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Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: A prospective cohort study with an embedded randomised controlled trial
Abstract
Background:
Existing approaches for the screening and treatment of asymptomatic bacteriuria in pregnancy are based on trials that were done more than 30 years ago. In this study, we reassessed the consequences of treated and untreated asymptomatic bacteriuria in pregnancy.
Methods:
In this multicentre prospective cohort study with an embedded randomised controlled trial, we screened women (aged ≥18 years) at eight hospitals and five ultrasound centres in the Netherlands with a singleton pregnancy between 16 and 22 weeks' gestation for asymptomatic bacteriuria. Screening was done with a single dipslide and two culture media. Dipslides were judged positive when the colony concentration was at least 1×10(5) colony-forming units (CFU) per mL of a single microorganism or when two different colony types were present but one had a concentration of at least 1×10(5) CFU per mL. Asymptomatic bacteriuria-positive women were eligible to participate in the randomised controlled trial comparing nitrofurantoin with placebo treatment. In this trial, participants were randomly assigned 1:1 to receive either nitrofurantoin 100 mg or identical placebo tablets, and were instructed to self-administer these tablets twice daily for 5 consecutive days. Randomisation was done by a web-based application with a computer-generated list with random block sizes of two, four, or six participants rendered by an independent data manager. 1 week after the end of treatment, they provided us with a follow-up dipslide. Women, treating physicians, and researchers all remained unaware of the bacteriuria status and treatment allocation. Women who refused to participate in the randomised controlled trial did not receive any antibiotics, but their outcomes were collected for analysis in the cohort study. We compared untreated and placebo-treated asymptomatic bacteriuria-positive women with asymptomatic bacteriuria-negative women and nitrofurantoin-treated asymptomatic bacteriuria-positive women. The primary endpoint was a composite of pyelonephritis with or without preterm birth at less than 34 weeks, analysed by intention to treat at 6 weeks post-partum. This trial is registered with the Dutch Trial Registry, number NTR3068.
Findings:
Between Oct 11, 2011, and June 10, 2013, we enrolled 5621 women into our screening cohort, of whom 5132 were eligible for screening. After exclusions for contaminated dipslides and patients lost to follow-up, in our final cohort of 4283 women, 248 were asymptomatic bacteriuria positive, of whom 40 were randomly assigned to nitrofurantoin and 45 to placebo for the randomised controlled trial, whereas the other 163 asymptomatic bacteriuria-positive women were followed without treatment. The proportion of women with pyelonephritis, preterm birth, or both did not differ between untreated or placebo-treated asymptomatic bacteriuria-positive women and asymptomatic bacteriuria-negative women (6 [2·9%] of 208 vs 77 [1·9%] of 4035; adjusted odds ratio [OR] 1·5, 95% CI 0·6-3·5) nor between asymptomatic bacteriuria-positive women treated with nitrofurantoin versus those who were untreated or received placebo (1 [2·5%] of 40 vs 6 [2·9%] of 208; risk difference -0·4, 95% CI -3·6 to 9·4). Untreated or placebo-treated asymptomatic bacteriuria-positive women developed pyelonephritis in five [2·4%] of 208 cases, compared with 24 [0·6%] of 4035 asymptomatic bacteriuria-negative women (adjusted OR 3·9, 95% CI 1·4-11·4).
Interpretation:
In women with an uncomplicated singleton pregnancy, asymptomatic bacteriuria is not associated with preterm birth. Asymptomatic bacteriuria showed a significant association with pyelonephritis, but the absolute risk of pyelonephritis in untreated asymptomatic bacteriuria is low. These findings question a routine screen-treat-policy for asymptomatic bacteriuria in pregnancy.
Funding:
ZonMw (the Netherlands Organisation for Health Research and Development).
... 5 Although early routine screening for and treatment of ASB in pregnancy are recommended in antenatal care guidelines, 6 the benefits and harm of screening and treatment are still questionable in low-risk singleton pregnancies. [7][8][9] Like most hospitals in Thailand, Siriraj Hospital does not perform screening for ASB during the antenatal period due to the low prevalence (2.3%) without a significant difference in prevalence by trimester. 9 Preterm birth is an important cause of neonatal morbidity and mortality due to the immaturity/prematurity of the newborn various organ systems. ...
... 14 However, newborns of pregnancies with positive MUCs were related to poor neonatal outcomes, such as risk of extremely low birth weight and NICU admission. 7,8 Our study revealed a rather low prevalence of abnormal urinalysis (4.1%) and positive urine culture (2.4%) in pregnancies with premature uterine contractions. We propose a strategy to identify those who need a urine culture in women diagnosed with TPL instead of universal culture. ...
Objective: This study aimed to determine the prevalence of urinary tract infection (UTI) among pregnant women with premature uterine contractions. Roles of the current practice of routine simultaneous urinalysis and urine culture in these cases were also evaluated. Materials and Methods: Medical records of pregnant women admitted with premature uterine contractions at Siriraj Hospital between January 2013 and December 2017 were reviewed. Prevalence of UTI in these women was determined. Women were divided into 2 groups based on diagnosis at admission; group 1 included preterm labor/preterm prelabor rupture of membranes (PTL/PPROM), and group 2 was threatened preterm labor (TPL). Evaluations of urinalysis and/or urine culture were performed in these two groups to establish a strategy to reduce unnecessary urine culture. Results: The prevalence of UTI among 2,286 women with premature uterine contractions was 4.9%. Prevalence of UTI were not different between the two groups of women. A positive urine culture was found in 2.4%. The most common organism identified in both groups of women was Escherichia coli. Urinalysis with abnormal cell counts and/or significant presence of bacteria could be used to screen for women in TPL group who should have urine culture with a positive screening rate of 6.5% and 90.9% sensitivity. With this strategy, unnecessary urine culture could be reduced. Conclusion: The prevalence of UTI among pregnant women admitted with premature uterine contractions was 4.9% and was not different between PTL/PPROM group and TPL group. Urinalysis with abnormal cell counts or significant bacteriuria could be a screening tool to reduce number of urine culture in women with TPL.
... Em alguns perfis, torna-se desvantajoso tratamentos que envolvem antibioticoterapia, especificamente em crianças, pacientes com diabetes, idosos, pacientes com lesões na medula espinhal e pacientes com cateteres urinários de demora. 13 Nesses pacientes, a incidência de infecções sintomáticas do trato urinário não diminui e nem se observa a sobrevida. 15 Em contrapartida, aumenta a probabilidade de efeitos adversos de antibióticos e o desenvolvimento de bactérias resistentes a antibióticos. ...
... 14 A cultura de urina é essencial; até 33% dos pacientes que se queixam de sintomas de ITU e 41% daqueles que têm piúria na urinálise terão uma cultura de urina negativa que pode descartar microrganismos comuns da ITU. 13 Além disso, as culturas auxiliam no diagnóstico diferencial dos sintomas urinários ou pélvicos, que podem ser causados por outras condições como doenças sexualmente transmissíveis, bexiga hiperativa, vulvovaginite, síndrome geniturinária da menopausa. 16 Da mesma forma, se desconsiderarmos os sintomas urinários e basearmos nosso diagnóstico apenas nos resultados da urocultura, diagnosticaremos (e poderemos tratar) muitos casos de bacteriúria. ...
A bacteriúria assintomática é caracterizada pela presença significativa de uropatógenos em amostras de urina de pacientes sem sintoma urinário e só deve ser tratada em grupos de pacientes em que os estudos clínicos demonstraram benefício. Entre a população adulta em geral, as mulheres, independente da faixa etária, tem maior prevalência de bacteriúria assintomática, embora observa-se aumento das taxas do quadro infeccioso conforme aumento da idade entre ambos os sexos. A prevalência de bacteriúria assintomática pode variar de acordo com idade, sexo, atividade sexual e presença de anormalidades geniturinárias. Quando o tratamento da bacteriúria assintomática não é indicado, a terapia antimicrobiana não diminui a morbidade da infecção sendo ainda associada a uma maior frequência de resultados negativos incluindo o surgimento de organismos resistentes e efeitos adversos relacionados aos medicamentos. Diante do exposto, o objetivo da presente revisão bibliográfica é apresentar a importância da bacteriúria assintomática na saúde pública.
... Untreated asymptomatic bacteriuria was associated with adverse maternal and fetal outcomes 19 . Maternal adverse outcomes are symptomatic cystitis (up to 30%), pyelonephritis (up to 50%) and sepsis 19 . ...
... Untreated asymptomatic bacteriuria was associated with adverse maternal and fetal outcomes 19 . Maternal adverse outcomes are symptomatic cystitis (up to 30%), pyelonephritis (up to 50%) and sepsis 19 . Adverse fetal outcomes are preterm labor, delivery, prematurity, low birth weight and increased perinatal mortality 20,21 . ...
Asymptomatic bacteriuria (ASB) is diagnosed by the presence of a 10*5 colony-forming units (CFU) in the urine without any urinary symptoms. It commonly occurs in pregnancy with the incidence ranging from 2-10%. It poses a risk of progressing into pyelonephritis in pregnancy. Adverse fetal outcomes include preterm labor, neonatal sepsis, intrauterine growth restriction (IUGR) and neonatal death. Anatomical and physiological changes during pregnancy make pregnant women more vulnerable to ASB and subsequently symptomatic UTI. E coli is the commonest organism involved in ASB, followed by Klebsilla and Enterobactericiae. Evidence suggests that importance of routine screening for ASB in early pregnancy to avoid adverse fetomaternal outcomes. Reduced adverse outcomes were noted with prompt antibiotic treatment for ASB compared to untreated pregnant women with ASB. Urine culture remains as the gold standard method to diagnose ASB in pregnancy. Using urine culture as a routine screening method in Sri Lanka is limited due to financial restrictions.
... However, it is important to note that this study only included low-risk women with uncomplicated singleton pregnancies who did not have diabetes mellitus or urinary tract abnormalities. Therefore, it is unclear if these findings can be applied to a broader population [8] . In the current study, urine nitrite dipstick test was positive among 10(76.9%) ...
... Untreated bacteriuria has been linked to a higher likelihood of preterm birth, low birth weight and perinatal mortality in the majority of studies, although not all. In a meta-analysis of 19 studies, it was found that among women who did not have bacteriuria, the chances of experiencing preterm delivery and having a low-birth-weight infant were 50% and 66% lower, respectively, compared to women with asymptomatic bacteriuria [2] . Bacteriuria has also been linked to other issues during pregnancy. ...
... Recomenda-se o rastreio com urocultura na primeira consulta de prénatal ou no primeiro trimestre, sendo controversa a periodicidade de novas avaliações; posicionamento italiano recomenda coleta mensal em pacientes de alto risco 56 . O tratamento parece estar associado a menor risco de pielonefrite, prematuridade, baixo peso ao nascer, mortalidade perinatal 57 e PE 58 , ainda que nem todos os estudos demonstrem a mesma associação 54,59 . ...
Resumo As mulheres portadoras de doença renal crônica apresentam menor probabilidade de engravidar e são mais propensas a complicações gestacionais quando comparadas a pacientes com função renal normal, sendo, portanto, consideradas gestantes de alto risco materno e fetal. Ao longo dos anos, verificou-se aumento da incidência de gestações em pacientes em diálise e melhora do desfecho materno e fetal. Acredita-se que a otimização do atendimento obstétrico e neonatal, o ajuste do tratamento dialítico (em especial, o aumento do número de horas e da frequência semanal das sessões de diálise) e o uso de agentes estimuladores da eritropoiese têm proporcionado melhor controle metabólico, volêmico, pressórico, eletrolítico e da anemia. Este artigo de revisão tem o objetivo de analisar os desfechos gestacionais em pacientes com doença renal crônica em diálise e revisar a condução médica nefrológica nesse cenário. Pelo crescente interesse pelo tema, as recomendações clínicas para a prática assistencial têm ganhado em consistência tanto no manejo medicamentoso quanto no manuseio dialítico, aspectos que tratamos na presente revisão.
... However, the frequency of further evaluations is controversial; the Italian positioning recommends monthly collection for high-risk patients 56 . Treatment seems to be associated with a reduced risk of pyelonephritis, prematurity, low birth weight, perinatal mortality 57 , and PE 58 , although not all studies demonstrate the same association 54,59 . ...
Women with chronic kidney disease are less likely to become pregnant and are more susceptible to pregnancy complications when compared to patients with normal kidney function. As a result, these are considered high-risk pregnancies, both maternal and fetal. Over the years, there has been an increase in the incidence of pregnancies in dialysis patients, and an improvement in maternal and fetal outcomes. It is believed that the optimization of obstetric and neonatal care, the adjustment of dialysis treatment (particularly the increase in the number of hours and weekly frequency of dialysis sessions), and the use of erythropoiesis-stimulating agents have provided better metabolic, volume, blood pressure, electrolyte, and anemia control. This review article aims to analyze pregnancy outcomes in chronic kidney disease patients undergoing dialysis and to review nephrological medical management in this scenario. Due to the growing interest in the subject, clinical recommendations for care practice have become more consistent in both drug and dialysis management, aspects that are addressed in this review.
