literature review of uti in pregnancy

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http://orcid.org/0000-0003-3121-0441 Dominique Esmée Werter 1 ,
Brenda M Kazemier 1 ,
Elisabeth van Leeuwen 2 ,
Maurits C F J de Rotte 3 ,
Sacha D Kuil 4 ,
Eva Pajkrt 5 ,
Caroline Schneeberger 6 , 7
1 Department of Obstetrics and Gynaecology , University of Amsterdam , Amsterdam , The Netherlands
2 Department of Obstetrics and Gynaecology , Amsterdam University Medical Centres , Duivendrecht , The Netherlands
3 Department of Clinical Chemistry , University of Amsterdam , Amsterdam , The Netherlands
4 Department of Microbiology , University of Amsterdam , Amsterdam , The Netherlands
5 Obstetrics and Gynaecology , Amsterdam UMC Location AMC , Amsterdam , The Netherlands
6 Department of Microbiology , Amsterdam UMC-Locatie AMC , Amsterdam , The Netherlands
7 Center for Infectious Disease Control , National Institute for Public Health and the Environment (RIVM) , Bilthoven , Netherlands
Correspondence to Ms Dominique Esmée Werter; d.e.werter{at}amsterdamumc.nl

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.

Urinary tract infections
BACTERIOLOGY
Protocols & guidelines
Microbiology
Maternal medicine

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2022-063813

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The urine of every participating woman will be tested with a set of tests including a urine dipstick, urine sediment and a urine culture.

We will investigate the course of complaints in pregnant women with a possible urinary tract infection to gain more insight in the diagnostic value.

The research will be done prospectively; therefore, we expect less bias than in a retrospective cohort.

It will be a single-centre cohort study, so it could possibly make the participants more homogeneous.

Introduction

The prevalence of urinary tract infections (UTIs) during pregnancy reported in literature varies between 2.3% and 15%. 1–5 It is hypothesised that anatomical changes during pregnancy such as dilatation of the ureters, decreased ureteral tone and increased bladder volume contribute to urinary stasis and ureterovesical reflux increasing the risk of a UTI. 6–8 Besides the anatomical changes, pregnancy-related glomerular filtration rate increases the alkalinity of the urine and the urinary glucose concentration, which facilitates bacterial growth. 9 The association between UTIs during pregnancy and maternal complications such as hypertensive disorders and caesarean delivery has been reported, although there is contradictory evidence. 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).

In contrast, overtreating pregnant women with antibiotics may also cause harm. Overuse and incorrect use of antibiotics are the main causes of antimicrobial resistance. Moreover, the unnecessary exposure of the unborn child to antibiotics may also not be without risks. Associations between antibiotics during pregnancy and adverse neonatal outcomes including increased risk of cerebral palsy, early-onset sepsis with antibiotic-resistant microorganisms, malformations and epilepsy have been published. 10 12 13 Also, maternal exposure to certain antibiotics is associated with childhood asthma and childhood obesity. 14 15 It is recently found that prenatal exposure to antibiotics can probably lead to alterations in the differential methylation at regulatory regions of imprinted genes. 16 If we can improve diagnostics and related antibiotic prescribing, we possibly can also influence fetal development and possibly long-term health with the results of this study. All of them impact future healthcare costs. Next to that, if we could decrease the number of tests for an accurate diagnosis, costs could be saved.

In the non-pregnant population, a diagnostic test to confirm the diagnosis of UTI is not always considered necessary, since typical clinical symptoms such as dysuria and urgency are regarded distinctive enough. 7 17–20 In pregnancy, the diagnosis of a UTI is less well studied and more challenging. First of all, many women during pregnancy experience symptoms that mimic a UTI such as frequency as a result of pressure of the baby’s head on the bladder. 8 21 On the other hand, symptoms of a UTI can be aspecific in pregnancy; UTIs in pregnant women may solely present with abdominal pain or Braxton Hicks contractions. 9 21 All this makes it more difficult to distinguish between asymptomatic bacteriuria (ASB) and UTI. Furthermore, in pregnancy, ASB can also be present: bacteriuria without any UTI signs or symptoms. ASB is not an active infection and the risk of adverse outcomes like preterm birth is low or absent compared with UTIs. 11 22

Most hospital protocols recommend testing pregnant women for a UTI when they present with symptoms suggestive of UTI or in case of symptoms suspicious of threatened preterm birth. In the diagnostic work-up, various methods are used: urine dipstick test, urine sediments and bacterial cultures, which are used in various ways and come with several limitations.

First, a urine dipstick is a strip with different reagents present. The reagents react on the presence of certain substances, for example, protein, glucose, nitrite and leucocyte esterase. The most important parameters to diagnose UTI on a dipstick are nitrite and leucocyte esterase. Many gram-negative bacteria produce the enzyme nitrate reductase, which converts urinary nitrate into nitrite indicating the presence of bacteria. 23 In the adult population, the sensitivity of nitrite dipstick reported in a systematic review is 0.54 (CI 0.44 to 0.64), the specificity is 0.98 (CI 0.96 to 0.99), positive likelihood ratio of 29.3 (CI 14.4 to 59.7) and a negative likelihood ratio of 0.48 (CI 0.37 to 0.62). Eight out of 14 of the studies included in this review reported on pregnant women, but none of them reported on symptomatic women. 24 Another study shows that the sensitivity and specificity of nitrite to test for ASB in pregnant women are, respectively, 0.55 (95% CI 0.42 to 0.67) and 0.99 (95% CI 0.98 to 0.99). 25

Leucocyte esterase is an enzyme released by neutrophils and macrophages. The leucocyte dipstick has a sensitivity of 0.72 (0.61 to 0.84) and a specificity of 0.82 (0.74 to 0.90), and a positive likelihood ratio of 4.87 (3.26 to 7.29) and a negative likelihood ratio of 0.31 (0.18 to 0.51) in the adult population. 24

Physiological pyuria can appear in pregnant women. 26

Second, for urine sediments, urine samples are centrifuged to obtain a sediment including red and white blood cells, squamous cells and bacteria, which are counted automatically by microscopy. 16 For a UTI, both the presence or absence of leucocytes and bacteria are of interest. A systematic review in the general population reported a sensitivity range of 57.1%–97%, a specificity of 27.0%–97.0%, a positive likelihood ratio of 1.59–24.57 and a negative likelihood ratio of 0.07–0.655 in studies where they used the sediment. 27 Yet again, physiological pyuria can appear in pregnant women. 26 The advantage of the urine sediment over the urine dipstick is that the urine sediment counts all bacteria. The urine dipstick only indicates if there are nitrite-forming bacteria present. However, not all bacteria are uropathogenic.

Finally, the reference test to detect a UTI is a urine culture, which determines bacterial growth. However, the urine dipstick takes a few minutes, the urine sediment about an hour and the urine culture at least 24 hours up to 5 days.

