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The Cochrane Database of Systematic... Jan 2015In 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 Review
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.
OBJECTIVES
The objectives of this review were to 1) determine whether procalcitonin, 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 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 (procalcitonin, CRP, ESR) against the results of an acute-phase 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 cutoff values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/h 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 24 studies met our inclusion criteria. Seventeen studies provided data for the primary analysis: six studies (434 children) included data on procalcitonin, 13 studies (1638 children) included data on CRP, and six studies (1737 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the procalcitonin, CRP, ESR tests at the aforementioned cutoffs were 0.86 (0.72 to 0.93), 0.94 (0.85 to 0.97), and 0.87 (0.77 to 0.93), respectively. The summary specificity values for procalcitonin, CRP, and ESR tests at these cutoffs were 0.74 (0.55 to 0.87), 0.39 (0.23 to 0.58), and 0.48 (0.33 to 0.64), 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; Pyelonephritis; Randomized Controlled Trials as Topic; Sensitivity and Specificity; Urinary Tract Infections
PubMed: 25603480
DOI: 10.1002/14651858.CD009185.pub2 -
BMJ Clinical Evidence Nov 2014Pyelonephritis is usually caused by ascent of bacteria (most often Escherichia coli) from the bladder, and is more likely in people with structural or functional urinary... (Review)
Review
INTRODUCTION
Pyelonephritis is usually caused by ascent of bacteria (most often Escherichia coli) from the bladder, and is more likely in people with structural or functional urinary tract abnormalities. The prognosis is good if pyelonephritis is treated appropriately, but complications include renal abscess, renal impairment, and septic shock.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of antibiotic treatments for acute pyelonephritis in non-pregnant women with uncomplicated infection? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found four studies that met our inclusion criteria.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (intravenous), antibiotics (oral), and antibiotics (switch therapy).
Topics: Anti-Bacterial Agents; Female; Humans; Pyelonephritis
PubMed: 25373019
DOI: No ID Found -
The Cochrane Database of Systematic... Jul 2014Urinary tract infection (UTI) is one of the most common bacterial infections in infants. The most severe form of UTI is acute pyelonephritis, which results in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Urinary tract infection (UTI) is one of the most common bacterial infections in infants. The most severe form of UTI is acute pyelonephritis, which results in significant acute morbidity and may cause permanent kidney damage. There remains uncertainty regarding the optimum antibiotic regimen, route of administration and duration of treatment. This is an update of a review that was first published in 2003 and updated in 2005 and 2007.
OBJECTIVES
To evaluate the benefits and harms of antibiotics used to treat children with acute pyelonephritis. The aspects of therapy considered were 1) different antibiotics, 2) different dosing regimens of the same antibiotic, 3) different duration of treatment, and 4) different routes of administration.
SEARCH METHODS
We searched the Cochrane Renal Group's Specialised Register, CENTRAL, MEDLINE, EMBASE, reference lists of articles and conference proceedings without language restriction to 10 April 2014.
SELECTION CRITERIA
Randomised and quasi-randomised controlled trials comparing different antibiotic agents, routes, frequencies or durations of therapy in children aged 0 to 18 years with proven UTI and acute pyelonephritis were selected.
DATA COLLECTION AND ANALYSIS
Four authors independently assessed study quality and extracted data. Statistical analyses were performed using the random-effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI).
MAIN RESULTS
This updated review included 27 studies (4452 children). This update included evidence from three new studies, and following re-evaluation, a previously excluded study was included because it now met our inclusion criteria.Risk of bias was assessed as low for sequence generation (12 studies), allocation concealment (six studies), blinding of outcome assessors (17 studies), incomplete outcome reporting (19 studies) and selective outcome reporting (13 studies). No study was blinded for participants or investigators. The 27 included studies evaluated 12 different comparisons. No significant differences were found in duration of fever (2 studies, 808 children: MD 2.05 hours, 95% CI -0.84 to 4.94), persistent UTI at 72 hours after commencing therapy (2 studies, 542 children: RR 1.10, 95% CI 0.07 to 17.41) or persistent kidney damage at six to 12 months (4 studies, 943 children: RR 0.82, 95% CI 0.59 to 1.12) between oral antibiotic therapy (10 to 14 days) and intravenous (IV) therapy (3 days) followed by oral therapy (10 days). Similarly, no significant differences in persistent bacteriuria at the end of treatment (4 studies, 305 children: RR 0.78, 95% CI 0.24 to 2.55) or persistent kidney damage (4 studies, 726 children: RR 1.01, 95% CI 0.80 to 1.29) were found between IV therapy (three to four days) followed by oral therapy and IV therapy (seven to 14 days). No significant differences in efficacy were found between daily and thrice daily administration of aminoglycosides (1 study, 179 children, persistent clinical symptoms at three days: RR 1.98, 95% CI 0.37 to 10.53). Adverse events were mild and uncommon and rarely resulted in discontinuation of treatment.