... 6,8 Prophylactic use of antibiotics to reduce infection in women undergoing caesarean delivery, and select other conditions, has shown benefit. [9][10][11][12][13][14] As an example, Knight and colleagues studied 3427 women randomized to amoxicillin and clavulanic acid or placebo within 6 h of operative vaginal delivery. 15 The primary outcome, confirmed or suspected maternal infection within 6 weeks of delivery, was significantly less common in the antibiotic (11%) versus the placebo (19%) group (risk ratio [RR] 0.58, 95% CI 0.49-0.69). ...
Objective
To describe the intrapartum and postpartum use of non‐study antibiotics in low‐ and middle‐income countries (LMICs) during the double‐blinded NICHD Global Network Azithromycin in Labor (A‐PLUS) trial.
Design
The antibiotic use sub‐study was a planned prospective, observational sub‐study of the A‐PLUS trial.
Settings
The study was carried out in hospitals or health centres affiliated with eight sites of the Global Network for Women's and Children's Health Research (Global Network) in seven countries: Bangladesh, Pakistan, India (two sites), Kenya, Zambia, The Democratic Republic of the Congo (DRC) and Guatemala.
Population
Totally, 29 278 pregnant women enrolled in the A‐PLUS trial.
Methods
We collected data on 29 278 pregnant women admitted to a facility for delivery related to non‐study antibiotic use overall and during three time periods: (1) in the facility prior to delivery, (2) after delivery until facility discharge and (3) after discharge to 42 days post‐partum.
Main Outcome Measures
Non‐study antibiotic use overall and for treatment or prophylaxis by the site during the three time periods.
Results
Of the 29 278 women in the study, 5020 (17.1%; 95% CI 16.7%–17.6%) received non‐study antibiotics in the facility prior to delivery, 11 956 (40.8%; 95% CI 40.3%–41.4%) received non‐study antibiotics in the facility after delivery, and 13 390 (47.6%; 95% CI 47.0%–48.2%) women received non‐study antibiotics after delivery and after facility discharge. Antibiotics were prescribed more often among women in the Asian and Guatemalan sites than in the African sites. In the three time‐periods, among those receiving antibiotics, prophylaxis was the indication in 82.3%, 97.7% and 90.7% of the cases, respectively. The type of antibiotics used varied substantially by time‐period and site, but generally, penicillin‐type drugs, cephalosporin‐type drugs and metronidazole were used more frequently than other types.
Conclusions
Across the eight sites of the Global Network, in the facility before delivery, and in the post‐partum periods before and after facility discharge, antibiotics were used frequently, but use was highly variable by site and time‐period.
... In pregnancy, asymptomatic bacteriuria can be present too. Asymptomatic bacteriuria has a smaller negative impact compared to a UTI in pregnancy, and therefore, it is arguable if pregnant women with asymptomatic bacteriuria should be treated [24]. ...
Objective: Urinary tract infections (UTIs) represent the most prevalent infections among pregnant women. Many pregnant women experience frequent voiding or lower abdominal pain during pregnancy due to physiologic changes. Due to the possible consequences of a UTI in pregnancy, pregnant women are more often tested for UTIs. This study aimed to assess the diagnostic accuracy of dipsticks in diagnosing UTIs in pregnant women while using the urine culture as the reference standard. Study design: This was a retrospective cohort study, conducted at two academic hospitals in the Netherlands among pregnant women. Pseudonymized data were collected from patient files. The results of the urine dipstick and the urine culture in pregnant women were linked. Additionally, nitrofurantoin prescriptions were linked to culture results. A positive urine culture was considered the reference test for a UTI. Results: Between 1 January 2017 and 28 February 2021, a total of 718 urine samples with leukocyte esterase dipstick results within 24 h of the urine culture were analyzed. Of these samples, a nitrite dipstick result was also available in 337 cases. Only 6.8% of the 718 urine samples yielded positive cultures. The sensitivity and specificity of leukocyte esterase were 75.5% and 40.4%, respectively; for nitrite, 72.0% sensitivity and 73.4% specificity were found. When at least one of the two tests was positive, the sensitivity and specificity were 92.0% and 27.9%, respectively. When both tests were positive, the sensitivity and specificity were 52.0% and 82.7%, respectively. In only 16.8% of the women to whom nitrofurantoin was prescribed, the urine cultures returned positive using a cut-off of 105 colony forming units/mL. Conclusion: The diagnostic performance of leukocyte esterase, nitrite, or their combination in clinical practice is lower than previously reported in study settings among pregnant women. A significant proportion of women treated with nitrofurantoin were found to have no UTI, suggesting potential over-prescription based on dipstick test results. Healthcare providers should be aware of this reduced performance in clinical practice and carefully weigh the risks of antibiotic treatment by suspicion of a UTI against the possibility of delayed treatment awaiting culture results in individual patients.
... 6,8,[11][12][13][14][15][16] However, some studies have reported that UTI during pregnancy does not cause preterm delivery. [17][18][19] Two studies have shown that UTI increases the risk of premature birth by 1.6 times and the risk of low birth weight by 1.4 times. 6 In the present study, preterm delivery rates were found to be similar between preg-nant women with UTI and the control group. ...
... Diagnostic and treatment protocols and access to medical services have dramatically changed since then; therefore, the quality of evidence for this recommendation is low. In a newer study of higher methodological quality, the beneficial effects of antibiotic treatment are not as evident [16]. ...
... The global prevalence of ASB in pregnant women ranges from 2% to 15%, thus underscoring the importance of prompt screening and intervention [7,8]. In India, the lack of standardized screening protocols for ASB in pregnant women results in underestimations of its importance and adds to the variation in the reported prevalence rates [9][10][11]. ...
Urinary tract infections (UTIs) are a significant health concern globally, with a pronounced impact on women's health in India. This systematic literature review aims to elucidate the factors associated with UTIs among women of reproductive age in India and focus on demographic, behavioral, and physiological factors to inform targeted public health and clinical interventions.
A systematic literature search was conducted on PubMed and Google Scholar using specific MeSH terms and preferred reporting items for systematic literature reviews and meta-analyses (PRISMA) guidelines to investigate the correlates of UTIs among Indian women. Studies were selected based on their relevance to the correlates of UTIs among Indian women, including risk factors, prevention strategies, and treatment outcomes.
The review identified a significant prevalence of UTIs among pregnant women, with Escherichia coli being the most common causative agent. Younger women, particularly those pregnant, were found to be at a higher risk, likely due to physiological changes during pregnancy and increased sexual activity. Behavioral and lifestyle factors, such as inadequate water intake and poor sanitation practices, were strongly associated with increased risks for UTIs. Factors that increase the risk of UTIs in women include frequent sexual activity, involvement with a new sexual partner, spermicide use that can potentially alter vaginal pH and impact its bacterial composition, and vulvovaginal atrophy. Additionally, nearly 60% of women globally with recurrent UTIs experienced sexual dysfunction, indicating the broader implications of UTIs on women's sexual health and quality of life.
UTIs among women in India are influenced by a complex interplay of factors. There is a critical need for enhanced public health initiatives focusing on sanitation, hydration, and hygiene, alongside holistic clinical management strategies that address both the infection and its broader health impacts. Future research should aim at developing innovative prevention and treatment strategies, with a particular focus on high-risk groups such as pregnant women, to mitigate the burden of UTIs in India.
... Asymptomatic bacteriuria does not warrant treatment, apart from pregnancy (where a 10-20% possibility of evolution to ascending infection and pyelonephritis has been traditionally reported) and prior to localized surgical interventions. The relevant EAU guidelines [7], as well as the IDSA ones [59], note that the available evidence on treatment of asymptomatic bacteriuria in pregnancy is based on older studies with numerous methodological drawbacks; both guidelines state that treatment of asymptomatic bacteriuria in pregnancy warrants further studies due to the results of a recent large, well-designed Dutch study that has raised the question of whether screening for asymptomatic bacteriuria (and subsequent treatment) is actually needed in all pregnancies [60]: the study showed that pregnant females with asymptomatic bacteriuria that were not treated with nitrofurantoin were more prone to developing pyelonephritis compared to pregnant women that received the antibiotic, but the overall prevalence of pyelonephritis was extremely low (2.4%). Furthermore, the presence of untreated bacteriuria did not exert an increased likelihood of preterm birth compared to pregnant women without bacteriuria. ...
Urinary tract infections (UTIs) cause a significant infectious burden in the community and demand a coordinated approach from all first-line health professionals. Uncomplicated UTIs refer to infections in non-pregnant females without any underlying localized or generalized pathology, diagnosed through history by the presence of specific local symptoms and in the absence of systemic ones like fever. Uncomplicated UTIs are usually caused by Escherichia coli species; thus, empirical antibiotic treatment can be immediately initiated. A percentage of patients can experience a resolution of symptoms without therapy; however, this “wait and observe” approach is supported only by the relevant British guidelines. There are limited quality studies in the literature on adjuvant treatment options; these can include BNO 145, a phytotherapeutic medicine, and XHP, a medical technology product. Despite being licensed by the European Medicines Agency on the basis of traditional use, there is inadequate support in the medical literature for the use of cranberry extracts and Arctostaphylos uva-ursi extracts. The use of antibiotics is associated with higher response rates and urine culture sterilization as well as lower recurrence/relapse rates; on the other hand, side effect rates are also higher. In choosing the proper empirical antibiotic therapy, one has to take into account individual patient characteristics and community resistance patterns as well as the antimicrobial resistance pressure exerted by the wide use of a specific antibiotic. There is a need for a common framework through which all frontline health practitioners should operate when faced with a case of uncomplicated UTI. In Greece, there are three different guidelines for UTI treatment, developed by the Ministry of Health, the National Organization for Medicines, and the Hellenic Society for Infectious Diseases. The authors of the present study aim at synthesizing these guidelines as well as relevant guidelines from international scientific or other national regulatory organizations while taking into account local resistance patterns. The authors propose the first-line use of either fosfomycin, nitrofurantoin, or pivmecillinam. The use of trimethoprim/sulfamethoxazole is discouraged due to increased resistance of Greek community E. coli isolates. Fluoroquinolone use should be avoided due to high E. coli community resistance (exceeding 20% for Greece), along with their unfavorable benefit/side effect balance in uncomplicated UTIs, as well as the overall community resistance pressure exerted by their use. A 5-day regimen remains superior to a 3-day one; the latter may be suitable for certain, not yet adequately characterized, patients.
... Researchers have recommended regular culture screening for all pregnant women visiting prenatal clinics due to the harmful consequences of undetected asymptomatic bacteriuria on the mother and the child. 3 E. coli, which is responsible for more than 80% of cases, is the more commonly known pathogen in women's uncomplicated UTIs. Of the cases, 15% have Staphylococcus saprophyticus. 4 Only in cases of symptomatic UTI is empirical therapy advised. ...
... Placebo was used in 10% (6/61) of protocols 42 43 and 15% (6/39) of RCTs. [44][45][46] The 'other' category included an active comparator. 47 In several cohorts, it was not stated what the trial comparators would be (eg 48 ), but as expected, all RCTs using the staged approach had a usual care comparator. ...
Introduction
Cohort studies generate and collect longitudinal data for a variety of research purposes. Randomised controlled trials (RCTs) increasingly use cohort studies as data infrastructures to help identify and recruit trial participants and assess outcomes.
Objective
To examine the extent, range and nature of research using cohorts for RCTs and describe the varied definitions and conceptual boundaries for RCTs using cohorts.
Design
Scoping review.
Data sources
Searches were undertaken in January 2021 in MEDLINE (Ovid) and EBM Reviews—Cochrane Methodology Registry (Final issue, third Quarter 2012).
Eligibility criteria
Reports published between January 2007 and December 2021 of (a) cohorts used or planned to be used, to conduct RCTs, or (b) RCTs which use cohorts to recruit participants and/or collect trial outcomes, or (c) methodological studies discussing the use of cohorts for RCTs.
Data extraction and synthesis
Data were extracted on the condition being studied, age group, setting, country/continent, intervention(s) and comparators planned or received, unit of randomisation, timing of randomisation, approach to informed consent, study design and terminology.
Results
A total of 175 full-text articles were assessed for eligibility. We identified 61 protocols, 9 descriptions of stand-alone cohorts intended to be used for future RCTs, 39 RCTs using cohorts and 34 methodological papers.The use and scope of this approach is growing. The thematics of study are far-ranging, including population health, oncology, mental and behavioural disorders, and musculoskeletal conditions.
Authors reported that this approach can lead to more efficient recruitment, more representative samples, and lessen disappointment bias and crossovers.