The exact number of bacteria present in urine to define a ‘positive’ urine culture and a UTI is not clear cut. The most common definition is ≥10 5 colony-forming units (CFU)/mL of uropathogens. 28 However, the cut-offs used in practice range from ≥10 3 CFU/mL to ≥10 5 CFU/mL. 18 29 30

The Dutch guideline of obstetrics and gynaecology recommends performing both a nitrite dipstick and a urine culture when pregnant women present with UTI symptoms. In case of a positive nitrite dipstick, treatment should start immediately. In case of a negative nitrite dipstick, treatment should only be started if the culture is positive. The role of the other diagnostic methods is unclear. 9 The Dutch general practitioners’ guideline recommends performing a nitrite dipstick. In case of a positive nitrite dipstick, people will be treated for UTI. Leucocyte esterase test will be performed when the nitrite result is negative. Urine sediments are recommended if leucocyte esterase is present since a positive result of leucocyte esterase is considered as insufficient proof of a UTI. When either the nitrite or the sediment is positive, treatment should be started. When the leucocyte esterase dipstick is negative but there is still a suspicion for a UTI, a sediment is performed additionally. When both urine dipstick and sediment are negative, a UTI is ruled out. If either urine dipstick or sediment results are positive, a urine culture is performed while antibiotics are directly initiated, awaiting the urine culture results. 31

Both in the UK and the USA, guidelines do not state the diagnostic work-up for UTIs in pregnancy (Royal College Obstetricians and Gynaecologist (RCOG) guideline, National Institue for Health and Care Excellence (NICE)guideline and American College of Obstetricians and Gynecologist (ACOG) guideline).

Despite the differences in guidelines, in daily practice, the urine is often only tested with a dipstick. In case of a negative test result, often no additional tests are done. The approach when to perform a sediment or a urine culture is equally ambiguous. There is no clear evidence that the diagnostic accuracy of a standalone dipstick urine (including both the presence of nitrite and leucocyte esterase) is equal to a combined approach of urine dipstick and sediment to diagnose a UTI in pregnancy. Furthermore, pyuria can be present in pregnant women without a UTI. 26 Moreover, the additional value of a urine culture in all women, as recommended by the Dutch guideline of obstetrics and gynaecology, is also unknown. For something as common as a UTI during pregnancy, it is undesirable that the available evidence is too limited to properly inform (diagnostic) guidelines, which results in great diagnostic variation, and potential harmful overtreatment and undertreatment.

Methods and analysis

This study aims to evaluate the diagnostic accuracy of urine dipstick analysis and urine sediment to bacterial cultures in the diagnosis of UTI in pregnant women.

Study design

This study is a single-centre prospective cohort study.

Participants

All consecutive pregnant women attending the outpatient clinic, the pregnancy ward or emergency department for women’s health in the Amsterdam UMC with symptoms warranting a diagnostic work-up to rule out a UTI can be included, after oral and written consent. These symptoms include dysuria, urgency, frequency, fluid loss, difficulties with voiding, painful voiding, haematuria, or aspecific abdominal pain, (Braxton Hicks) contractions and vaginal blood loss. 7 9

Exclusion criteria are a previous UTI episode in the past 2 weeks, antibiotic use in the past 2 weeks or a structural abnormality of the urogenital tract.

Inclusion of women in the study takes place since 1 November 2021. We plan to include all women in the study in 3 years.

Test methods

The urine samples will be clean-catch midstream urine samples. The index test will be a urine dipstick and a urine sediment. The dipstick that we will use is Clinitek novus 10 (Siemens). The urine sediment will be checked with Atellica 1500 Siemens. For both the urine dipstick and the urine sediment, different cut-offs will be used to investigate which cut-off has the best diagnostic value ( table 1 ).

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Expected outcomes

The reference test will be a urine culture.

No blinding will take place for the different tests. The outcome of the test has no influence on the treatment and is necessary for daily practice.

Because of the difficulties to distinguish between ASB and UTI, we will use a different definition for UTI than commonly used. We would like to make sure that we are dealing with a UTI and not ASB.

In this study, a ‘true UTI’ is present when the following three criteria are met:

Presence of at least two specific or non-specific symptoms of a UTI. 26

A positive urine culture.

Symptom improvement during adequate antibiotic treatment, where adequate treatment is defined by proven susceptibility of isolated uropathogens to the administered antibiotic.

The definition of a positive culture is:

Urine with ≥10 3 CFU/mL of a uropathogen.

Maximum of two uropathogens ≥10 3 CFU/mL present. When there are more than two uropathogens present of ≥10 3 CFU/mL, the culture will be considered as contaminated.

Next to that, the woman will be asked to fill out a questionnaire. The questionnaire contains questions about risk factors for UTI and possible clinical symptoms of a UTI. After 5–8 days, when the result of the culture will be available, the woman will be called to evaluate the presenting symptoms. This check-up is part of standard care. Both the woman and the clinician have access to the test result; it is not blinded. Women will be asked permission to collect data from the midwife, gynaecologist or general practitioner about their pregnancy and delivery.

The statistical analysis will be performed using IBM SPSS Statistics V.26.

Primary outcome

We will determine which combination of leucocyte esterase, nitrite presence in the dipstick and bacteria presence and leucocyte count in the sediment yield the best performance of both methods separately and combined to predict a ‘true UTI’ according to our definition. Different cut-offs and combinations of cut-offs of the urine analysis components will be explored to calculate sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios ( table 1 ). In addition, we aim to develop a diagnostic model based on all available evidence on leucocyte esterase, nitrite presence, bacteria presence, leucocyte count and symptoms.

After the best performing cut-offs for both urine dipstick and urine sediment have been determined, we will compare the performance of these two tests together in terms of sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios. Urine culture will be used as the reference test. The performance will be compared with the predefined ‘true’ UTI. To do this, we first select all true positives and true negatives using the reference test. In addition, we compare the classifications of urine dipstick with urine sediment in a 2×2 table for true positives (sensitivity) and a 2×2 table for true negatives (specificity) and calculate a p value for the difference in classification using a paired McNemar test.

Planned sensitivity analyses will also be performed for different cut-off values for pathogens in urine cultures ≥10 3 CFU/mL, ≥ 10 4 CFU/mL and ≥10 5 CFU/mL.

Contaminated urine cultures will be considered as negative cultures.

Secondary outcome

We will evaluate which clinical symptoms are best at predicting a UTI in pregnancy and which symptoms are not. The symptoms of a UTI will be studied with incidences and p values to identify which symptoms are associated with UTI.

To identify risk factors for UTI, univariate logistic regression will be used. In case it is possible, multivariate logistic regression will be used to identify the risk factors. We will use a forward stepwise selection for our regression model.

Pregnancy duration will be measured in weeks and days of gestational age and will be compared between women with and without UTI with a Student’s t-test.