AUTHORS' CONCLUSIONS
This updated review increases the body of evidence that oral antibiotics alone are as effective as a short course (three to four days) of IV antibiotics followed by oral therapy for a total treatment duration of 10 to 14 days for the treatment of acute pyelonephritis in children. When IV antibiotics are given, a short course (two to four days) of IV therapy followed by oral therapy is as effective as a longer course (seven to 10 days) of IV therapy. If IV therapy with aminoglycosides is chosen, single daily dosing is safe and effective. Insufficient data are available to extrapolate these findings to children aged less than one month of age or to children with dilating vesicoureteric reflux (grades III-V). Further studies are required to determine the optimal total duration of antibiotic therapy required for acute pyelonephritis.
Topics: Acute Disease; Administration, Oral; Adolescent; Anti-Bacterial Agents; Child; Drug Therapy, Combination; Humans; Infant; Injections, Intravenous; Pyelonephritis; Randomized Controlled Trials as Topic
PubMed: 25066627
DOI: 10.1002/14651858.CD003772.pub4 -
The Journal of Antimicrobial... Oct 2013Acute pyelonephritis is a frequent cause of morbidity, with a wide variation in duration of therapy. We performed a systematic review of all randomized controlled trials... (Meta-Analysis)
Meta-Analysis Review
Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection-- 7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Acute pyelonephritis is a frequent cause of morbidity, with a wide variation in duration of therapy. We performed a systematic review of all randomized controlled trials (RCTs) comparing ≤7 days treatment with a longer course.
METHODS
Electronic databases were searched to identify RCTs that assessed adults treated for pyelonephritis, comparing a 7 day or shorter versus longer therapy. Primary outcome was clinical failure at the end of the long treatment arm (EOT). Secondary outcomes included clinical failure at the end of follow-up (EOF), microbiological failure, all-cause mortality, the development of resistance and adverse events.
RESULTS
Clinical failure at EOT did not significantly differ between the two treatment arms [relative risk (RR) 0.63, 95% CI 0.33-1.18, I(2) = 41%]. Results did not differ when including studies comparing only fluoroquinolones, reducing the heterogeneity (RR 0.76, 95% CI 0.49-1.17, I(2) = 0%). We found no difference between the short and long treatment arms regarding clinical failure at EOF, even in a small subgroup of bacteraemic patients. No difference was found between the arms regarding microbiological failure at EOF, except in a subgroup of studies with a high percentage of patients with urogenital abnormalities, where microbiological failure at EOF was significantly higher in the short treatment arm (RR 1.78, 95% CI 1.02-3.10, I(2) = 21%). Adverse events were similar between the arms.
CONCLUSIONS
Seven days of treatment for acute pyelonephritis is equivalent to longer treatment in terms of clinical failure and microbiological failure, including in bacteraemic patients. In patients with urogenital abnormalities, the evidence, although weak, suggests that longer treatment is required.
Topics: Anti-Bacterial Agents; Bacterial Infections; Humans; Pyelonephritis; Randomized Controlled Trials as Topic; Time Factors; Urinary Tract Infections
PubMed: 23696620
DOI: 10.1093/jac/dkt177 -
Pediatrics May 2013Urinary tract infections (UTIs) are common childhood bacterial infections that may involve renal parenchymal infection (acute pyelonephritis [APN]) followed by late... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVE
Urinary tract infections (UTIs) are common childhood bacterial infections that may involve renal parenchymal infection (acute pyelonephritis [APN]) followed by late scarring. Prompt, high-quality diagnosis of APN and later identification of children with scarring are important for preventing future complications. Examination via dimercaptosuccinic acid scanning is the current clinical gold standard but is not routinely performed. A more accessible assay could therefore prove useful. Our goal was to study procalcitonin as a predictor for both APN and scarring in children with UTI.
METHODS
A systematic review and meta-analysis of individual patient data were performed; all data were gathered from children with UTIs who had undergone both procalcitonin measurement and dimercaptosuccinic acid scanning.