Conclusion
This review outlines the development of cohorts to conduct RCTs including the range of use and innovative changes and adaptations. Inconsistencies in the use of terminology and concepts are highlighted. Guidance now needs to be developed to support the design and reporting of RCTs conducted using cohorts.
... Данные о результатах лечения ББУ получены в основном более 40 лет назад и требуют современной верификации [4,6]. Протективные свойства некоторых компонентов уробиома [5,7], а также результаты исследования NTR3068 [8] подвергают сомнению текущие подходы к тактике лечения ББУ у беременных. В указанной работе при достаточно большой выборке наблюдений (5621 человек) у пациенток без ББУ было зарегистрировано 16 случаев эндометрита против 0 случаев у пациенток с ББУ, причем как получавших антибактериальную терапию, так и входивших в группу плацебо. ...
Introduction. Pregnant women with pathology of the urinary system are at high risk of complications. The aim of the study was to assess the prevalence and structure of diseases of the urinary system in maternity women with endometritis after cesarean section, to determine their prognostic value as independent predictors of the development of postoperative infectious and inflammatory complications. Materials and methods. A retrospective multicenter statistical analysis of the medical histories and primary medical documentation data of 648 women delivered by caesarean section, 406 of them with a diagnosis of "endometritis after cesarean section" (main group) and 242 with the physiological course of the postoperative period (control group). Results and discussion. The prevalence of diseases of the urinary system in puerperant with endometritis was 56.5% and is mainly represented by urinary tract infection. Asymptomatic bacteriuria complicates the course of pregnancy 3.3 times more often in women with endometritis after cesarean section compared with the corresponding indicator in women with uncomplicated course of the postoperative period (20.9% vs. 6.3%), which makes it possible to attribute it to significant predictors of the development of postoperative infectious and inflammatory complications in obstetrics. Conclusion. According to the results of multivariate regression analysis, chronic and gestational pyelonephritis had less pronounced associations with the prediction of endometritis development after cesarean section.
... Корреляция между ББУ, низким весом при рождении и преждевременными родами является спорной, поскольку биологический механизм связи между этими событиями не установлен. Недавнее исследование показало, что ББУ не была связана с преждевременными родами [21]. ...
Introduction. Asymptomatic bacteriuria (ABU) occurs in 2–15% of pregnant women, but opinions about ABU in pregnant women are controversial. The aim of the study was to assess the outcomes of delivery in pregnant women with ABU, depending on the therapy and urological history. Material and methods. The histories of childbirth of 46 women with ABU detected during prenatal screening, were analyzed. The outcomes of pregnancies were analyzed, and the relationship between the presence of ABU, the type of therapy, the presence of pyelonephritis in history and the development (exacerbation) of pyelonephritis during pregnancy was determined. Results. The structure of uropathogens was typical: E. coli was found in 36 cases (78.3%), Enterococcus faecalis - in 10 cases (21.7%). Seven women (15.2%) had a history of chronic pyelonephritis, 4 (8.7%) had chronic cystitis. The remaining 35 pregnant women (76.1%) had no any urological diseases. More than half of pregnant women with ABU (32/69.6%) received Сanephron; all of them had normal delivery. The average weight of newborns was 3768±101.9 grams. The rest of the 14 (30.4%) pregnant women with ABU, including 7 patients with a history of pyelonephritis, received amoxicillin with clavulonic acid. In more than half of the them (4/57.1%) gestational pyelonephritis developed. Correlational analysis showed that the low weight of the newborn, the development of gestational pyelonephritis and the likelihood of preterm birth did not depend on the therapy for ABU (antibacterial or herbal medicine), but on the presence of chronic pyelonephritis in the pregnant woman. Conclusion. The detection of ABU in a healthy pregnant woman without urological history is not a convincing basis for prescribing antibiotics. Preventive phytotherapy with the drug «Canephron» in such women was sufficient; none of the cases developed gestational pyelonephritis or preterm labor
... La fosfomicina (categoría "B") también es segura en el embarazo, es bien tolerada y no se han reportado efectos adversos. 15 La nitrofurantoína (categoría "B") debe evitarse durante el primer trimestre 16,17,18 si existe otro antibiótico que sea efectivo y seguro. También debe evitarse cerca del término por el riesgo remoto de anemia hemolítica en la madre y el feto (0.0004%). ...
OBJETIVO:
Determinar la prevalencia de bacteriuria asintomática, su adecuado tratamiento con base en el reporte del antibiograma de pacientes embarazadas que acudieron a control prenatal en una clínica privada.
MATERIALES Y MÉTODOS:
Estudio retrospectivo de una serie de casos, descriptivo y transversal efectuado en mujeres embarazadas que acudieron a control prenatal en la consulta externa del Hospital Fray Juan de San Miguel de Uruapan, Michoacán, entre el 1 de enero de 2019 y el 31 de diciembre de 2021. Variables de estudio: edad de las madres, semanas de embarazo, embarazos, bacteriuria, agente causal, antibiótico indicado y respuesta al tratamiento. Para interpretar los resultados obtenidos se aplicaron estadística descriptiva, medidas de tendencia central y de frecuencias simples.
RESULTADOS:
Se estudiaron 227 embarazadas; de ellas, 49 tuvieron un urocultivo positivo. La prevalencia de bacteriuria asintomática fue de 21.59. Escherichia coli fue el agente causal más reportado. De los urocultivos de control 36 de 37 resultaron negativos y solo 1 de 37 fue positivo.
CONCLUSIÓN:
La prevalencia de bacteriuria asintomática de este estudio fue de 21.59% y el principal agente etiológico asilado E. coli en la mayoría de los casos, con sensibilidad a nitrofurantoína en la mayoría de los casos.
... Untreated bacteriuria during pregnancy can lead to complications, including preterm labour, pre-eclampsia, hypertension, pyelonephritis, anaemia, amnionitis, low birth weight, neonatal deaths (stillbirths), bacteremia, and toxic septicemia (Kazemier et al., 2015). ...
Asymptomatic bacteriuria is a common problem in pregnancy and is associated with the risk of preterm birth and pyelonephritis if untreated. This study aims to determine the prevalence and aetiology of asymptomatic bacteriuria and the susceptibility pattern in pregnant women attending antenatal clinics in a tertiary hospital in South-South Nigeria. Urine samples from 30 pregnant women were analysed using conventional microbiology techniques, and the mean age of the respondents was 29.57±5.89 years. The prevalence of asymptomatic bacteriuria in this study is 66.6%, with a higher prevalence in the third trimester (73.3%). The subjects aged 31-35 had the highest prevalence of Klebsiella pneumoniae as the common isolate, followed by Escherichia coli at 45% to 40%, respectively. Reflacine was more susceptible to Escherichia coli (87.5%), while ciprofloxacin was more susceptible to Klebsiella pneumoniae (88.8%) in this study. Asymptomatic bacteriuria is not uncommon among antenatal patients in the population studied. Routine urine culture tests should be conducted on all antenatal patients to identify any unsuspecting infection. This measure will go a long way in reducing maternal and obstetric complications associated with pregnancy, such as preterm labour and low birth weight babies.
... 13,14 Nonetheless, the advantages of screening for Asymptomatic bacteriuria during pregnancy have been questioned in light of more rigorous study designs to determine the relationship between Asymptomatic bacteriuria and acute pyelonephritis in pregnancy. 15,16 Up to 85% of infections in women resulting from UTIs are caused by Escherichia coli. 10,11,17,18 Other Enterobacteriaceae and grampositive bacteria are blamed for the remaining illnesses. ...
Urinary tract infections are the most common illnesses that impact pregnant women. This study aimed to investigate bacterial urinary tract infections and antibiotic susceptibility profiles in pregnant women. This study was conducted on pregnant women between April and October 2021 in clinics and hospitals in the Damt district. Midstream urine samples were collected, cultured, identified and tested for antibiotic susceptibility. The prevalence of UTI in pregnant women was 210/350 (60%). Escherichia coli accounted for 90/210 (42.9%), Staphylococcus aureus 50/210 (23.8%), and Klebsiella pneumoniae 25/210 (11.9%). Staphylococcus epidermidis, Pseudomonas aeruginosa, and Proteus mirabilis exhibited 15/210 (7.1%) of each with the moderately identified bacterial species. Antimicrobial sensitivity testing showed that bacterial isolates were resistant to amoxicillin (80-100%), ceftriaxone (40-70%), gentamycin (0-60%), amikacin (0-50%), tetracycline, ciprofloxacin, azithromycin, and amoxiclav (0-40%), and azithromycin (0-30%). Significant bacteriuria was associated with age (p = 0.01), pregnancy trimesters (p = 0.00), gestation (p = 0.00), and residence (p = 0.03), whereas there was no association with education (p = 0.05). Most isolates have become resistant toward antibiotic used in the study treatments, especially ceftriaxone and amoxicillin. Therefore, it is recommended that pregnant women undergo health education on the prevalence and causes of urinary tract infections.
... Apart from the pregnant state, there are additional risk factors for UTI in pregnancy, such as a past history of UTI, advanced maternal age, low educational level, low socioeconomic status, smoking, unsatisfactory personal hygiene, anemia, multi parity, as well as diabetes and sickle cell disease [5,[29][30][31]. ASB without treatment can lead to symptomatic UTI and pyelonephritis in almost a quarter of the patients during pregnancy, although a study from the Netherlands suggested a low rate of pyelonephritis among low-risk women with ASB and uncomplicated singleton pregnancies without diabetes mellitus or urinary tract abnormalities without treatment [32][33][34]. ...
Background:
Urinary tract infection (UTI) is a common complication in pregnancy. The prevalence varies between countries. This research aims at estimating the prevalence, clinico-bacteriological profile, antibiotic resistance, and risk factor analysis of symptomatic UTI in pregnancy.
Method:
This is a prospective observational study conducted at the Abdullah Bin Omran Hospital, RAK, UAE, from March 2019 to February 2020. All pregnant women attending the antenatal clinic during this period were given a pre-validated questionnaire for the symptoms of UTI. In symptomatic patients, urine was sent for microscopy, culture, and sensitivity. Women were treated for UTI and were followed up for the rest of the pregnancy. Data analysis was performed by SPSS software version 24 using descriptive statistics and comparisons with significance at a p-value of <0.05.
Results:
The prevalence of symptomatic UTI was 17.9%. E.coli was the commonest isolate followed by Group B streptococcus. The commonest symptom reported was loin pain and the most common risk factor was diabetes. Women with risk factors are significantly more likely to have culture-positive UTIs. Most of the pathogens were sensitive to cefuroxime and benzyl penicillin. Risk of preterm labor was higher.
Conclusions:
Regular antenatal care and routine urine testing in all visits are recommended for early detection and treatment of UTI.
... The only two European guidelines that do not recommend this screening anymore are the ones from Germany and Switzerland [11,12], with the exception of women at high risk for developing UTI (women with diabetes mellitus, immunosuppression, functional or structural abnormalities of the urinary tract, previous episodes of pyelonephritis, previous premature births or late pregnancy loss). This recommendation is mainly due to a recent high-quality study that demonstrated that in women with an uncomplicated singleton pregnancy, untreated ASB is related to a low risk of developing APN but it is not associated with an increased risk of premature birth or other neonatal or maternal complications [31]. ...
Urinary tract infection (UTI) is considered to be a major problem in pregnant women. It is also one of the most prevalent infections during pregnancy, being diagnosed in as many as 50–60% of all gestations. Therefore, UTI treatment during pregnancy is extremely important and management guidelines have been published worldwide to assist physicians in selecting the right antibiotic for each patient, taking into account the maternal and fetal safety profile. A review of the literature was carried out and all international guidelines giving recommendations about antibiotic treatments for pregnancy-related UTI were selected. The search came back with 13 guidelines from 4 different continents (8 from Europe, 3 from South America, 1 from North America and 1 from Oceania). Our review demonstrated concordance between guidelines with regard to several aspects in the antibiotic treatment of UTI during pregnancy and in the follow-up after treatment. Nonetheless, there are some areas of discordance, as in the case of antenatal screening for bacteriuria and the use of fluoroquinolones in lower or upper UTI. Given the current evidence that we have from international guidelines, they all agree on several key points about antibiotic use.
... It increases the risk for symptomatic UTI and pyelonephritis. German guidelines do not recommend screening for and treatment of asymptomatic bacteriuria anymore [14,34], based on data from a Dutch randomized controlled trial (RCT), which did not show a significant association of asymptomatic bacteriuria with preterm birth [35], but there is no international consensus. As 12.5% of our cohort received antibiotics for UTI which is a lot more than reported in literature, it can be suspected that there is potential for antibiotic stewardship in this indication. ...
Introduction Antibiotics are powerful drugs to prevent and treat perinatal infections. Overuse of antibiotics leads to antibiotic resistance, has potential side effects and influences the maternal and neonatal microbiome.