The timing of the performed urine test (urine dipstick, urine sediment and urine culture) and the gestational age of delivery will be noted. Time between diagnosis of UTI and delivery will be compared using Kaplan-Meier survival curve.

Power analysis

To provide an estimated sample size, we calculated the sample sizes necessary for 80% power in a McNemar paired test comparing urine dipstick with urine sediment in women with true-positive UTI (sensitivity) and true-negative UTI (specificity). The expected discrepant cells for sensitivity are 14% and 5%, with a calculated 181 true-positive cases necessary for 80% power. The expected discrepant cells for specificity are 10% and 4% with a calculated 302 true-negative cases necessary for 80% power. We expect that around 30% of the included women will have a UTI such that the necessary sample size to include is 603 for sensitivity and 432 for specificity.

With a 10% expected drop-out, the sample size would be 660 pregnant women.

Data will be collected using Castor, which is an application system that enables collection and clean-up of trial data using the internet. Data handling will be done coded. The data will be saved for 15 years.

Patient and public involvement

There was no patient or public involvement in this research.

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 (METC review number W21_291 #21.318). All participants will give written and oral informed consent prior to entry to the study and will be made aware that participation is strictly voluntary.

The outcomes of this study will be published in a peer-reviewed journal.

The diagnostic accuracy of a urine dipstick and, less often, a urine sediment for the diagnosis of bacteriuria in pregnancy has been evaluated. 23 32 However, no studies are available in pregnant women on the diagnostic accuracy of symptomatic UTIs. As a result, different guidelines in the Netherlands advise different ways of testing for UTIs in pregnant women. International guidelines lack any recommendations on specific urine tests. However, in pregnant women with a UTI, both undertreatment and overtreatment are potentially harmful; therefore, correct diagnosis is very important.

The focus of this study is the diagnostic work-up. We will not intervene in the treatment given or follow-up provided to the participating women. It is likely that certain types of bias will be introduced as a result of implementation of this study. Bias could be introduced because more diagnostics will be performed and all three urine test results will be reported to the treating clinician (not blinded). Since more result will be available, this could affect the prescription of antibiotics.

We do not expect a lot of women with partial verification bias since the three different urine tests will be most of the time executed at the same time from the same urine sample. Because of this, we avoid that only the urine dipstick and/or sediment is performed and the urine culture is not executed.

The urine culture has been used, both in daily practice and in research, for a long time. There are no logical alternative reference standards. The urine culture has been proven to be effective. We do not expect an inappropriate reference standard.

Since the result of the urine culture is only available a few days after the results of the urine dipstick and sediment, we do not expect a review bias.

Clinical impact

Due to the different cut-offs to report uropathogens and their susceptibilities (10 3 instead of 10 4 ), the rate of prescribing antibiotics may increase too. However, the result of the culture will only come in after a few days, so the decision to start antibiotics has most likely already been made. With this study, we hope to provide either better evidence for the current advice in guidelines and/or guide necessary adjustments.

To avoid unnecessary treatments, diagnostic tests and costs, and to minimise possible harmful neonatal outcomes, the diagnostic process of UTIs should be optimised. This new workflow should be implemented in the daily care to create a more evidence-based treatment strategy. Since the diagnostic work-up for UTIs takes place on a daily basis, the results of this research will have a major impact on daily routine care. To find an optimal strategy for diagnosing a UTI is only the start of tackling the challenges around the diagnosis of UTIs in pregnancy.

Ethics statements

Patient consent for publication.

Not required.

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Contributors DEW wrote the proposal and the manuscript. BMK initiated the research, and critically revised the proposal and manuscript. EvL critically revised the proposal and manuscript. MCFJdR critically revised the manuscript. SDK critically revised the proposal and manuscript. EP critically revised the proposal and manuscript. CS critically revised the proposal and manuscript. All authors read and approved the final manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Global prevalence of urinary tract infection in pregnant mothers: a systematic review and meta-analysis

Affiliations.

1 Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran; Sleep Disorders Research Centre, Kermanshah University of Medical Sciences, Kermanshah, Iran. Electronic address: [email protected].
2 Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran. Electronic address: [email protected].
3 Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran. Electronic address: [email protected].
4 Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran. Electronic address: [email protected].
5 Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran. Electronic address: [email protected].
6 Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran. Electronic address: [email protected].
7 Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor, Malaysia. Electronic address: [email protected].
8 Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran. Electronic address: [email protected].
PMID: 37734277
DOI: 10.1016/j.puhe.2023.08.016

Objective: Urinary tract infection (UTI) is a prevalent infection during pregnancy that can lead to complications for both the mother and the foetus. The objective of this systematic review and meta-analysis is to determine the global prevalence of UTIs (both symptomatic and asymptomatic) during pregnancy, based on previous studies in this area. Furthermore, this study aims to identify any factors that contribute to heterogeneity in the prevalence of UTIs during pregnancy.

Study design: Systematic review and meta-analysis.

Methods: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines on August 8, 2022. To conduct the systematic review and meta-analysis, a search was performed using the keywords "urinary tract system", "UTI", "pregnancy", and "gestation" was performed in several databases, including Web of Science (WoS), PubMed, Scopus, ScienceDirect, Embase, and Google Scholar, without a time limit until September 18, 2022. The analysis was performed using a random-effects model, and the heterogeneity of the studies was assessed using the I 2 index. The Comprehensive Meta-Analysis software (Version 2) was used for data analysis.

Results: The systematic review and meta-analysis of 27 studies, which included a total of 30,641 pregnant women, showed an overall prevalence of UTI (both symptomatic and asymptomatic) to be 23.9% (95% confidence interval: 16.2-33.8). Meta-regression analysis was conducted to examine the impact of two factors, namely study sample size and study year, on the heterogeneity of the meta-analysis. The results revealed that an increase in sample size, and the study year was associated with a decrease in the prevalence of UTI in pregnant women (P < 0.05).

Conclusion: The results of our study indicate a global prevalence of UTI in pregnant women to be 23.9%. Therefore, it is recommended that all pregnant women undergo regular UTI screening tests and receive prompt treatment if diagnosed with UTI. Early detection and treatment of UTI during pregnancy are crucial to prevent complications that may affect the health of both the mother and the foetus.

Keywords: Gestation; Pregnancy; Prevalence; UTI; Urinary tract infection.

Publication types

Open access
Published: 08 November 2023

Bacterial profile and prevalence of urinary tract infections in pregnant women in Latin America: a systematic review and meta-analysis

Henrique Diório de Souza 1 , 2 ,
Giselle Rodrigues Mota Diório 3 ,
Stela Verzinhasse Peres 1 ,
Rossana Pulcineli Vieira Francisco 1 &
Marco Aurélio Knippel Galletta 1

BMC Pregnancy and Childbirth volume 23 , Article number: 774 ( 2023 ) Cite this article

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Given the physiological changes during pregnancy, pregnant women are likely to develop recurrent urinary tract infections (UTIs) and pyelonephritis, which may result in adverse obstetric outcomes, including prematurity and low birth weight preeclampsia. However, data on UTI prevalence and bacterial profile in Latin American pregnant women remain scarce, necessitating the present systematic review to address this issue.

