studies have shown a small benefit of antibiotic prophylaxis in preventing symptomatic and febrile... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Acute pyelonephritis may result in renal scarring. Recent prospective studies have shown a small benefit of antibiotic prophylaxis in preventing symptomatic and febrile urinary tract infections (UTIs), while being underpowered to detect any influence in prevention of renal damage.
OBJECTIVES
Review of the literature and a meta-analysis to evaluate the effect of antibiotic prophylaxis on UTI-related renal scarring.
DATA SOURCES
Medline, Embase, and Cochrane Controlled Trials Register electronic databases were searched for studies published in any language and bibliographies of identified prospective randomized controlled trials (RCTs) performed and published between 1946 and August 2016.
STUDY SELECTION
Subjects 18 years of age or younger with symptomatic or febrile UTIs, enrolled in prospective RCTs of antibiotic prophylaxis where Tc dimercaptosuccinic acid scans were performed at entry into the study and at late follow-up to detect new scar formation.
DATA EXTRACTION
The literature search, study characteristics, inclusion and exclusion criteria, and risk of bias assessment were independently evaluated by 2 authors.
RESULTS
Seven RCTs (1427 subjects) were included in the meta-analysis. Our results show no influence of antibiotic prophylaxis in preventing renal scarring (pooled risk ratio, 0.83; 95% confidence interval, 0.55-1.26) as did a subanalysis restricted to those subjects with vesicoureteral reflux (pooled risk ratio, 0.79; 95% confidence interval, 0.51-1.24).
LIMITATIONS
Limitations include the small number of studies, short duration of follow-up, and insufficient children with high-grade dilating reflux and/or renal dysplasia enrolled in the studies.
CONCLUSIONS
Antibiotic prophylaxis is not indicated for the prevention of renal scarring after a first or second symptomatic or febrile UTI in otherwise healthy children.
Topics: Acute Disease; Antibiotic Prophylaxis; Child; Cicatrix; Humans; Kidney; Pyelonephritis; Urinary Tract Infections
PubMed: 28557737
DOI: 10.1542/peds.2016-3145 -
The Cochrane Database of Systematic... Aug 2015Asymptomatic bacteriuria occurs in 2% to 10% of pregnancies and, if not treated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Asymptomatic bacteriuria occurs in 2% to 10% of pregnancies and, if not treated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth.
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
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 March 2015) and reference lists of retrieved studies.
SELECTION CRITERIA
Randomized trials comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.
MAIN RESULTS
Fourteen studies, involving almost 2000 women, were included. Antibiotic treatment compared with placebo or no treatment reduced the incidence of pyelonephritis (average risk ratio (RR) 0.23, 95% confidence interval (CI) 0.13 to 0.41; 11 studies, 1932 women; very low quality evidence). Antibiotic treatment was also associated with a reduction in the incidence of low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; six studies, 1437 babies; low quality evidence) and preterm birth (RR 0.27, 95% CI 0.11 to 0.62; two studies, 242 women; low quality evidence). A reduction in persistent bacteriuria at the time of delivery was seen (average RR 0.30, 95% CI 0.18 to 0.53; four studies; 596 women). 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, all 14 studies were assessed as being at high or unclear risk of bias. While many studies lacked an adequate description of methods and the risk of bias could only be assessed as unclear, in almost all studies there was at least one domain where the risk of bias was judged as high. The three primary outcomes were assessed with GRADE software and given a quality rating. Evidence for pyelonephritis, preterm birth and birthweight less than 2500 g was assessed as of low or very low quality.
AUTHORS' CONCLUSIONS
While antibiotic treatment is effective in reducing the risk of pyelonephritis in pregnancy, the estimate of the effect is very uncertain because of the very low quality of the evidence. The reduction in low birthweight and preterm birth with antibiotic treatment is consistent with theories about the role of infection in adverse pregnancy outcomes, but this association should be interpreted with caution given the very poor quality of the included studies.
Topics: Anti-Bacterial Agents; Asymptomatic Infections; Bacteriuria; Confidence Intervals; Female; Humans; Infant, Low Birth Weight; Infant, Newborn; Odds Ratio; Pregnancy; Pregnancy Complications, Infectious; Pyelonephritis; Randomized Controlled Trials as Topic
PubMed: 26252501
DOI: 10.1002/14651858.CD000490.pub3 -
The Cochrane Database of Systematic... Feb 2015Pyelonephritis is a type of urinary tract infection (UTI) that affects the upper urinary tract and kidneys, and is one of the most common conditions for hospitalisation... (Review)
Review
BACKGROUND
Pyelonephritis is a type of urinary tract infection (UTI) that affects the upper urinary tract and kidneys, and is one of the most common conditions for hospitalisation among pregnant women, aside from delivery. Samples of urine and blood are obtained and used for cultures as part of the diagnosis and management of the condition. Acute pyelonephritis requires hospitalisation with intravenous administration of antimicrobial agents. Several studies have questioned the necessity of obtaining blood cultures in addition to urine cultures, citing cost and questioning whether blood testing is superfluous. Pregnant women with bacteraemia require a change in the initial empirical treatment based on the blood culture. However, these cases are not common, and represent approximately 15% to 20% of cases. It is unclear whether blood cultures are essential for the effective management of the condition.
OBJECTIVES
To assess the effectiveness of routine blood cultures to improve health outcomes in the management of pyelonephritis in pregnant women.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register without language or date restrictions (31 December 2014).
SELECTION CRITERIA
Randomised controlled trials and quasi-randomised trials comparing outcomes among pregnant women with pyelonephritis who received initial management with or without blood cultures. Cluster-randomised trials were eligible for inclusion in this review but none were identified. Clinical trials using a cross-over design were not eligible for inclusion.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed one trial report for inclusion.
MAIN RESULTS
We identified one trial report but this was excluded. No clinical trials met the inclusion criteria for this review.
AUTHORS' CONCLUSIONS
There are no large-scale randomised controlled trials to assess outcomes in the management of pyelonephritis in pregnancy with or without blood cultures. Randomised controlled trials are needed to evaluate the effectiveness of managing pyelonephritis in pregnant women with or without blood cultures, and to assess any adverse outcomes as well as the cost-effectiveness of excluding blood cultures from treatment.
Topics: Adult; Female; Humans; Microbiological Techniques; Pregnancy; Pregnancy Complications, Infectious; Pyelonephritis
PubMed: 25679346
DOI: 10.1002/14651858.CD009216.pub2