Patients and Methods We performed a prospective observational study on the prevalence, indications, and prescribing patterns of antibiotics during pregnancy and childbirth. We included women who had given birth after 23+0 weeks of gestation at a single tertiary center in Germany from January 2020 to March 2021. Descriptive statistics and binomial regression were performed to analyze the factors influencing the prescription of antibiotics.
Results We included 522 postpartum women into our study. 337 (64.6%) were exposed to antibiotics during pregnancy and/or childbirth. 115 women received antibiotics during pregnancy, 291 during birth. Most antibiotics during pregnancy were prescribed for urinary tract infections (UTIs) (56.0%). Most prescriptions were issued by obstetrics and gynecology physicians (65.8%), followed by hospitals (16.7%) and family medicine physicians (8.8%). Most antibiotics during childbirth were given for a cesarean section (64.3%), followed by preterm rupture of membranes (41.2%). 95.3% of women who had a preterm birth were exposed to antibiotics. In logistic regression models, lower gestational age at birth, higher maternal body-mass-index and smoking were independently associated with antibiotic use during pregnancy and childbirth.
Conclusion We found a high rate of antibiotic exposure during pregnancy and childbirth. Our results imply an urgent need for antibiotic stewardship programs in perinatal medicine as well as further research on the effects of perinatal antibiotic exposure on microbiome development and childhood health.
... 4 6 10 Moreover, UTIs during pregnancy have also been associated with neonatal complications such as preterm birth, low birth weight and perinatal death. 2 4 10 In addition, an untreated UTI may lead to pyelonephritis, which further increases the risk of preterm birth. 11 Preterm birth has major consequences at the individual level as well as for society (costs). ...
Introduction
Symptoms of urinary tract infections in pregnant women are often less specific, in contrast to non-pregnant women where typical clinical symptoms of a urinary tract infection are sufficient to diagnose urinary tract infections. Moreover, symptoms of a urinary tract infection can mimic pregnancy-related symptoms, or symptoms of a threatened preterm birth, such as contractions. In order to diagnose or rule out a urinary tract infection, additional diagnostic testing is required.
The diagnostic accuracy of urine dipstick analysis and urine sediment in the diagnosis of urinary tract infections in pregnant women has not been ascertained nor validated.
Methods and analysis
In this single-centre prospective cohort study, pregnant women (≥16 years old) with a suspected urinary tract infection will be included. The women will be asked to complete a short questionnaire regarding complaints, risk factors for urinary tract infections and baseline characteristics. Their urine will be tested with a urine dipstick, urine sediment and urine culture. The different sensitivities and specificities per test will be assessed. Our aim is to evaluate and compare the diagnostic accuracy of urine dipstick analysis and urine sediment in comparison with urine culture (reference test) in pregnant women. In addition, we will compare these tests to a predefined ‘true urinary tract infection’, to distinguish between a urinary tract infection and asymptomatic bacteriuria.
Ethics and dissemination
Approval was requested from the Medical Ethics Review Committee of the Academic Medical Centre; an official approval of this study by the committee was not required. The outcomes of this study will be published in a peer-reviewed journal.
... The data regarding untreated asymptomatic bacteriuria and perinatal outcomes are conflicting. Research has shown that untreated asymptomatic bacteriuria is associated with preterm birth, low birth weight, and increased perinatal mortality [15], while in other studies this association was not found [16]. ...
Background
Decidual polyps are protruding nodules of ectopic deciduosis of endocervical stroma that occur during pregnancy. They are benign changes, associated with recurrent vaginal bleeding and infections, which can result in miscarriage, preterm premature rupture of membranes (PPROM), premature labor and/or delivery. There are no strict treatment guidelines for decidual polyps during pregnancy.
Case
This paper describes a case of recurring symptomatic decidual polyp in each of the three pregnancies of a woman treated in our clinic for primary infertility. During the first and second pregnancy, we opted for polypectomy and conservative treatment, respectively. In both cases this led to loss of the fetus. During the patient’s third pregnancy we performed polypectomy and closely monitored both the patient and the fetus; she delivered a healthy baby in the 38th week of gestation.
Conclusions
Due to the lack of clear guidelines, we maintain that frequent checkups, urethral swabs and polypectomy during the first trimester will lead to a positive outcome, i.e., delivery of a healthy baby by a healthy mother.
... La antibioticoterapia constituye el tratamiento más recomendado para las ITU, atendiendo a los perfiles determinados en el laboratorio clínico, la administración en etapas tempranas de la enfermedad previene posibles complicaciones durante el embarazo. (7,8) Varias fuentes asocian las ITU en el embarazo con el aumento del riesgo de bajo peso al nacer, parto prematuro, hipertensión, anemia, trombosis y abortos; lo que dependerá de la base fisiopatológica de una serie de condiciones gestacionales, tales como: aumento del volumen de la vejiga, disminución del tono del músculo detrusor y dilatación ureteral por relajación del músculo liso que provoca hidronefrosis por la presencia de progesterona. (7,9) El conocimiento acerca de los perfiles de resistencia microbiana a antibióticos es necesaria para el manejo acertado de las ITU. ...
Introduction: urinary tract infections (UTI)are a common complication during pregnancy, which can increase maternal and fetal morbidity. Objective: to determine the etiology and resistance profile of bacteria isolated in urine cultures of pregnant women diagnosed with UTI. Methodology: A non-experimental, descriptive and cross-sectional research was carried out. The population consisted of 124 medical records of pregnant patients treated at the Sangolquí Hospital from January 2017 to April 2018, with positive reports of urine cultures. Results: the mean age of the participants was 24.75. E. coli was isolated in 73.39% of the samples. Most of the pregnant women were between 20 and 30 years old. Conclusion: Escherichia Coli was the most observed microorganism in positive urine cultures, establishing greater susceptibility to ceftriaxone, nitrofurantoin and fosfomycin; being more resistant to cefuroxime and ampicillin.
... However, Kazemier et al. in 2015 suggested a lower rate of pyelonephritis in women with untreated asymptomatic bacteriuria. It should be noted that only low-risk single pregnancy, without diabetes or abnormalities of the urinary tract were included in this study and is not sure that these results are can be generalized [21]. The purpose of the study was to evaluate the type of bacterial aetiology that causes urinary tract infections, the antibiotic susceptibility pattern in pregnant women and if there are correlations between asymptomatic bacteriuria and adverse maternal and neonates' outcomes. ...
Urinary tract infection is one of the common infections in the pregnancy causing disturbances in the foetal growing and development. This study was conducted to determine the distribution and antimicrobial susceptibility of uropathogens in the pregnant women attending County Emergency Clinical Hospital Oradea, Romania as well as to determine the potential effect of foetal development and/or birth defects. Clean catch midstream urine was collected from 427 patients of the age ranging from 13 to 44 years. Urine specimens were chemically analysed (by dipstick) and microscopy, and then cultured in laboratory. After identification, antimicrobial susceptibility was performed on all isolated bacteria by Kirby Bauer's disc diffusion method and the multiple antibiotic resistance (MAR) index of each antibiotic was calculated. The prevalence of ITU was 65.33% in our patients and it was significantly higher in third trimester of the pregnancy. Gram negative bacteria (90.11%) were found in higher prevalence than Gram positive (9.88%). Escherichia coli (76.31%) was the most prevalent isolate. All isolated strains have shown good susceptibilities rates. We found association between UTIs and mean birth weight and preterm birth. Rezumat Infecția tractului urinar este una dintre cele mai obișnuite în sarcină determinând tulburări în creșterea și dezvoltarea fătului. Acest studiu a fost realizat pentru a evalua distribuția și sensibilitatea antimicrobiană a uropatogenilor la femei însărcinate internate la Spitalul Clinic Județean de Urgență Oradea, precum și pentru a determina efectul potențial asupra dezvoltării fetale. Urina a fost recoltată din jetul mijlociu de la 427 de paciente cu vârsta cuprinsă între 13 și 44 de ani. Probele au fost analizate chimic și microscopic, apoi cultivate în laborator. După identificare, sensibilitatea antimicrobiană a tulpinilor izolate a fost realizată prin metoda difuzimetrică (Kirby Bauer) și a fost calculat indicele de rezistență multiplă la antibiotice (MAR) al fiecărui antibiotic. Prevalența infecției urinare a fost de 65,33% și a fost semnificativ mai mare în al treilea trimestru de sarcină. Prevalența bacterilor Gram negative (90,11%) a fost mai mare decât a celor Gram pozitive (9,88%). Escherichia coli (76,31%) a fost cel mai frecvent izolat. Toate tulpinile izolate au prezentat rate de susceptibilitate bune. Prezența infecției urinare a fost asociată cu greutatea medie la naștere și nașterea prematură.
Üriner sistem üst ve alt üriner sistem olarak ikiye ayrılmaktadır. Alt üriner sistem, mesane, prostat ve üretradan üst üriner sistem ise böbrekler ve üreterlerden oluşmaktadır. Bu bölge-lerin enfeksiyonları da bu şekilde gruplandırılmaktadır. Üst üriner sistem enfeksiyonların-dan en sık görüleni akut piyelonefrittir (Johansen ve ark. 2011). 3.A.9.1.a. Akut Piyelonefrit Böbreğin akut bakteriyel enfeksiyonu neticesinde gelişen ateş, yan ağrısı ve bulantı-kusma gibi şikayetlerin meydana geldiği klinik tablodur. Akut piyelonefrit komplike olan ve ol-mayan olarak sınıflandırılabilir. Komplike olmayan piyelonefrit hastalarında üriner sistem yapısal ve işlevsel olarak normaldir. Bu hastaların çoğunluğu genç-orta yaşlardaki kadın-lardır. Komplike piyelonefrit, enfeksiyon riskini artıran ve/veya savunma mekanizmaları-nın bozulduğu durumlara bağlı olarak gelişen enfeksiyonu tanımlamaktadır. Bu hastaların çoğunluğunu ise erkekler oluşturmaktadır. Komplike Piyelonefrit için Risk Faktörleri Üriner sistemin herhangi bir yerinde obstrüksiyon, Erkeklerde üriner sistem enfeksiyonu, Yabancı cisim, Gebelik, Rezidü idrar varlığı, Diabetes mellitus, Vezikoüreteral reflü, İmmünsüpresyon, Üriner sisteme girişim, Hastane kaynaklı enfeksiyon. Klinik Piyelonefrit tablosu ateş, halsizlik ve yan ağrısı ile birlikte seyretmektedir. Bu hastalar-da bulantı ve kusma da görülebilmektedir. Fizik muayenede kostovertebral açı hassasiyeti önemli bir bulgudur. İleri yaşlarda olan ve altta yatan başka patolojileri olan hastalarda böbrek apsesi de piyelonefrite eşlik edebilmektedir (Fulop 2012). Gebelerde, akut piyelonefrit tanısı ve tedavisi önemlidir, çünkü bu tür bir enfeksiyon sa-dece annede anemi, böbrek ve solunum yetmezliği gibi olumsuz etkilere neden olmakla kalmaz, aynı zamanda erken doğum ile de sonuçlanabilir (Hill ve ark. 2005). Tanı Tam idrar tahlili (eritrosit, lökosit ve nitrit değerlendirmesini içermeli) rutin tanı için öne-rilmektedir. Ek olarak, tüm piyelonefrit olgularında idrar kültürü ve antimikrobiyal duyar
Introduction
Low birth weight (LBW), which is a risk factor for noncommunicable diseases throughout life, is a significant public health concern. In addition to regulating myeloid cell differentiation and proliferation, a transcriptional repressor identified as growth factor independence-1 (GFI-1) is essential for hematopoietic stem cell maintenance and self-renewal. The current study was designed to compare the expression of the GFI-1 gene in the differentiation of hematopoietic stem cells in newborns with LBW and those with normal birth weight (NBW).
Methods
A prospective comparative analytical study was carried out from September 2019 to September 2021 after obtaining Institute Ethical Committee approval at a tertiary care center in north India.
The GFI-1 gene expression levels in 50 cord blood samples from women with term gestation and LBW newborns (<2500 grams) were measured using quantitative real-time polymerase chain reaction (RT-PCR) and compared to gene expression levels in 50 cord blood samples from women with term gestation and NBW newborns (≥2500 grams). The data were analyzed using IBM SPSS statistics software version 24.0 (IBM Corp., Armonk, NY).
Results
The median GFI-1 expression in LBW newborns is 3.1, whereas among NBW newborns it is 9.39. The difference is significant (P <0.001). The level of GFI-1 gene expression in LBW newborns was correlated with their birth weight. The coefficient of correlation was found to be weakly positive (r = 0.223). The birth weight of NBW newborns was correlated to the level of expression of the GFI-1 gene, which was found to be positively correlated (r = 0.332).