To identify eligible observational studies published up to September 2022, keywords were systematically searched in Medline/PubMed, Cochrane Library, Embase, Web of Science, and Bireme/Lilacs electronic databases and Google Scholar. The systematic review with meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the quality of studies was classified according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. The meta-analysis employed a random-effects method with double-arcsine transformation in the R software.

Database and manual searches identified 253,550 citations published until September 2022. Among the identified citations, 67 met the inclusion criteria and were included in the systematic review, corresponding to a sample of 111,249 pregnant women from nine Latin American countries. Among Latin American pregnant women, the prevalence rates of asymptomatic bacteriuria, lower UTI, and pyelonephritis were estimated at 18.45% (95% confidence interval [CI]: 15.45–21.53), 7.54% (95% CI: 4.76–10.87), and 2.34% (95% CI: 0.68–4.85), respectively. Some regional differences were also detected. Among the included studies, Escherichia coli (70%) was identified as the most frequently isolated bacterial species, followed by Klebsiella sp. (6.8%).

Pregnant women in Latin America exhibit a higher prevalence of bacteriuria, UTI, and pyelonephritis than pregnant women globally. This scenario reinforces the importance of universal screening with urine culture during early prenatal care to ensure improved outcomes. Future investigations should assess the microbial susceptibility profiles of uropathogens isolated from pregnant women in Latin America.

Trial registration

This research was registered at PROSPERO (No. CRD42020212601).

Peer Review reports

Bacteriuria reportedly affects 1.78–48.3% of pregnant women [ 1 , 2 ]. Its prevalence depends on the geographic region or age group analyzed. Although the frequency of bacteriuria among pregnant and non-pregnant women appears to be similar, pyelonephritis and recurrent urinary tract infection (UTI) are more frequent in women during the pregnancy-puerperal cycle [ 3 ].

UTIs are classified into three subgroups: (a) asymptomatic bacteriuria (ASB); (b) lower UTI, characterized by vaginal mucosa inflammation and irritative urinary tract symptoms; and (c) acute pyelonephritis or upper UTI, a systemic condition. In addition, UTIs can be classified as simple or complicated, depending on the presence of kidney and ureter involvement [ 4 ].

Urinary tract dilation and ureteral smooth muscle relaxation during pregnancy increase the susceptibility of the urinary tract to microorganisms. The implementation of universal screening for bacteriuria during pregnancy has substantially reduced the incidence of pyelonephritis; thus, urine culture should be routinely requested for all pregnant women at their first prenatal visit [ 5 , 6 , 7 ].

Bacterial colonization of the urinary tract during pregnancy may also be associated with adverse perinatal outcomes such as prematurity [ 8 , 9 ], low birth weight [ 10 ], premature rupture of ovular membranes, and hypertensive syndromes [ 11 , 12 , 13 ]. Treating bacteriuria can mitigate some of these adverse obstetric outcomes.

Notably, there are substantial discrepancies in data regarding the prevalence of bacteriuria during pregnancy. In 2019, Latin America recorded the highest regional UTI incidence globally (13,852.9 cases per 100,000 population), the highest mortality from UTI (10.0 per 100,000 population), and the highest number of disability-adjusted life years (DALYs) secondary to UTI (171.3 per 100,000 population) [ 14 ]. However, these aspects have been poorly explored in pregnant Latin American women, encouraging the present systematic review with meta-analysis.

The present systematic review would help plan public policies and the implementation of measures to optimize perinatal outcomes related to urinary tract infections during pregnancy.

Study protocol and selection

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The studies were selected independently by two reviewers (MAKG and HD). Disagreements regarding study inclusion or exclusion were resolved through discussions until a consensus was reached. This systematic review is registered at PROSPERO (No. CRD42020212601).

Search strategy

The researchers systematically searched Medline/PubMed, Cochrane Library, Embase, Web of Science, and Bireme/Lilacs electronic databases, as well as the Google Scholar search engine. Studies published up to September 2022 were deemed eligible. The studies were searched using the following keywords alone or in combination: bacteriuria OR urinary tract infection OR pyelonephritis OR cystitis OR asymptomatic bacteriuria OR bacteriuria in pregnancy OR urinary tract infection in pregnancy OR pyelonephritis in pregnancy OR cystitis in pregnancy.

Inclusion and exclusion criteria

Inclusion criteria were as follows: observational studies regarding the prevalence of bacterial urinary tract colonization in pregnant women from Latin American countries; objective diagnostic criteria for UTI, including urine culture reports with minimum bacterial growth of 1 × 10 5 CFU/ml in a midstream urine sample or of 1 × 10 2 CFU/ml in a sample obtained by urinary catheterization; published in English, Spanish, or Portuguese; and reported relative risks (RRs) or odds ratios (ORs) or presented original datasets that allowed the calculation of these association measures. This systematic review only included studies conducted in the 20 most populous countries in Latin America, according to the 2020 United Nations Statistical Division: Brazil, Mexico, Colombia, Argentina, Peru, Venezuela, Chile, Guatemala, Ecuador, Bolivia, Haiti, Cuba, Dominican Republic, Honduras, Paraguay, Nicaragua, El Salvador, Costa Rica, Panama, and Uruguay [ 15 ]. Exclusion criteria were as follows: non-pregnant women; women residing in non-Latin American countries; incomplete information, such as the absence of prevalence data; duplicate studies; case reports or review articles or secondary analyses; or qualitative studies.

Data extraction

Two investigators (MAKG and HD) independently extracted relevant data from the studies using a standardized form. The retrieved data included first author details, year of publication, study demographic coverage area, study design, sample size, the prevalence of bacteriuria, the prevalence of UTI, diagnostic criteria for bacteriuria, and association measures such as RRs or ORs. In addition, information on the frequency of microorganism isolation in urine cultures of pregnant women was extracted.

Quality assessment

Considering the quality, the studies were classified according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, analyzing five dimensions: sample population, sample size, percentage of participation among those eligible, result evaluation, and analysis of statistical methods employed. Each of these dimensions received a score ranging from 0 to 2 points. The final total score ranged from 0–10 points, with 10 representing the lowest overall risk of study bias and 0 representing the highest overall risk of study bias [ 16 , 17 ].

Statistical analysis

Study-specific synthesized estimates were pooled using the random-effects meta-regression model to estimate the overall prevalence across studies after stabilizing the variance of individual studies using the Freeman-Tukey double-arcsine transformation [ 18 ]. Heterogeneity between study results was assessed using Cochran’s Q test and the I 2 index. Publication bias was measured by reviewing the funnel plots and using Begg’s and Egger’s tests. The random-effects model was used to combine highly heterogeneous data. The adjusted ORs and 95%CI of included studies were used for data analysis. Study results were combined to produce a pooled OR-95%CI. Statistical analyses were performed using the R statistical software. Statistical significance was set as p < 0.05.