RESULTS
A total of 1011 patients (APN in 60.6%, late scarring in 25.7%) were included from 18 studies. Procalcitonin as a continuous, class, and binary variable was associated with APN and scarring (P < .001) and demonstrated a significantly higher (P < .05) area under the receiver operating characteristic curve than either C-reactive protein or white blood cell count for both pathologies. Procalcitonin ≥0.5 ng/mL yielded an adjusted odds ratio of 7.9 (95% confidence interval [CI]: 5.8-10.9) with 71% sensitivity (95% CI: 67-74) and 72% specificity (95% CI: 67-76) for APN. Procalcitonin ≥0.5 ng/mL was significantly associated with late scarring (adjusted odds ratio: 3.4 [95% CI: 2.1-5.7]) with 79% sensitivity (95% CI: 71-85) and 50% specificity (95% CI: 45-54).
CONCLUSIONS
Procalcitonin was a more robust predictor compared with C-reactive protein or white blood cell count for selectively identifying children who had APN during the early stages of UTI, as well as those with late scarring.
Topics: Acute Disease; Adolescent; Area Under Curve; Biomarkers; C-Reactive Protein; Calcitonin; Calcitonin Gene-Related Peptide; Child; Child, Preschool; Cicatrix; Confidence Intervals; Disease Progression; Female; Follow-Up Studies; Humans; Incidence; Likelihood Functions; Male; Odds Ratio; Predictive Value of Tests; Protein Precursors; Pyelonephritis; Risk Assessment; Severity of Illness Index; Urinary Tract Infections
PubMed: 23629615
DOI: 10.1542/peds.2012-2408 -
Critical Care (London, England) 2011The optimal duration of antibiotic therapy for bloodstream infections is unknown. Shorter durations of therapy have been demonstrated to be as effective as longer... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The optimal duration of antibiotic therapy for bloodstream infections is unknown. Shorter durations of therapy have been demonstrated to be as effective as longer durations for many common infections; similar findings in bacteremia could enable hospitals to reduce antibiotic utilization, adverse events, resistance and costs.
METHODS
A search of the MEDLINE, EMBASE and COCHRANE databases was conducted for the years 1947-2010. Controlled trials were identified that randomized patients to shorter versus longer durations of treatment for bacteremia, or the infectious foci most commonly causing bacteremia in critically ill patients (catheter-related bloodstream infections (CRBSI), intra-abdominal infections, pneumonia, pyelonephritis and skin and soft-tissue infections (SSTI)).
RESULTS
Twenty-four eligible trials were identified, including one trial focusing exclusively on bacteremia, zero in catheter related bloodstream infection, three in intra-abdominal infection, six in pyelonephritis, thirteen in pneumonia and one in skin and soft tissue infection. Thirteen studies reported on 227 patients with bacteremia allocated to 'shorter' or 'longer' durations of treatment. Outcome data were available for 155 bacteremic patients: neonatal bacteremia (n = 66); intra-abdominal infection (40); pyelonephritis (9); and pneumonia (40). Among bacteremic patients receiving shorter (5-7 days) versus longer (7-21 days) antibiotic therapy, no significant difference was detected with respect to rates of clinical cure (45/52 versus 47/49, risk ratio 0.88, 95% confidence interval [CI] 0.77-1.01), microbiologic cure (28/28 versus 30/32, risk ratio 1.05, 95% CI 0.91-1.21), and survival (15/17 versus 26/29, risk ratio 0.97, 95% CI 0.76-1.23).
CONCLUSIONS
No significant differences in clinical cure, microbiologic cure and survival were detected among bacteremic patients receiving shorter versus longer duration antibiotic therapy. An adequately powered randomized trial of bacteremic patients is needed to confirm these findings.
Topics: Anti-Bacterial Agents; Bacteremia; Catheter-Related Infections; Humans; Intraabdominal Infections; Pneumonia, Bacterial; Pyelonephritis; Soft Tissue Infections; Time Factors
PubMed: 22085732
DOI: 10.1186/cc10545 -
BMJ Clinical Evidence Jan 2011Pyelonephritis is usually caused by ascent of bacteria, most often Escherichia coli, from the bladder, and is more likely in people with structural or functional urinary... (Review)
Review
INTRODUCTION
Pyelonephritis is usually caused by ascent of bacteria, most often Escherichia coli, from the bladder, and is more likely in people with structural or functional urinary tract abnormalities. The prognosis is good if pyelonephritis is treated appropriately, but complications include renal abscess, renal impairment, and septic shock.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: antibiotic treatments for acute pyelonephritis in women with uncomplicated infection; inpatient versus outpatient management in women with uncomplicated infection; and analgesia in uncomplicated acute pyelonephritis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found three systematic reviews, RCTs, or observational studies that met our inclusion criteria.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (intravenous), antibiotics (oral), antibiotics (switch therapy), inpatient versus outpatient management, non-steroidal anti-inflammatory drugs, simple analgesics (non-opioid), and urinary analgesics.