Conclusion
The levels of the GFI-1 gene and newborn birth weight were compared in LBW infants, which were weakly positively correlated. The level of GFI-1 gene expression at birth was compared to the birth weight of NBW newborns, which was positively correlated.
Background
Antibiotics for bacteriuria and urinary tract infection are commonly prescribed during pregnancy to avoid adverse pregnancy outcomes. The aim of this study was to evaluate the association between significant bacteriuria in pregnancy and any of the four pregnancy outcomes: preterm delivery; low birth weight; small for gestational age; and preterm labour.
Methods
Systematic review with meta-analysis of observational studies. We searched PubMed, EMBASE, the Cochrane CENTRAL library, and Web of Science for observational studies published before 1 March 2022. The risk of bias was assessed using the Newcastle–Ottawa scale. Study identification, data extraction and risk-of-bias assessment was performed by two independent authors. We combined the included studies in meta-analyses and expressed results as ORs with 95% CIs (Prospero CRD42016053485).
Results
We identified 58 studies involving 421 657 women. The quality of the studies was mainly poor or fair. The pooled, unadjusted OR for the association between any significant bacteriuria and: (i) preterm delivery was 1.62 (95% CI: 1.30–2.01; 27 studies; I2 = 61%); (ii) low birth weight was 1.50 (95% CI: 1.30–1.72; 47 studies; I2 = 74%); (iii) preterm labour was 2.29 (95% CI: 1.53–3.43; 3 studies; I2 = 0%); and (iv) small for gestational age was 1.33 (95% CI: 0.88–2.02; 7 studies; I2 = 54%). Four studies provided an adjusted OR, but were too diverse to combine in meta-analysis.
Conclusions
This systematic review identified an association between significant bacteriuria in pregnancy and the three complications: preterm delivery; low birth weight; and preterm labour. However, the quality of the available evidence is insufficient to conclude whether this association is merely due to confounding factors. There is a lack of high-quality evidence to support active identification and treatment of bacteriuria in pregnancy.
Background:
Asymptomatic bacteriuria is prevalent during pregnancy. If it goes undetected, it can lead to urinary tract infection with severe maternal and neonatal complications. Until date, India does not have any guidelines to test for ASB during pregnancy.
Objective:
To estimate the pooled prevalence of asymptomatic bacteriuria in pregnant women at national level in India.
Material and Methods:
We searched Medline, Embase, Web of Science, and Google Scholar using search strategy with keyword. Two authors independently assessed the eligibility of study. The checklist of the JBI was used for evaluating the quality of reporting. The extracted data were analyzed, and the results were reported using a random-effects model with 95% confidence interval (CI). Subgroup analysis was conducted for zones of India, parity and trimester. Publication bias is reported as funnel plot.
Result:
Pooled prevalence of asymptomatic bacteriuria among pregnant women in India is 13.5% [CI 11.1; 15.8]. Subgroup analysis based on the various geographic zones of the country the pooled prevalence ranged from 9.2% in central zone to 14.8% in south zone. Distribution of prevalence of ASB as per parity was approximately identical. The prevalence of ASB was found to be high in third (21.8%).
Conclusion:
The prevalence of ASB is found to be high among Indian pregnant women, especially in third trimester. It is therefore recommended for guideline to screen and treat every pregnant woman for ASB to prevent further complications.
Background:
Current national guidance in Ireland states that asymptomatic bacteriuria (AB) should be screened for at 12-16 weeks' gestation and treated with a seven-day course of antimicrobials, due to the potential risk of preterm birth and low birth weight infants (LBWI), however, this is based on low quality evidence.
Methods:
Over a three-year period (2018-2020), a retrospective review was undertaken in two neighbouring maternity hospitals; one of which screens for AB (Rotunda hospital (RH)) and one which does not (National Maternity Hospital (NMH)). Patients were included on the basis of fulfilling the IDSA definition for pyelonephritis and requiring admission for intravenous antibiotics. Rates of antenatal pyelonephritis were compared between hospitals, and between screened and unscreened populations. Secondary outcomes including rates of preterm births and LBWI were compared across sites.
Results:
A total of 47,676 deliveries between the two centres (24,768 RH; 22,908 NMH) were assessed, of which 158 patients met inclusion criteria for antenatal pyelonephritis (n = 88 RH, n = 70 NMH). There was no statistically significant difference in the rate of antenatal pyelonephritis (p = 0.34) or preterm births (p = 0.21) across sites. RH had a significantly higher rate of LBWI at 6.45% versus 5.68% of all births in NMH (p=<0.004). Given the screening rate in RH was below 100%, this cohort was further subdivided into 'RH screened' and 'RH unscreened'. There was no statistically significant difference in the rate of antenatal pyelonephritis both between the 'NMH unscreened' group (n = 70) versus the 'RH screened' group (n = 62) (p = 0.53), or in the 'RH screened' group (n = 62) versus the 'RH unscreened' group (n = 26) (p = 0.53).
Conclusion:
Omission of a screening programme for AB in NMH did not result in higher rates of antenatal pyelonephritis, preterm birth or LBWI. Our findings may inform decision-making on screening protocols and whether selective screening (i.e. screening in high-risk patients only) could be more cost-effective without compromising best quality of care.
La segunda patología más frecuente encontrada en la mujer embarazada son las infecciones del tracto urinario, suponiendo un gran reto terapéutico dado al compromiso materno y fetal que pueden ocasionar. Durante el embarazo existen cambios funcionales, estructurales y fisiológicos del tracto urinario, dichos cambios promueven la invasión de los gérmenes desde la uretra y el desarrollo de la patología urinaria. Por lo anterior mencionado, toda la mujer embarazada debe someterse a un cribado de bacteriuria asintomática mediante urocultivo, y en caso de ser positivo, siempre recibir tratamiento antimicrobiano, pues es un factor de riesgo importante para el desarrollo de Pielonefritis durante el embarazo, a diferencia de la mujer no gestante. Palabras clave: Infección urinaria, Bacteriuria asintomática, Embarazo, Cistitis, Pielonefritis aguda.
Background:
Asymptomatic bacteriuria (ASB) is associated with adverse maternal and neonatal outcomes and is routinely screened for and treated in the first trimester. Prevalence of ASB in the second and third trimesters of pregnancy is unknown.
Aims:
The aim is to determine the prevalence of ASB in the second and third trimesters of pregnancy.
Methods:
Prospective cohort study of 150 pregnant women. Mid-stream urine samples were tested for ASB in the second (24-28+6 ) and third (32-36+6 ) trimesters. Women were assigned to one of two groups: (i) ASB in any trimester of pregnancy and (ii) no evidence of ASB in pregnancy. Maternal and neonatal outcomes were compared between groups.
Results:
Among 143 women included in the study, the rate of ASB was 4.9% (2.1, 2.1 and 3.2% in the first, second and third trimesters, respectively). Of those with ASB, 14% had it in every trimester, whereas 43% had it on two or more samples. Of those with ASB in pregnancy, 43% were detected for the first time in the third trimester. Rates of maternal and neonatal outcomes were not statistically significantly different between the two groups. No women with ASB were induced for chorioamnionitis or growth restriction.
Conclusion:
The rate of ASB was highest in the third trimester of pregnancy, with rates of 2.1, 2.1 and 3.2% in the first, second and third trimesters, respectively. This study was underpowered to assess maternal and fetal outcomes. Although numbers were small, the absence of ASB in the first trimester was a poor predictor of ASB in the third trimester.
Purpose of Review
This review will summarize the recent evidence and practice essentials regarding asymptomatic bacteriuria in different populations.
Recent Findings
The current evidence suggests that routine screening and treatment of asymptomatic bacteriuria in various populations are not recommended with exception of some selected populations. There is mixed data on role of screening and treatment of asymptomatic bacteria in pregnant women, and recent recipients of kidney transplant.
Summary
Asymptomatic bacteriuria is widely common among different populations. In most conditions, treatment of symptomatic bacteriuria did not reduce risk of adverse clinical outcomes. Furthermore, overtreatment of asymptomatic bacteriuria is associated with emergence of antibiotic-resistant bacteria.
Background
Urinary tract infections (UTI) are the most common infection in pregnant women and have been associated with maternal and foetal complications. Antimicrobial exposure in pregnancy is not without risk. International guidelines recommend a single screen-and-treat approach to asymptomatic bacteriuria (ASB) but this approach has been questioned by recent studies.
Objectives
The aim of this narrative review is to assess the pathophysiology, current risk factors and management of UTI in pregnancy, its impact on pregnancy outcomes, and to synthesise the recommendations for best antimicrobial use.
Sources
PubMed, Cochrane database and ClinicalTrials.gov.
Content
Due to the physiological changes related to pregnancy, pregnant women are at higher risk of UTI. All types of UTI combined have been estimated to affect around 2-15% of women.
ASB affects 2-7% of pregnant women. Recent studies do not provide good quality evidence for an association between ASB and APN if ASB is untreated.
There is low-to-moderate quality evidence that treatment of ASB results in a reduction in the incidence of low birth weight and of preterm birth, which justifies screening practices for ASB with only a single urine culture in the first trimester. If the clinician opts for treatment, a short course of beta-lactams, nitrofurantoin or fosfomycin should be favoured.
Studies on cystitis in pregnancy are limited. APN has been shown to be associated with increased maternal complications and in some studies has also been associated with preterm delivery and low birth weight. Preferred antimicrobials for management of pyelonephritis are amoxicillin combined with an aminoglygoside, 3rd generation cephalosporins or carbapenems.
Studies on recurrent UTI in pregnancy are limited making it difficult to draw conclusions regarding prophylactic measures.
Implications
Further research is required to understand the true incidence of ASB-related complications, the benefit and modalities of screening for ASB, and to further explore prophylactic measures.
Background
Relatively high perinatal mortality rates have led to a critical assessment of the organization of care in The Netherlands. Policy recommendations emphasize the need for improved coordination between community midwives and obstetric caregivers in hospitals. As such, coordination between the autonomous professional groups in midwifery and obstetrics has become a key debate. However, it remains unclear what the current coordination challenges are. This study focuses on community midwives’ and obstetric caregivers’ perception of coordination …
This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 12 http://www.thecochranelibrary.com Buprenorphine for treating cancer pain (Protocol)
Coordination between the autonomous professional groups in midwifery and obstetrics is a key debate in the Netherlands. At the same time, it remains unclear what the current coordination challenges are.
To examine coordination challenges that might present a barrier to delivering optimal care, we conducted a qualitative field study focusing on midwifery and obstetric professional's perception of coordination and on their routines. We undertook 40 interviews with 13 community midwives, 8 hospital-based midwives and 19 obstetricians (including two resident obstetricians), and conducted non-participatory observations at the worksite of these professional groups.
We identified challenges in terms of fragmented organizational structures, different perspectives on antenatal health and inadequate interprofessional communication. These challenges limited professionals' coordinating capacity and thereby decreased their ability to provide optimal care. We also found that pregnant women needed to compensate for suboptimal coordination between community midwives and secondary caregivers by taking on an active role in facilitating communication between these professionals.
The communicative role that pregnant women play within coordination processes underlines the urgency to improve coordination. We recommend increasing multidisciplinary meetings and training, revising the financial reimbursement system, implementing a shared maternity notes system and decreasing the expertise gap between providers and clients. In the literature, communication by clients in support of coordination has been largely ignored. We suggest that studies include client communication as part of the coordination process.
Resistance to antibiotics is a major public-health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Our aim was to assess outpatient use of antibiotics and the association with resistance.
We investigated outpatient antibiotic use in 26 countries in Europe that provided internationally comparable distribution or reimbursement data, between Jan 1, 1997, and Dec 31, 2002, by calculating the number of defined daily doses (DDD) per 1000 inhabitants per day, according to WHO anatomic therapeutic chemical classification and DDD measurement methodology. We assessed the ecological association between antibiotic use and antibiotic resistance rates using Spearman's correlation coefficients.
Prescription of antibiotics in primary care in Europe varied greatly; the highest rate was in France (32.2 DDD per 1000 inhabitants daily) and the lowest was in the Netherlands (10.0 DDD per 1000 inhabitants daily). We noted a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics. We also recorded striking seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics. We showed higher rates of antibiotic resistance in high consuming countries, probably related to the higher consumption in southern and eastern Europe than in northern Europe.
These data might provide a useful method for assessing public-health strategies that aim to reduce antibiotic use and resistance levels.