Search results

Initial database and manual searches identified 253,550 citations (Medline/PubMed, 267; Google Scholar, 252,446; Lilacs/Bireme, 119; and Embase, 718). Studies were selected by title and abstract, resulting in the exclusion of 253,315 irrelevant studies. Of the remaining 235 citations, 27 were removed as duplicates. Thus, 208 full-text citations were evaluated for eligibility, with 141 excluded owing to unclear assessment methods or uncertain bacteriuria definitions ( n = 63); non-Latin American pregnant women ( n = 30); incomplete information ( n = 24); qualitative studies, review articles, or case reports ( n = 24). Overall, 67 citations published until September 2022 met the established inclusion criteria and were included in the present systematic review (Fig. 1 ).

PRISMA flowchart diagram of the study selection

Study characteristics

The present systematic review with meta-analysis included 67 articles, comprising 111,249 pregnant women from 9 Latin American countries (Brazil, Colombia, Cuba, Ecuador, Guatemala, Paraguay, Peru, Mexico, and Venezuela) (Table 1 ). All included studies were cross-sectional in design, including 44 published articles, one doctoral dissertation, two master’s theses, and 20 undergraduate course papers. The sample size of the included studies ranged from 34–32,641 pregnant women [ 19 , 20 ]. The largest number of studies were conducted in Brazil [ 20 ], followed by Peru [ 16 ] and Mexico [ 10 ]. No studies conducted in Argentina, Chile, Bolivia, Haiti, Dominican Republic, Honduras, Nicaragua, El Salvador, Costa Rica, Panama, or Uruguay were selected. The lowest prevalence of bacteriuria was 1.78%, recorded in Mexico, and the highest was 56%, documented in Brazil [ 1 , 19 ]. Studies reporting the presence of irritative urinary tract symptoms showed that the lowest prevalence of ASB was 1.57% in Ecuador, while the highest was 20.83% in Mexico. The lowest rate of cystitis was 3.1% (Mexico), and the highest was 20.9% (Peru) [ 21 , 22 , 23 , 24 , 25 ].

The overall prevalence of ASB, lower UTI, and pyelonephritis

The heterogeneity rate for ASB prevalence was high ( I 2 = 99.5%, p < 0.001). The prevalence of ASB in Latin American pregnant women was 18.39% (95% CI: 15.45–21.53) (Figs. 2 and 3 ) [ 1 , 2 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 ]. Egger's linear regression test was performed to evaluate the asymmetry of the funnel plot, revealing no statistical significance ( p = 0.767) (Available in Supplementary Material – Suppl 1 ).

Prevalence of bacteriuria in pregnant women in Latin America

Prevalence of urinary tract infection in pregnant women in Latin America

The heterogeneity rate for lower UTI prevalence was high ( I 2 = 86.5%, p < 0.001). The prevalence of lower UTI in Latin American pregnant women was 7.54% (95%CI: 4.76–10.87) in 10 studies comprising 5,781 participants [ 21 , 23 , 24 , 25 , 35 , 38 , 47 , 49 , 81 , 86 ]. Egger’s linear regression test to evaluate the asymmetry of the funnel plot showed statistical significance ( p = 0.038) (Available in Supplementary Material – Suppl 2 ).

The heterogeneity rate for the prevalence of pyelonephritis was high ( I 2 = 88.4%, p < 0.001). The prevalence of pyelonephritis in Latin American pregnant women was 2.34% (95% CI: 0.68–4.85) in five studies comprising a sample size of 4,349 participants (Figs. 4 ) (Available in Supplementary Material – Suppl 3 ) [ 21 , 25 , 35 , 81 , 88 ].

Prevalence of pyelonephritis in pregnant women in Latin America

Specific subgroups underwent additional analyses to reduce sample heterogeneity and enhance clinical and public health applicability.

Subgroup analysis of the prevalence of ASB in articles comprising more than 500 participants

Studies with a larger sample underwent an initial analysis to reduce sample size biases. However, the heterogeneity rate for the prevalence of ASB in Latin American articles with more than 500 participants was also high ( I 2 = 99.2%, p < 0.001). The prevalence of ASB in Latin American pregnant women was 13.11% (95% CI: 8.42–18.65) in 15 studies comprising 23,782 participants, which was lower than the previous global rate (Fig. 2 ) (Available in Supplementary Material – Suppl 4 ) [ 1 , 31 , 35 , 41 , 45 , 65 , 66 , 67 , 68 , 69 , 71 , 80 , 81 , 82 , 84 ]. Egger’s linear regression test, performed to evaluate the asymmetry of the funnel plot, revealed statistical significance ( p = 0.02), i.e., persistent publication bias (Supplementary Material – Suppl 5 ).

Subgroup analysis of the prevalence of ASB in published Latin American articles, except Brazilian articles

The heterogeneity rate for the prevalence of ASB in the Latin American articles, except the Brazilian articles, was high ( I 2 = 98.6%, p < 0.05). The prevalence of ASB in Latin American pregnant women was 14.97% (95% CI: 11.10–19.28) in 26 studies comprising 20,896 participants (Supplementary Material – Suppl 6 ) [ 1 , 27 , 28 , 29 , 30 , 31 , 38 , 41 , 45 , 46 , 47 , 51 , 55 , 56 , 57 , 61 , 66 , 67 , 68 , 71 , 72 , 80 , 81 , 82 , 83 , 85 ]. Egger’s linear regression test to evaluate the asymmetry of the funnel plot showed statistical significance ( p = 0.015).

Subgroup analysis of the prevalence of ASB in Latin American articles (published or unpublished) with a sample of at least 200 participants, except for Brazilian articles

The heterogeneity rate for the prevalence of ASB in the Latin American articles with a sample of at least 200 participants, except for Brazilian articles, was high ( I 2 = 99.8%, p < 0.001). The prevalence of ASB in Latin American pregnant women, except Brazilian women, was 12.62% (95% CI: 9.26–16.40) (Supplementary Material – Suppl 7 ) [ 1 , 20 , 21 , 24 , 26 , 29 , 30 , 31 , 34 , 38 , 41 , 45 , 46 , 47 , 51 , 55 , 56 , 57 , 59 , 61 , 66 , 67 , 68 , 70 , 71 , 72 , 73 , 74 , 75 , 79 , 80 , 81 , 82 , 83 , 85 , 87 , 89 ]. Egger’s linear regression test to evaluate the asymmetry of the funnel plot showed statistical significance ( p = 0.015) (Supplementary Material – Suppl 8 ).