Topics: Acute Disease; Administration, Oral; Anti-Bacterial Agents; Escherichia coli; Female; Humans; Incidence; Pyelonephritis; Urinary Tract Infections
PubMed: 21477395
DOI: No ID Found -
International Journal of Clinical... Nov 2010With the introduction of screening programmes for haemoglobinopathies (HbP), more women will be aware of their HbP status. The genetic risk for women who are carriers of... (Review)
Review
With the introduction of screening programmes for haemoglobinopathies (HbP), more women will be aware of their HbP status. The genetic risk for women who are carriers of HbP is well known. However, midwives and obstetricians need to know whether there are other risks involved in the pregnancies of women who are carriers of HbP. The objective of this study was to investigate the hypothesis that being a carrier of HbP has no consequences for the health of pregnant women and the outcome of their pregnancies. A systematic search was carried out until August 2008 in the Cochrane Library, Medline, EMBASE and CINAHL databases. All references were inspected to identify further studies. The authors of key publications were contacted for any unpublished research. Selection of studies was made on the basis of the following criteria: Cohort and case-control studies, pregnant women with a singleton pregnancy, exposure: HbAS or thalassaemia minor and the following outcomes: urinary tract infection (UTI), anaemia, (pre-)eclampsia, gestational diabetes, premature labour, low birth weight, intrauterine growth retardation, miscarriage, neonatal death, low Apgar score, neural tube defects. Quality assessment and data extraction were carried out by two researchers. A total of 780 subjects were identified of which nine were included in the study. A protective effect of sickle cell trait was found for premature birth, low Apgar score and perinatal mortality rate. No significant effect was found for low birth weight, growth retardation, UTI or high blood pressure. The risk of anaemia and bacteriuria was increased. In conclusion, the risks amongst pregnant HbP carriers are low. Midwives and obstetricians need to be aware of the risk of anaemia and UTI.
Topics: Abortion, Spontaneous; Apgar Score; Diabetes, Gestational; Female; Fetal Growth Retardation; Hemoglobinopathies; Heterozygote; Humans; Hypertension, Pregnancy-Induced; Neural Tube Defects; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy Complications, Infectious; Pregnancy Outcome; Premature Birth; Pyelonephritis; Risk Factors; Urinary Tract Infections
PubMed: 20946275
DOI: 10.1111/j.1742-1241.2010.02451.x -
Current Medical Research and Opinion Dec 2008Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis.
OBJECTIVE
We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis.
METHODS
We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment.
RESULTS
Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations.
CONCLUSION
Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.
Topics: Administration, Oral; Adolescent; Adult; Anti-Infective Agents; Child; Child, Preschool; Female; Hospitalization; Humans; Infusions, Intravenous; Male; Meta-Analysis as Topic; PubMed; Pyelonephritis; Randomized Controlled Trials as Topic; Time Factors; Treatment Outcome
PubMed: 19032124
DOI: 10.1185/03007990802550679 -
The Journal of Urology May 2008There is no current consensus on what constitutes the ideal management of emphysematous pyelonephritis. We review the current management strategies including the role of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
There is no current consensus on what constitutes the ideal management of emphysematous pyelonephritis. We review the current management strategies including the role of nephron preserving percutaneous drainage in the treatment of emphysematous pyelonephritis.
MATERIALS AND METHODS
We searched MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from 1966 to 2006. Abstracts were reviewed including all types of studies from prospective randomized controlled studies to small retrospective series. All relevant English language articles reporting on at least 5 patients were reviewed.
RESULTS
Ten retrospective studies on 210 patients with emphysematous pyelonephritis met the inclusion criteria. There were 167 females and 43 males with a mean age of 57 years (range 24 to 83). Of the patients 96% had diabetes mellitus and 29% had urinary tract obstruction. The diagnostic accuracy of computerized tomography was 100%. Escherichia coli and Klebsiella were the most common causative agents. The mortality from medical management alone was 50%, medical management combined with emergency nephrectomy was 25% and medical management combined with percutaneous drainage was 13.5%. Mortality was significantly less in patients undergoing percutaneous drainage compared to other treatments (Pearson chi-square p <0.001). Of the patients who underwent medical treatment with percutaneous drainage a small number (15) underwent elective nephrectomy and mortality was 6.6% (1 of 15).
CONCLUSIONS
Percutaneous drainage should be part of the initial management strategy for emphysematous pyelonephritis. This strategy is associated with a lower mortality than medical management or emergency nephrectomy. Delayed elective nephrectomy may be required in some patients.
Topics: Drainage; Emphysema; Humans; Punctures; Pyelonephritis
PubMed: 18353396
DOI: 10.1016/j.juro.2008.01.019