The ECO.SENS study is the first international survey to investigate the prevalence and susceptibility of pathogens causing community-acquired acute uncomplicated urinary tract infections (UTIs). Midstream urine samples were taken for culture and for testing for the presence of leucocytes from 4734 women not older than 65 years presenting with symptoms of acute UTI at 252 community health care centres in 17 countries. Recognized urinary tract pathogens were identified and the susceptibility to 12 antimicrobials determined. Pathogens were present in 3278 (69.2%) patients, Escherichia coli accounting for 77.0% of isolates. In E. coli, 42% of the isolates were resistant to one or more of the 12 antimicrobial drugs investigated. Resistance was most common to ampicillin (29.8%) and sulfamethoxazole (29.1%), followed by trimethoprim (14.8%), trimethoprim/sulfamethoxazole (14.1%) and nalidixic acid (5.4%). Resistance in E. coli to co-amoxiclav, mecillinam, cefadroxil, nitrofurantoin, fosfomycin, gentamicin and ciprofloxacin was <3%. However, co-amoxiclav resistance was apparent in Portugal (9.3%) as was resistance to the quinolones, nalidixic acid and ciprofloxacin, in Portugal (11.6% and 5.8%, respectively) and Spain (26.7% and 14.7%, respectively). Overall, Proteus mirabilis were less resistant to ampicillin (16.1%) and more resistant to trimethoprim (25.5%) than E. coli, whereas Klebsiella spp. were more resistant to ampicillin (83.5%) and fosfomycin (56.7%). 'Other Enterobacteriaceae' were more resistant to the broad spectrum beta-lactams (ampicillin 45.9%, co-amoxiclav 21.3% and cefadroxil 24.6%), nitrofurantoin (40.2%) and fosfomycin (15.6%). In Staphylococcus saprophyticus resistance development was rare. Overall, antimicrobial resistance was lowest in the Nordic countries and Austria and highest in Portugal and Spain.
Background:
Midwives and obstetricians are the key providers of care during pregnancy and postpartum. Information about the consultations with a general practitioner (GP) during this period is generally lacking.The aim of this study is to compare consultation rates, diagnoses and GP management of pregnant women with those of non-pregnant women.
Methods:
Data were retrieved from the Netherlands Information Network of General Practice (LINH), a nationally representative register. This register holds longitudinal data on consultations, prescriptions and the referrals of all patients listed at 84 practices in the Netherlands in 2007-2009, including 15,123 pregnant women and 102,564 non-pregnant women in the same age-range (15 to 45 years). We compared consultation rates (including all contacts with the practice), diagnoses (ICPC-1 coded), medication prescriptions (coded according to the Anatomical Therapeutic Chemical classification system), and rate and type of referrals from the start of the pregnancy until six weeks postpartum (336 days).
Results:
Pregnant women contacted their GP on average 3.6 times, compared to 2.2 times for non-pregnant women. The most frequently recorded diagnoses for pregnant women were 'pregnancy' and 'cystitis/urinary infection', and 'cystitis/urinary infection' and 'general disease not otherwise specified' for non-pregnant women. The mean number of prescribed medications was lower in pregnant women (2.1 against 4.4). For pregnant women, the most frequent referral indication concerned obstetric care, for non-pregnant women this concerned physiotherapy.
Conclusions:
GP consultation rates in pregnancy and postpartum shows that GPs are important providers of care for pregnant women. Therefore, the involvement of GPs in collaborative care during pregnancy and postpartum should be reinforced.
The prevalence of asymptomatic bacteriuria (ASB) in pregnancy is 2-10% and is associated with both maternal and neonatal adverse outcomes as pyelonephritis and preterm delivery. Antibiotic treatment is reported to decrease these adverse outcomes although the existing evidence is of poor quality.
We plan a combined screen and treat study in women with a singleton pregnancy. We will screen women between 16 and 22 weeks of gestation for ASB using the urine dipslide technique. The dipslide is considered positive when colony concentration ≥105 colony forming units (CFU)/mL of a single microorganism or two different colonies but one ≥105 CFU/mL is found, or when Group B Streptococcus bacteriuria is found in any colony concentration. Women with a positive dipslide will be randomly allocated to receive nitrofurantoin or placebo 100 mg twice a day for 5 consecutive days (double blind). Primary outcomes of this trial are maternal pyelonephritis and/or preterm delivery before 34 weeks. Secondary outcomes are neonatal and maternal morbidity, neonatal weight, time to delivery, preterm delivery rate before 32 and 37 weeks, days of admission in neonatal intensive care unit, maternal admission days and costs.
This trial will provide evidence for the benefit and cost-effectiveness of dipslide screening for ASB among low risk women at 16-22 weeks of pregnancy and subsequent nitrofurantoin treatment.
Dutch trial registry: NTR-3068.
Urinary tract infections (UTI) are one of the most common medical complications of pregnancy. The emergence of drug resistance and particularly the Extended-spectrum beta-lactamase production by Escherichia coli and methicillin resistance in Staphylococci, limits the choice of antimicrobials.
Patients in different stages of pregnancy with or without symptoms of urinary tract infection attending the antenatal clinic of obstetrics and gynaecology were screened for significant bacteriuria, by standard loop method on 5% sheep blood agar and teepol lactose agar. Isolates were identified by using standard biochemical tests and antimicrobial susceptibility testing was done using Kirby Bauer disc diffusion method.
A total of 4290 (51.2%) urine samples from pregnant females showed growth on culture. Prevalence of asymptomatic bacteriuria 3210 (74.8%) was higher than symptomatic UTI 1080 (25.2%). Escherichia coli was the most common pathogen accounting for 1800 (41.9%) of the urinary isolates. Among the gram-positive cocci, coagulase negative species of Staphylococci 270 (6.4%) were the most common pathogen. Significantly high resistance was shown by the gram negative bacilli as well as gram positive cocci to the β-lactam group of antimicrobials, flouroquinolones and aminoglycosides. Most alarming was the presence of ESBL in 846 (47%) isolates of Escherichia coli and 344 (36.9%) isolates of Klebsiella pneumoniae, along with the presence of methicillin resistance in 41% of Staphylococcus species and high-level aminoglycoside resistance in 45(30%) isolates of Enterococcus species. Glycopeptides and carbepenems were the only group of drugs to which all the strains of gram positive cocci and gram negative bacilli were uniformly sensitive, respectively.
Regular screening should be done for the presence of symptomatic or asymptomatic bacteriuria in pregnancy and specific guidelines should be issued for testing antimicrobial susceptibility with safe drugs in pregnant women so that these can be used for the treatment. For empirical treatment cefoperazone-sulbactum can be recommended, which is a safe drug, covering both gram positive and gram negative organisms and with a good sensitivity.
Acute pyelonephritis causes significant morbidity, tends to recur, and can be fatal; however, little is known regarding its epidemiology. In this paper, the authors describe the epidemiology of acute pyelonephritis in South Korea by using nationwide heath insurance claims data from 1997 to 1999. The National Health Insurance System of South Korea covers almost the entire population (99%). The overall average annual incidence rate of pyelonephritis in 1997-1999 was 35.7 per 10,000 population (male, 12.6; female, 59.0). Approximately one of every seven patients was hospitalized (incidence per 10,000: inpatients, 5.5; outpatients, 30.1). Incidence varied with age and was higher in the summer season. Following an initial episode, the risk of a second episode within 12 months was 9.2% for females and 5.7% for males; by contrast, the risk of a fifth episode within a year following a fourth episode was 50.0% for females and 53.0% for males. Female sex (hazard ratio = 1.89, 95% confidence interval: 1.60, 2.23), advancing age, outpatient treatments (hazard ratio = 1.35, 95% confidence interval: 1.14, 1.60), and medical aid (hazard ratio = 1.23, 95% confidence interval: 1.08, 1.40) increased the risk of any recurrence. Pyelonephritis has a clear seasonal pattern and high rate of recurrence. The incidence of hospitalization for pyelonephritis in South Korea is similar to that in the United States and Canada.
In most situations, simple techniques for handling missing data (such as complete case analysis, overall mean imputation, and the missing-indicator method) produce biased results, whereas imputation techniques yield valid results without complicating the analysis once the imputations are carried out. Imputation techniques are based on the idea that any subject in a study sample can be replaced by a new randomly chosen subject from the same source population. Imputation of missing data on a variable is replacing that missing by a value that is drawn from an estimate of the distribution of this variable. In single imputation, only one estimate is used. In multiple imputation, various estimates are used, reflecting the uncertainty in the estimation of this distribution. Under the general conditions of so-called missing at random and missing completely at random, both single and multiple imputations result in unbiased estimates of study associations. But single imputation results in too small estimated standard errors, whereas multiple imputation results in correctly estimated standard errors and confidence intervals. In this article we explain why all this is the case, and use a simple simulation study to demonstrate our explanations. We also explain and illustrate why two frequently used methods to handle missing data, i.e., overall mean imputation and the missing-indicator method, almost always result in biased estimates.
Background:
The cause of acute uncomplicated cystitis is determined on the basis of cultures of voided midstream urine, but few data guide the interpretation of such results, especially when gram-positive bacteria grow.
Methods:
Women from 18 to 49 years of age with symptoms of cystitis provided specimens of midstream urine, after which we collected urine by means of a urethral catheter for culture (catheter urine). We compared microbial species and colony counts in the paired specimens. The primary outcome was a comparison of positive predictive values and negative predictive values of organisms grown in midstream urine, with the presence or absence of the organism in catheter urine used as the reference.
Results:
The analysis of 236 episodes of cystitis in 226 women yielded 202 paired specimens of midstream urine and catheter urine that could be evaluated. Cultures were positive for uropathogens in 142 catheter specimens (70%), 4 of which had more than one uropathogen, and in 157 midstream specimens (78%). The presence of Escherichia coli in midstream urine was highly predictive of bladder bacteriuria even at very low counts, with a positive predictive value of 10(2) colony-forming units (CFU) per milliliter of 93% (Spearman's r=0.944). In contrast, in midstream urine, enterococci (in 10% of cultures) and group B streptococci (in 12% of cultures) were not predictive of bladder bacteriuria at any colony count (Spearman's r=0.322 for enterococci and 0.272 for group B streptococci). Among 41 episodes in which enterococcus, group B streptococci, or both were found in midstream urine, E. coli grew from catheter urine cultures in 61%.
Conclusions:
Cultures of voided midstream urine in healthy premenopausal women with acute uncomplicated cystitis accurately showed evidence of bladder E. coli but not of enterococci or group B streptococci, which are often isolated with E. coli but appear to rarely cause cystitis by themselves. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).
To describe the incidence of acute pyelonephritis in pregnancy, and to assess its association with perinatal outcomes in an integrated healthcare system.
A retrospective cohort study was performed using medical records on 546,092 singleton pregnancies delivered in all Kaiser Permanente Southern California hospitals from 1993 through 2010. These medical records include the Perinatal Service System, inpatient, and outpatient encounter files. Adjusted odd ratios (OR) and 95% confidence intervals (CI) were used to estimate associations.
The incidence of acute antepartum pyelonephritis was 0.5% (2,894/543,430). Women with pyelonephritis in pregnancy were more likely to be black or Hispanic, young, less educated, nulliparous, initiate prenatal care late, and smoke during pregnancy. Pregnancies of women with pyelonephritis compared to those without were more likely to be complicated by anemia (26.3% vs. 11.4%; OR 2.6, 95% CI 2.4, 2.9), septicemia (1.9% vs. 0.03%; OR 56.5, 95% CI 41.3, 77.4), acute pulmonary insufficiency (0.5% vs. 0.04%; OR 12.5, 95% CI 7.2, 21.6), acute renal dysfunction (0.4% vs.0.03%; OR 16.5, 95% CI 8.8, 30.7) and spontaneous preterm birth (10.3% vs. 7.9%; OR 1.3, 95% CI 1.2, 1.5). Most of the preterm births occurred between 33 and 36 weeks (9.1%).
We characterize the incidence of pyelonephritis in an integrated health care system where routine prenatal screening for asymptomatic bacteriuria is employed. Maternal complications are commonly encountered and the risk of preterm birth is higher than the baseline obstetric population.
In women with a multiple pregnancy, spontaneous preterm delivery is the leading cause of perinatal morbidity and mortality. Interventions to reduce preterm birth in these women have not been successful. We assessed whether a cervical pessary could effectively prevent poor perinatal outcomes.
We undertook a multicentre, open-label randomised controlled trial in 40 hospitals in the Netherlands. We randomly assigned women with a multiple pregnancy between 12 and 20 weeks' gestation (1:1) to pessary or control groups, using a web-based application with a computer-generated list with random block sizes of two to four, stratified by hospital. Participants and investigators were aware of group allocation. For women in the pessary group, a midwife or obstetrician inserted a cervical pessary between 16 and 20 weeks' gestation. Women in the control group did not receive the pessary, but otherwise received similar obstetrical care to those in the pessary group. The primary outcome was a composite of poor perinatal outcome: stillbirth, periventricular leucomalacia, severe respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, necrotising enterocolitis, proven sepsis, and neonatal death. Analyses were by modified intention to treat. This trial is registered in the Dutch trial registry, number NTR1858.
Between Sept 21, 2009, and March 9, 2012, 813 women underwent randomisation, of whom 808 were analysed (401 in the pessary group; 407 in the control group). At least one child of 53 women (13%) in the pessary group had poor perinatal outcome, compared with 55 (14%) in the control group (relative risk 0·98, 95% CI 0·69-1·39).