Subgroup analysis of the prevalence of ASB considering only Brazilian articles (published or unpublished)

Considering only Brazilian articles, the heterogeneity rate for the prevalence of ASB was high ( I 2 = 97.5%, p < 0.001). The prevalence of ASB in Brazilian pregnant women was 23.62% (95% CI: 18.0–29.74) (Figs. 4 and 5 ) [ 2 , 19 , 23 , 35 , 37 , 39 , 40 , 42 , 43 , 44 , 48 , 53 , 54 , 60 , 65 , 69 , 76 , 77 , 78 , 84 , 86 ]. Egger’s linear regression test to evaluate the asymmetry of the funnel plot showed no statistical significance ( p = 0.831) (Supplementary Material – Suppl 9 ).

Prevalence of bacteriuria in Brazilian pregnant women, considering published or unpublished studies

Subgroup analysis of the prevalence of ASB considering only Brazilian articles (published or unpublished) with a sample of at least 200 participants

Considering only Brazilian articles (published or unpublished), the heterogeneity rate for the prevalence of ASB was high ( I 2 = 98.7%, p < 0.001). The prevalence of ASB in Brazilian pregnant women was 19.05% (95% CI: 13.18–25.70) in 10 studies comprising 18,137 participants (Supplementary Material – Suppl 10 ) [ 2 , 35 , 37 , 42 , 43 , 53 , 65 , 69 , 76 , 84 , 86 , 90 ]. Egger’s linear regression test to evaluate the asymmetry of the funnel plot showed no statistical significance ( p = 0.595) (Supplementary Material – Suppl 11 ).

Isolated bacteria

In the present systematic review with meta-analysis of 67 studies, we examined the profile of microorganisms isolated in positive urine cultures of pregnant women residing in the 20 most populous countries in Latin America, comprising a sample of 8,840 urine cultures (Table 2 ). The most frequently isolated bacterial species in Latin American pregnant women were Escherichia coli (pooled prevalence of 70%, 95% CI: 65.3–74.6%); Klebsiella sp. (pooled prevalence of 6.4%, 95% CI: 4.3–8.7%); Staphylococcus sp., excluding Staphylococcus aureus , (pooled prevalence of 3.0%, 95%CI: 1.7%–4.5%); Proteus mirabilis (pooled prevalence of 2.8%, 95% CI: 1.9–3.9%); and Enterobacter sp. (pooled prevalence of 1.6%, 95% CI: 0.7–2.7%) (Supplementary Material – Suppl 12 – 21 ).

Based on the present meta-analysis, the frequency of ASB in Latin American pregnant women was 18.39% (95% CI: 15.45–21.53). This prevalence is higher than frequencies reported in international meta-analyses, including those from Ethiopia (15.37%), Africa (11.1%), and Iran (8.7%) [ 125 , 126 , 127 ].

Despite the current propensity to prevent unnecessary antibiotic use, screening and treatment for asymptomatic bacteriuria have become routine in almost all prenatal care guidelines. This occurs because, when the incidence of bacteriuria reaches values greater than 2%, the cost-effectiveness of universal screening appears to be adequate to prevent the occurrence of pyelonephritis during pregnancy [ 128 , 129 ]. Our study demonstrated a high prevalence of bacteriuria among pregnant Latin American women, reinforcing the importance of universal screening for bacterial colonization of the urinary tract in this population.

In a broad worldwide study in 2019, Tropical Latin America had the highest worldwide UTI incidence standardized by age, with approximately 13,852.9 cases per 100,000 population. Notably, Ecuador presented the highest incidence of UTI globally, with approximately 15,511.3 cases per 100,000 population. In 2019, a global analysis of UTI revealed that the highest mortality rate was recorded in southern Latin America (10 deaths per 100,000 population), and the highest number of DALYs lost was recorded in Tropical Latin America (171.3 per 100,000 population) [ 14 ]. Evaluating women only, the highest regional incidences are found, in descending order, in Andean Latin America, Tropical Latin America, Australasia, the Caribbean, and southern Latin America. In 2019, over 404 million individuals had UTIs, with over 236,000 UTI-related deaths recorded [ 14 ].

Between 1990 and 2019, the global UTI incidence rate adjusted for age increased from 4,715 to 5,229 per 100,000 population, with the global death rate due to UTI increasing from 1.8 to 3.1 per 100,000 population. A comparison between three-decade-old and current data revealed an absolute increase of approximately 130,000 UTI-related deaths. Over the past three decades, the largest estimated annual percentage changes in UTI incidence rates were observed in Central Latin America (0.48, 95% CI: 0.29–0.67) and Andean Latin America (0.45, 95% CI: 0.4–0.51), and the highest estimated annual percentage changes in UTI mortality rates were documented in southern Latin America (4.92, 95% CI: 4.26–5.59) and Tropical Latin America (3.50, 95% CI: 3.14–3.87). Given the impact of bacterial urinary tract colonization on public health outcomes and the highest global percentage of bacteriuria prevalence documented in Latin America, it is crucial to further explore this topic [ 14 , 130 ].

Bacteriuria is associated with some adverse perinatal outcomes. Antimicrobial treatment of bacteriuria can reduce the incidence of pyelonephritis in pregnant women (RR 0.24, 95% CI = 0.13–0.41; 12 studies, 2017 women), premature birth (RR 0.34, 95% CI = 0.13–0.88; 3 studies, 327 women) and low birth weight (RR 0.64, 95% CI = 0.45–0.93; 6 studies, 1437 newborns) [ 131 ]. There is also evidence that urinary tract infection during pregnancy corresponds to a risk factor for the occurrence of pre-eclampsia (OR 1.31; 95% CI = 1.22–1.40) [ 13 ]. The increase in the global mortality rate from UTI in the last three decades, associated with unfavorable obstetric results related to the diagnosis of bacteriuria, reinforces the importance of our study.

Based on the present study, E. coli was the most frequently isolated uropathogen in the urine cultures of Latin American pregnant women. The results of this meta-analysis corroborate documented findings in the literature, with up to a 95% frequency of E. coli noted among the total number of bacteria isolated from the urinary tract [ 3 ].

Considering the total number of uropathogens, the second most isolated bacterial species belonged to the Enterobacteriaceae family ( Klebsiella sp. or Proteus sp.) [ 3 ]. The present review revealed that Klebsiella sp. was the second most frequently isolated bacterial species among Latin American pregnant women (pooled prevalence of 6.4%, 95% CI: 4.3–8.7), followed by Proteus mirabilis as the fourth most frequently identified species in urine cultures (pooled prevalence of 2.8%, 95% CI: 1.9–3.9) and Enterobacter sp. as the fifth (pooled prevalence of 1.6%, 95% CI: 0.7–1.7).

This meta-analysis supports previously reported findings regarding the frequency of Streptococcus agalactiae among the total number of uropathogens. Collin et al. have analyzed the prevalence of Lancefield group B Streptococcus in non-invasive bacterial infections worldwide. The authors identified UTI prevalence rates of 1.61% among bacterial isolates collected from the community and 0.72% among UTI bacterial isolates collected from a hospital environment [ 132 ].