In unselected women with a multiple pregnancy, prophylactic use of a cervical pessary does not reduce poor perinatal outcome.
The Netherlands Organisation for Health Research and Development.
Background:
Maternal infections during pregnancy have been associated with an increased risk for neurological outcomes in the child, including epilepsy. We examined cystitis antibiotics commonly used during pregnancy, as a marker of cystitis, and the risk of childhood epilepsy in a population-based cohort in Denmark.
Methods:
We examined all liveborn singletons born in Denmark between January 1996 and September 2004, identified from the Danish National Birth Registry. Epilepsy diagnoses were obtained from the Danish National Hospital Register and maternal antibiotic use from the National Register of Medicinal Product Statistics. Cystitis antibiotics consisted of pivmecillinam, sulphamethizole and nitrofurantoin. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated with Cox proportional hazard regression models.
Results:
The study followed 447629 singletons for up to 9.9 years and identified 2848 children diagnosed with epilepsy. We found slightly increased risks of epilepsy in children whose mothers had redeemed prescriptions during pregnancy for pivmecillinam HR=1.2 [95% CI 1.0, 1.4], sulphamethizole HR=1.2 [95% CI 1.1, 1.4] or nitrofurantoin HR=1.1 [95% CI 0.8, 1.5], compared with those unexposed. Among mothers with multiple redeemed prescriptions during pregnancy, adjusted HR were for pivmecillinam HR=1.3 [95% CI 1.1, 1.5], sulphamethizole HR=1.3 [95% CI 1.1, 1.5] and nitrofurantoin HR=1.3 [95% CI 1.0, 1.8].
Conclusions:
Similar magnitudes of associations between chemically different drugs, used almost exclusively to treat cystitis, may suggest an impact of maternal infection on the fetal brain. However, direct drug effects or confounding factors are also possible explanations.
In a case-cohort study of early-onset sepsis, antibiotic resistance was more likely for infections in neonates born to mothers who were given antibiotics during pregnancy (odds ratio 4.6; 95% confidence interval: 1.1-19;P = 0.05). Risk of resistance increased with duration of antibiotics and number of antibiotic courses during pregnancy. Preterm birth and hospitalization during pregnancy were also associated with resistance. These risk factors should be considered when selecting empiric antibiotics for therapy of early-onset sepsis in infants.
To test the incidence and sonographic parameters of pyelonephritis during pregnancy, and to examine risk factors and pregnancy outcomes of women with acute antepartum pyelonephritis.
A retrospective population-based study comparing all singleton pregnancies of patients with and without acute antepartum pyelonephritis was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the study. Multiple logistic regression models were used to control for confounders.
Out of 219,612 singleton deliveries in 1988-2010, 165 women (0.07%) suffered from acute antepartum pyelonephritis. Abnormal sonographic findings were found in 85.7% of the patients with pyelonephritis. Pyelonephritis was significantly associated with nulliparity (46.1% vs. 24.4%, p<0.001), younger maternal age (26.3 ± 6.0 vs. 28.6 ± 5.8 years, p<0.001), intrauterine growth restriction (IUGR) (6.7% vs. 2.1%, p<0.001), placental abruption (3.6% vs. 0.7%, p<0.001), low 1 min Apgar scores (10.3% vs. 6.0%, p<0.05), urinary tract infection (UTI) (4.2% vs. 0.4%, p<0.001) and preterm delivery (less than 37 weeks gestation; 20.0% vs. 7.8%; p<0.001). Using a multivariable analysis, independent risk factors for acute antepartum pyelonephritis were nulliparity (OR 2.0; 95% C.I 1.4-2.9; p<0.001), UTI (OR 10.3; 95% C.I 4.8-22.1; p<0.001) and younger maternal age (OR 0.96; 95% C.I 0.93-0.99; p=0.009). Using another multivariable analysis, with preterm delivery as the outcome variable, acute antepartum pyelonephritis was found as an independent risk factor for preterm delivery (OR 2.6; 95% C.I 1.7-3.9; p<0.001).
Acute antepartum pyelonephritis is associated with adverse perinatal outcomes and specifically is an independent risk factor for preterm delivery.
Induction of labour is a common obstetric procedure. Both mechanical (eg, Foley catheters) and pharmacological methods (eg, prostaglandins) are used for induction of labour in women with an unfavourable cervix. We aimed to compare the effectiveness and safety of induction of labour with a Foley catheter with induction with vaginal prostaglandin E2 gel.
We did an open-label, randomised controlled trial in 12 hospitals in the Netherlands between Feb 10, 2009, and May 17, 2010. We enrolled women with a term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix, an indication for induction of labour, and no prior caesarean section. Participants were randomly allocated by an online randomisation system to induction of labour with a 30 mL Foley catheter or vaginal prostaglandin E2 gel (1:1 ratio). Because of the nature of the intervention this study was not blinded. The primary outcome was caesarean section rate. Secondary outcomes were maternal and neonatal morbidity and time from intervention to birth. All analyses were done on an intention-to-treat basis. We also did a meta-analysis that included our trial. The trial was registered with the Dutch trial registry, number NTR 1646.
824 women were allocated to induction of labour with a Foley catheter (n=412) or vaginal prostaglandin E2 gel (n=412). Caesarean section rates were much the same between the two groups (23%vs 20%, risk ratio [RR] 1·13, 95% CI 0·87-1·47). A meta-analysis including our trial data confirmed that a Foley catheter did not reduce caesarean section rates. We recorded two serious maternal adverse events, both in the prostaglandin group: one uterine perforation and one uterine rupture.
In women with an unfavourable cervix at term, induction of labour with a Foley catheter is similar to induction of labour with prostaglandin E2 gel, with fewer maternal and neonatal side-effects.
None.
Several studies have reported increasing trends in preterm birth in developed countries, mainly attributable to an increase in medically indicated preterm births. Our aim was to describe trends in preterm birth among singleton and multiple pregnancies in the Netherlands.
Prospective cohort study.
Nationwide study.
We studied 1,451,246 pregnant women from 2000 to 2007.
We assessed trends in preterm birth. We subdivided preterm birth into spontaneous preterm birth after premature prelabour rupture of membranes (pPROM), medically indicated preterm birth and spontaneous preterm birth without pPROM. We performed analyses separately for singletons and multiples.
The primary outcome was preterm birth, defined as birth before 37 weeks of gestation, with very preterm birth (<32 weeks of gestation) being a secondary outcome.
The risk of preterm birth was 7.7% and the risk of very preterm birth was 1.3%. In singleton pregnancies, the preterm birth risk decreased significantly from 6.4% to 6.0% (P < 0.0001), mainly as a result of the decrease in spontaneous preterm birth without pPROM (3.6-3.1%, P < 0.0001). In multiple pregnancies, the preterm birth risk increased significantly (47.3-47.7%, P = 0.047), mainly as a result of medically indicated preterm birth, which increased from 15.0% to 17.9% (P < 0.0001).
In the Netherlands, the preterm birth risk in singleton pregnancies decreased significantly over the years. The trend of increasing preterm birth risk reported in other countries was only observed in (medically indicated) preterm birth in multiple pregnancies.
Background:
Asymptomatic bacteriuria occurs in 5% to 10% of pregnancies and, if left untreated, can lead to serious complications.
Objectives:
To assess which antibiotic is most effective and least harmful as initial treatment for asymptomatic bacteriuria in pregnancy.
Search strategy:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2010) and reference lists of retrieved studies.
Selection criteria:
Randomized controlled trials comparing two antibiotic regimens for treating asymptomatic bacteriuria.
Data collection and analysis:
Review authors independently screened the studies for inclusion and extracted data.
Main results:
We included five studies involving 1140 women with asymptomatic bacteriuria. We did not perform meta-analysis; each trial examined different antibiotic regimens and so we were not able to pool results. In a study comparing a single dose of fosfomycin trometamol 3 g with a five-day course of cefuroxime, there was no significant difference in persistent infection (risk ratio (RR) 1.36, 95% confidence interval (CI) 0.24 to 7.75), shift to other antibiotics (RR 0.08, 95% CI 0.00 to 1.45), or in allergy or pruritus (RR 2.73, 95% CI 0.11 to 65.24). A comparison of seven-day courses of 400 mg pivmecillinam versus 500 mg ampicillin, both given four times daily, showed no significant difference in persistent infection at two weeks or recurrent infection, but there was an increase in vomiting (RR 4.57, 95% CI 1.40 to 14.90) and women were more likely to stop treatment early with pivmecillinam (RR 8.82, 95% CI 1.16 to 66.95). When cephalexin 1 g versus Miraxid(R) (pivmecillinam 200 mg and pivampicillin 250 mg) were given twice-daily for three days, there was no significant difference in persistent or recurrent infection. A one- versus seven-day course of nitrofurantoin resulted in more persistent infection with the shorter course (RR 1.76, 95% CI 1.29 to 2.40), but no significant difference in symptomatic infection at two weeks, nausea, or preterm birth. Comparing cycloserine with sulphadimidine, no significant differences in symptomatic, persistent, or recurrent infections were noted.
Authors' conclusions:
We cannot draw any definite conclusion on the most effective and safest antibiotic regimen for the initial treatment of asymptomatic bacteriuria in pregnancy. One study showed advantages with a longer course of nitrofurantoin, and another showed better tolerability with ampicillin compared with pivmecillinam; otherwise, there was no significant difference demonstrated between groups treated with different antibiotics. Given this lack of conclusive evidence, it may be useful for clinicians to consider factors such as cost, local availability and side effects in the selection of the best treatment option.
A dipslide is a plastic paddle coated with agar that is attached to a plastic cap that screws onto a sterile plastic vial. Our objective was to estimate the diagnostic accuracy of the dipslide culture technique to detect asymptomatic bacteriuria during pregnancy and to evaluate the accuracy of nitrate and leucocyte esterase dipslides for screening.
This was an ancillary study within a trial comparing single-day with 7-day therapy in treating asymptomatic bacteriuria. Clean-catch midstream samples were collected from pregnant women seeking routine care. Positive and negative likelihood ratios and sensitivity and specificity for the culture-based dipslide to detect and chemical dipsticks (nitrites, leukocyte esterase, or both) to screen were estimated using traditional urine culture as the "gold standard."
: A total of 3,048 eligible pregnant women were screened. The prevalence of asymptomatic bacteriuria was 15%, with Escherichia coli the most prevalent organism. The likelihood ratio for detecting asymptomatic bacteriuria with a positive dipslide test was 225 (95% confidence interval [CI] 113-449), increasing the probability of asymptomatic bacteriuria to 98%; the likelihood ratio for a negative dipslide test was 0.02 (95% CI 0.01-0.05), reducing the probability of bacteriuria to less than 1%. The positive likelihood ratio of leukocyte esterase and nitrite dipsticks (when both or either one was positive) was 6.95 (95% CI 5.80-8.33), increasing the probability of bacteriuria to only 54%; the negative likelihood ratio was 0.50 (95% CI 0.45-0.57), reducing the probability to 8%.
A pregnant woman with a positive dipslide test is very likely to have a definitive diagnosis of asymptomatic bacteriuria, whereas a negative result effectively rules out the presence of bacteriuria. Dipsticks that measure nitrites and leukocyte esterase have low sensitivity for use in screening for asymptomatic bacteriuria during gestation.
ISRCTN, isrctn.org, 1196608
II.
The ORACLE II trial compared the use of erythromycin and/or amoxicillin-clavulanate (co-amoxiclav) with that of placebo for women in spontaneous preterm labour and intact membranes, without overt signs of clinical infection, by use of a factorial randomised design. The aim of the present study--the ORACLE Children Study II--was to determine the long-term effects on children after exposure to antibiotics in this clinical situation.
We assessed children at age 7 years born to the 4221 women who had completed the ORACLE II study and who were eligible for follow-up with a structured parental questionnaire to assess the child's health status. Functional impairment was defined as the presence of any level of functional impairment (severe, moderate, or mild) derived from the mark III Multi-Attribute Health Status classification system. Educational outcomes were assessed with national curriculum test results for children resident in England.
Outcome was determined for 3196 (71%) eligible children. Overall, a greater proportion of children whose mothers had been prescribed erythromycin, with or without co-amoxiclav, had any functional impairment than did those whose mothers had received no erythromycin (658 [42.3%] of 1554 children vs 574 [38.3%] of 1498; odds ratio 1.18, 95% CI 1.02-1.37). Co-amoxiclav (with or without erythromycin) had no effect on the proportion of children with any functional impairment, compared with receipt of no co-amoxiclav (624 [40.7%] of 1523 vs 608 [40.0%] of 1520; 1.03, 0.89-1.19). No effects were seen with either antibiotic on the number of deaths, other medical conditions, behavioural patterns, or educational attainment. However, more children whose mothers had received erythromycin or co-amoxiclav developed cerebral palsy than did those born to mothers who received no erythromycin or no co-amoxiclav, respectively (erythromycin: 53 [3.3%] of 1611 vs 27 [1.7%] of 1562, 1.93, 1.21-3.09; co-amoxiclav: 50 [3.2%] of 1587 vs 30 [1.9%] of 1586, 1.69, 1.07-2.67). The number needed to harm with erythromycin was 64 (95% CI 37-209) and with co-amoxiclav 79 (42-591).