Although the present systematic review with meta-analysis presents up-to-date evidence on the prevalence of bacteriuria in Latin American pregnant women, the limitations should be addressed. First, the lack of studies in southern Latin America and Central America may hinder generalization, warranting further investigation of UTIs in these regions. Second, there was significant heterogeneity in the overall pooled prevalence analysis of bacteriuria in Latin American pregnant women, a characteristic maintained in almost all subgroup analyses. Third, we noted a significant publication bias in the general assessment of the prevalence of bacteriuria among pregnant women, both in funnel plots and Egger’s test, reinforcing the need for careful data interpretation. The inclusion of non-published studies in the sub-analyses helped reduce this bias.

Our systematic review with meta-analysis included a total of 67 studies. Of this total research, more than a third had not been published. Of the articles published, only a few were selected in journals indexed in the main international databases. Although bacteriuria is a common topic in obstetric clinical practice, available data on Latin American pregnant women were scarce or difficult to obtain and, according to our review, at rates much higher than those from other regions and indicated by other previous studies, strengthening the value of our current research.

In our study we also examined the profile of microorganisms isolated in positive urine cultures from pregnant women living in the 20 most populous countries in Latin America. This information can help in the construction of care protocols guided by the local bacterial profile, favoring treatments with lower-cost antimicrobials. There are still limitations to Latin American pregnant women's access to health services. In the most populous country in the region, Brazil, in 2021, only two thirds (76.55%) of women had access to adequate prenatal care, that is, starting in the first trimester of pregnancy and with at least six outpatient consultations [ 133 ]. Therefore, considering the deficiencies in access to health professionals and laboratory tests during pregnancy, knowledge of the bacterial colonization profile of pregnant women in Latin America can help in planning care for this population.

UTI and asymptomatic bacteriuria are markedly common among Latin American pregnant women. The prevalence of bacteriuria among Brazilian pregnant women tends to be higher than the mean of Latin America or other regions worldwide. These results reinforce the need for universal screening with urine culture during early prenatal care. Evidence supporting repeated screening for bacteriuria during different trimesters or gestational ages is lacking. Among Latin American pregnant women, the most common microorganism in the etiology of bacteriuria was E.coli . Another frequently isolated uropathogen was S. agalactiae , with a higher prevalence than that reported in other international studies. This information is highly relevant, as maternal colonization with Lancefield group B streptococci has been associated with adverse perinatal outcomes, such as neonatal sepsis. Given the higher frequency of UTI among Latin American pregnant women, additional studies are needed to assess the effectiveness of screening protocols and better identify the different microbial sensitivity profiles of uropathogens isolated from these women.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

Asymptomatic bacteriuria

Disability-adjusted life years

Odds ratios

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Relative risks

Urinary tract infection

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Additional file 1:.

Supp 1. Funnel plot to test the publication bias in 67 studies with 95% Confidence limits. Suppl 2. Funnel plot to test the publication bias in 10 studies with 95% Confidence limits. Supp 3. Funnel plot to test the publication bias in 5 studies with 95% Confidence limits. Supp 4. Prevalence of bacteriuria in pregnant women in Latin America, considering only articles published with samples greater than 500 individuals. Supp 5. Funnel plot to test the publication bias in 15 studies with 95% Confidence limits. Supp 6. Prevalence of bacteriuria in pregnant women in Latin America, with the exception of Brazilian articles. Supp 7. Prevalence of bacteriuria in pregnant women in Latin America, with the exception of Brazilian articles, in studies with samples greater than 200 individuals. Supp 8. Funnel plot to test the publication bias in 28 studies with 95% Confidence limits. Supp 9. Funnel plot to test the publication bias in 20 studies with 95% Confidence limits. Supp 10. Prevalence of bacteriuria in Brazilian pregnant women, considering published or unpublished studies, in studies with samples greater than 200 individuals. Supp 11 Funnel plot to test the publication bias in 10 studies with 95% Confidence limits. Supp 12. Prevalence of Escherichia coli among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 13. Prevalence of Klebsiella sp . among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 14. Prevalence of Staphilococcus sp. (except Staphilococcus aureus ) among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 15. Prevalence of Proteus mirabilis among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 16. Prevalence of Enterobacter sp . among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 17. Prevalence of Enterococcus sp . among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 18. Prevalence of Streptococcus agalactiae among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 19. Prevalence of Staphilococcus aureus among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 20 Prevalence of Citrobacter sp. among the total number of uropathogens isolated from urine cultures of Latin American pregnant women. Supp 21. Prevalence of Pseudomonas aeruginosa among the total number of uropathogens isolated from urine cultures of Latin American pregnant women.

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de Souza, H.D., Diório, G.R.M., Peres, S.V. et al. Bacterial profile and prevalence of urinary tract infections in pregnant women in Latin America: a systematic review and meta-analysis. BMC Pregnancy Childbirth 23 , 774 (2023). https://doi.org/10.1186/s12884-023-06060-z

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DOI : https://doi.org/10.1186/s12884-023-06060-z

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Gestational Diabetes Mellitus and Associated Placental Histopathology: A Narrative Literature Review

Illustration by Taimi Xu

This narrative literature review explores the relationship between Gestational Diabetes Mellitus (GDM) and placental histopathology. The placenta, a crucial fetal organ, plays a vital role in maternal-fetal exchanges during pregnancy. GDM, a common complication affecting 2 to 10 percent of pregnancies in the US, is characterized by glucose intolerance. Placental hormones, particularly lactogen, influence maternal metabolic changes in GDM, leading to insulin resistance. However, the link between placental histopathology and GDM remains unclear. The review employed a narrative approach, searching databases for studies between 2010 and 2023. Sixteen quantitative studies focusing on the influence of GDM on placental histopathology were included. The studies varied in GDM definitions, diagnostic methods, and geographical locations. Placental histopathologic findings in GDM pregnancies included increased placental weight, chorangiosis, villous immaturity, and maternal vascular malperfusion. However, the understanding of these associations is limited, necessitating further research. Research gaps exist with only a few studies conducted in the USand limited exploration of maternal race as a potential risk factor. The need for tailored maternal recommendations and prevention strategies for adverse perinatal outcomes is emphasized. In conclusion, the review highlights the diverse placental histopathological characteristics associated with GDM. Future research should focus on larger prospective studies, exploring social determinants of health, non-clinical factors, and refining strategies for early detection and intervention to improve maternal and neonatal outcomes in GDM pregnancies.

Introduction

The human placenta, a transient fetal organ, serves as the interface between maternal and fetal circulatory systems. Formed from trophoblast cells, it consists of syncytiotrophoblast and cytotrophoblast layers, creating chorionic villi that connect to maternal blood.¹ As pregnancy progresses, cytotrophoblast decreases, facilitating maternal-fetal exchanges. The umbilical cord links to chorionic villi, the tiny, finger-like projections involved in uteroplacental circulation that promote the exchange of nutrients, oxygen, and waste between the mother and fetus. 2 The placenta is vital for a healthy pregnancy, with functions such as implantation, blood circulation, hCG synthesis, hormone production, immune defense, and preventing immune rejection. Limited data on placental functions in fetal development exists, but abnormalities can lead to complications. Placental hormones mediate maternal adaptations, and issues may result in conditions like gestational diabetes and fetal abnormalities. Further research on placental pathology is crucial for a comprehensive understanding.