The prescription of erythromycin for women in spontaneous preterm labour with intact membranes was associated with an increase in functional impairment among their children at 7 years of age. The risk of cerebral palsy was increased by either antibiotic, although the overall risk of this condition was low.
UK Medical Research Council.
The ORACLE I trial compared the use of erythromycin and/or amoxicillin-clavulanate (co-amoxiclav) with that of placebo for women with preterm rupture of the membranes without overt signs of clinical infection, by use of a factorial randomised design. The aim of the present study--the ORACLE Children Study I--was to determine the long-term effects on children of these interventions.
We assessed children at age 7 years born to the 4148 women who had completed the ORACLE I trial and who were eligible for follow-up with a structured parental questionnaire to assess the child's health status. Functional impairment was defined as the presence of any level of functional impairment (severe, moderate, or mild) derived from the mark III Multi-Attribute Health Status classification system. Educational outcomes were assessed with national curriculum test results for children resident in England.
Outcome was determined for 3298 (75%) eligible children. There was no difference in the proportion of children with any functional impairment after prescription of erythromycin, with or without co-amoxiclav, compared with those born to mothers who received no erythromycin (594 [38.3%] of 1551 children vs 655 [40.4%] of 1620; odds ratio 0.91, 95% CI 0.79-1.05) or after prescription of co-amoxiclav, with or without erythromycin, compared with those born to mothers who received no co-amoxiclav (645 [40.6%] of 1587 vs 604 [38.1%] of 1584; 1.11, 0.96-1.28). Neither antibiotic had a significant effect on the overall level of behavioural difficulties experienced, on specific medical conditions, or on the proportions of children achieving each level in reading, writing, or mathematics at key stage one.
The prescription of antibiotics for women with preterm rupture of the membranes seems to have little effect on the health of children at 7 years of age.
UK Medical Research Council.
To describe an efficient, generalizable approach to validate probabilistic record linkage results, in particular by a model-guided detection of linking errors, and to apply this approach to validate linkage of admissions of newborns.
Our double-blind validation procedure consisted of three steps: sample selection, data collection and data analysis. The linked Dutch national newborn admission registry contained 30,082 records for 2001 including readmissions (7.4%) and twins (9.7%). A highly informative sample was selected from the linked file by oversampling uncertain links based on model-derived linking weight. Four hundred and eight fax forms with minimal registry information (admissions of 191 children) were sent out to different pediatric units. The pediatricians were asked to create a short detailed patient history from independent sources. The linkage status and additional record data was validated against this external information.
Response rate was 97% (395/408 faxes). Accuracy of the linkage of singleton admissions was high: except for some expected errors in the uncertain area (0.02% of record pairs), linkage was error-free. Validation of multiple birth readmissions showed 37% linkage errors due to low data quality of the multiple birth variables. The quality of the linked registry file was still high; only 1.7% of the children were from a multiple birth with multiple admissions, resulting in less than 1% linking error.
Our external validation procedure of record linkage was feasible, efficient, and informative about identifying the source of the errors.
To examine the incidence of pyelonephritis and the incidence of risk factors, microbial pathogens, and obstetric complications in women with acute antepartum pyelonephritis.
For 2 years, information on pregnant women with acute pyelonephritis was collected in a longitudinal study. All women were admitted to the hospital and treated with intravenous antimicrobial agents. We compared the pregnancy outcomes of these women with those of the general obstetric population received at our hospital during the same time period.
Four hundred forty cases of acute antepartum pyelonephritis were identified during the study period (incidence 1.4%). Although there were no significant differences in ethnicity, pyelonephritis was associated with nulliparity (44% versus 37%, P = .003) and young age (P = .003). Thirteen percent of the women had a known risk factor for pyelonephritis. Acute pyelonephritis occurred more often in the second trimester (53%), and the predominant uropathogens were Escherichia coli (70%) and gram-positive organisms, including group B beta Streptococcus (10%). Complications included anemia (23%), septicemia (17%), transient renal dysfunction (2%), and pulmonary insufficiency (7%).
The incidence of pyelonephritis has remained low in the era of routine prenatal screening for asymptomatic bacteriuria. First-trimester pyelonephritis accounts for over 1 in 5 antepartum cases. Gram-positive uropathogens are found more commonly as pregnancy progresses. Maternal complications continue, but poor obstetrical outcomes are rare.
Asymptomatic bacteriuria is common. Pregnant women with asymptomatic bacteriuria are at an increased risk for adverse outcomes, and these can be prevented with antimicrobial treatment of asymptomatic bacteriuria. Thus, pregnant women should be screened for bacteriuria and treated if test results are positive. Asymptomatic bacteriuria is also a risk for patients who undergo traumatic urologic interventions with mucosal bleeding, and such patients should be treated prior to such interventions. For all other adult populations, asymptomatic bacteriuria has not been shown to be harmful. Although persons with bacteriuria are at an increased risk of symptomatic urinary infection, treatment of asymptomatic bacteriuria does not decrease the frequency of symptomatic infection or improve other outcomes. Thus, in populations other than those for whom treatment has been documented to be beneficial, screening for or treatment of asymptomatic bacteriuria is not appropriate and should be discouraged. © 2005 by the Infectious Diseases Society of America. All rights reserved.
To compare the following 4 screening strategies for detecting asymptomatic bacteriuria (ABU) in pregnancy: urine testing with leukocyte-esterase-nitrite (LEN) strips at each prenatal visit followed by a urine culture if positive; a single urine culture at fewer than 20 weeks' gestation; 2 urine cultures, at fewer than 20 weeks' gestation and at 28 weeks' gestation; or 3 urine cultures, at fewer than 20 weeks', at 28 weeks', and at 36 weeks' gestation.
Participants were pregnant women presenting to 2 obstetricians and 6 family physicians at outpatient family medicine and obstetrical clinics in a large Canadian urban teaching hospital. LEN dipstick urine testing was conducted at each prenatal visit. A midstream urine culture was obtained from all women before 20 weeks' gestation and at 28 weeks' and 36 weeks' gestation, as well as for positive LEN tests. Any positive urine culture in an asymptomatic woman was designated a case of ABU. The total number of ABU cases that would be detected by each of the 4 strategies (LEN dipstick testing only, a single urine culture, 2 cultures, and 3 cultures) was determined and compared.
There were 49 cases of ABU among 1050 women (4.7%). LEN testing at each prenatal visit identified 7 cases (14.3%), compared with 20 cases (40.8%) with 1 urine culture, 31 (63.3%) with 2 urine cultures, and 43 (87.8%) with 3 urine cultures.
A single urine culture before 20 weeks' gestation missed more than one-half the ABU cases. A culture in each trimester identified most ABU cases.
Epidemiologic studies commonly estimate associations between predictors (risk factors) and outcome. Most software automatically exclude subjects with missing values. This commonly causes bias because missing values seldom occur completely at random (MCAR) but rather selectively based on other (observed) variables, missing at random (MAR). Multiple imputation (MI) of missing predictor values using all observed information including outcome is advocated to deal with selective missing values. This seems a self-fulfilling prophecy.
We tested this hypothesis using data from a study on diagnosis of pulmonary embolism. We selected five predictors of pulmonary embolism without missing values. Their regression coefficients and standard errors (SEs) estimated from the original sample were considered as "true" values. We assigned missing values to these predictors--both MCAR and MAR--and repeated this 1,000 times using simulations. Per simulation we multiple imputed the missing values without and with the outcome, and compared the regression coefficients and SEs to the truth.
Regression coefficients based on MI including outcome were close to the truth. MI without outcome yielded very biased--underestimated--coefficients. SEs and coverage of the 90% confidence intervals were not different between MI with and without outcome. Results were the same for MCAR and MAR.
For all types of missing values, imputation of missing predictor values using the outcome is preferred over imputation without outcome and is no self-fulfilling prophecy.
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 delivery.
To assess the effect of antibiotic treatment for asymptomatic bacteriuria on persistent bacteriuria during pregnancy, the development of pyelonephritis and the risk of low birthweight and preterm delivery.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007).
Randomized trials comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening.
We assessed trial quality.
Fourteen studies were included. Overall the study quality was poor. Antibiotic treatment compared to placebo or no treatment was effective in clearing asymptomatic bacteriuria (risk ratio (RR) 0.25, 95% confidence interval (CI) 0.14 to 0.48). The incidence of pyelonephritis was reduced (RR 0.23, 95% CI 0.13 to 0.41). Antibiotic treatment was also associated with a reduction in the incidence of low birthweight babies (RR 0.66, 95% CI 0.49 to 0.89) but a difference in preterm delivery was not seen.
Antibiotic treatment is effective in reducing the risk of pyelonephritis in pregnancy. A reduction in low birthweight is consistent with current theories about the role of infection in adverse pregnancy outcomes, but this association should be interpreted with caution given the poor quality of the included studies.
To describe the technical approach and subsequent validation of the probabilistic linkage of the three anonymous, population-based Dutch Perinatal Registries (LVR1 of midwives, LVR2 of obstetricians, and LNR of pediatricians/neonatologists). These registries do not share a unique identification number.
A combination of probabilistic and deterministic record linkage techniques were applied using information about the mother, delivery, and child(ren) to link three known registries. Rewards for agreement and penalties for disagreement between corresponding variables were calculated based on the observed patterns of agreement and disagreements using maximum likelihood estimation. Special measures were developed to overcome linking difficulties in twins. A subsample of linked and nonlinked pairs was validated.
Independent validation confirmed that the procedure successfully linked the three Dutch perinatal registries despite nontrivial error rates in the linking variables.
Probabilistic linkage techniques allowed the creation of a high-quality linked database from crude registry data. The developed procedures are generally applicable in linkage of health data with partially identifying information. They provide useful source date even if cohorts are only partly overlapping and if within the cohort, multiple entities and twins exist.
Asymptomatic bacteriuria is common, and screening for this condition in pregnant women is a well-established, evidence-based standard of current medical practice. Screening other groups of adults has not been shown to improve outcomes.
To review new and substantial evidence on screening for asymptomatic bacteriuria, to support the work of the U.S. Preventive Services Task Force.
English-language studies of adults (age >18 years) indexed in PubMed and the Cochrane Library and published from 1 January 2002 through 30 April 2007.
For benefits of screening or treatment for screened populations, systematic reviews; meta-analyses; and randomized, controlled trials were included. For harms of screening, systematic reviews; meta-analyses; randomized, controlled trials; cohort studies; case-control studies; and case series of large multisite databases were included. Two reviewers independently reviewed titles, abstracts, and full articles for inclusion.
Two reviewers extracted data from studies on benefits of screening and treatment (including decreases in the incidence of adverse maternal and fetal outcomes, symptomatic urinary tract infections, hypertension, and renal function decline).
An updated Cochrane systematic review of 14 randomized, controlled trials of treatment supports screening for asymptomatic bacteriuria in pregnant women. A randomized, controlled trial and a prospective cohort study show that screening nonpregnant women with diabetes for asymptomatic bacteriuria is unlikely to produce benefits. No new evidence on screening men for asymptomatic bacteriuria or on harms of screening was found.
The focused search strategy may have missed some smaller studies on the benefits and harms of screening for asymptomatic bacteriuria.
The available evidence continues to support screening for asymptomatic bacteriuria in pregnant women, but not in other groups of adults.
NVOG Guideline: urineweginfectie in de zwangerschap
- Nederlandse Vereniging Voor Obstetrie En Gynaecologie
Nederlandse Vereniging voor Obstetrie en Gynaecologie. NVOG
Guideline: urineweginfectie in de zwangerschap. 2011. http://nvogdocumenten.nl/index.php?pagina=/richtlijn/pagina.php&fSelectTG_
62=75&fSelectedSub=62&fSelectedParent=75 (accessed July 26, 2015).
Australian Government Department of Health and Ageing
Australian Government Department of Health and Ageing. Clinical
Practice Guidelines. Antenatal care -module 1. 2013. http://www.
health.gov.au/internet/main/publishing.nsf/content/015FBFDD266
Outpatient antibiotic use in Europe and association with resistance: a cross-national database study.
- Goossens H
- Ferech M
- Vander SR
- Elseviers M
NHG-standaard Urineweginfectie (Tweede herziening). 8[Huisarts Wet], 341–52.
- Van Haaren