Gestational diabetes mellitus (GDM), one of the most common pregnancy complications, is defined as glucose intolerance that develops or is first recognized during pregnancy, and affects 2 to 10 percent of pregnancies in the US. 3 The significant amount of the variability in GDM rates and prevalence between states can be attributed to racial/ethnic factors, maternal age, insurance at the individual level, hospital factors (type and bed count), and state-level factors (prevalence of obesity, income levels, poverty rates, etc). 4 The hormone, lactogen, released by the placenta in pregnancy, is crucial for the promotion of maternal metabolic changes that occur during pregnancy to support the development and maintenance of the fetus. 3 However, while lactogen is necessary for fetal nutrition, it is also an antagonist to insulin in pregnancy and promotes maternal insulin resistance. While the role of placental hormones and mechanisms in GDM is still unclear, less is known about the relationship between placental histopathology, specifically placental lesions, in pregnancies complicated with GDM, as well as the adverse pregnancy outcomes that may result from this histopathology.

This paper aims to synthesize current research regarding the placental histopathology of pregnancies complicated by GDM, identify limitations and strengths of current research, and recommend areas of improvement based on the literature. Throughout this paper, gendered language (“maternal”, “women”, etc) and non-gendered language (“people”, “persons”, “individuals”) will be used interchangeably with the intention to be inclusive of all identities while acknowledging that not all people who are pregnant or give birth identify themselves as women.

Search Methodology

Due to the broadness of placenta pathology and quantitative/qualitative gestational diabetes research literature, a narrative review approach was conducted. Systematized database searches were performed on November 30, 2023 for the time period of January 2010 to November 2023 and conducted using the databases Scopus, PubMed, Medline, Embase, and Cochrane for primary studies. Keywords searched included ‘placenta’, ‘placental histopathology’, ‘placenta pathology’, ‘gestational diabetes’, ‘abnormalities’, ‘adverse’, ‘neonatal’, ‘fetal’, and ‘vascular malperfusion’ (a complete list of search terms can be found in the appendix). Search terms were clustered according to the formatting requirements of each database to identify original, peer-reviewed research reports investigating the placental histopathology of gestational diabetes mellitus. Additional references were identified from a manual search of the cited references of research papers that were included from the initial search. The inclusion criteria for the full-text screening were English language or available translation, full-text availability, original research in peer-reviewed journals, published between 2010 and 2023, and described histopathological findings of pregnancies complicated by GDM. Gray literature and studies that did not clearly study the effect of GDM on placental histopathology were excluded. (See Table 1 for full search terms)

Table 1 Search Terms

Search Results

A total of 184 records were identified through database searching, and after removing duplicates 167 articles were screened against the eligibility criteria. Of these, 97 were excluded after screening the study title and abstract, leaving 70 full-text studies assessed for inclusion. A total of 16 quantitative studies that focused on the influence of GDM on placental histopathologic characteristics were eligible for inclusion and data extraction.

Figure 1 PRISMA: Search Flow-chart of identified papers published between 2010 and 2023.

Gestational Diabetes Mellitus diagnosis

All studies, except one that relied on medical records and patient charts for GDM diagnosis, used a variation of the oral glucose tolerance test (OGTT) for biochemically confirmed GDM diagnosis. Studies varied by the guidelines and criteria that the OGTT was scored against, including: International Association of the Diabetes and Pregnancy Study Groups (IADPSG), International Federation of Gynecology and Obstetrics (FIGO), American Diabetes Association (ADA), American College of Obstetricians and Gynecologists (ACOG), Carpenter-Coustan, and glucose challenge test (GCT, the UK version of the OGTT), departmental protocol, and Japanese criteria.

Placental histopathologic findings

Prospective cohort studies

Berceanu et al. compared the morphology of placentas of Type 1 diabetes mellitus and GDM complicated pregnancies. 5 Majority of the Type 1 diabetes mellitus and GDM cases presented with placentomegaly, an enlarged or oversized placenta, at the end of the third trimester with 40 percent of GDM cases presenting with immature appearance of the placenta. Villous immaturity, the underdevelopment of placental villi relative to gestational age, was found in 81.25 percent of GDM cases and chorangiosis in 37.5 percent. 5

Rudge et al. compared the placental histopathology between placentas of pregnancies complicated by mild hyperglycemia (MGH), GDM, and pregestational diabetes. 6 The placentas of GDM pregnancies had characteristics of delayed placental maturation (absence of syncytial nodes, high incidence of dysmaturity), yet 25 percent of neonates were classified as large for gestational age (LGA). 6 Placental characteristics only observed in the GDM placentas included chorial and intimal edemas (lesions of circulatory pathology), Hofbauer cell hyperplasia (enlargement of fetal macrophages), and villitis (inflammatory lesion).¹

Retrospective cohort studies

Ganer Herman et al. investigated in vitro fertilization (IVF) pregnancies and unassisted complications by GDM and found that IVF neonates were more likely to suffer from one or more adverse outcomes such as respiratory distress syndrome. 7 This was not explained by placental histology as there were no significant differences between IVF and unassisted pregnancies regarding maternal vascular malperfusion (MVM) lesions, abnormalities of the blood vessels supplying the placenta. Nor were there significant differences regarding fetal vascular malperfusion lesions (FVM), abnormalities of the blood vessels within the placenta that supply the fetus. Also, there were no significant differences between groups regarding the prevalence of histological chorioamnionitis, the inflammation of the membranes surrounding the fetus.

Kleiner et al. compared pregnancy outcomes and placental pathology among pregnancies complicated by macrosomia (neonatal birth weight of 4000g or greater), a condition associated with diabetic pregnancies, prolonged labor, shoulder dystocia, and neonatal hypoglycemia. 8 Due to low sample size, GDM placentas and pre-pregnancy diabetes placentas were aggregated under the “diabetic macrosomia” group. 8 The study concluded that the diabetic macrosomia group had mothers of more advanced age and higher BMI and did not differ significantly in terms of neonatal outcomes compared to the non-diabetic macrosomia group, though both groups had high rates of adverse neonatal outcomes (27.5 percent and 29 percent, respectively). Surprisingly, the placentas from the non-diabetic macrosomia group had greater rates of MVM and FVM and higher placental weights compared to the diabetic macrosomia group.

After adjusting for maternal age, race, educational attainment, and pre-pregnancy BMI across 1,186 placentas, Scifres et al. concluded that MVM lesions were the most common placental pathology among women with GDM, with respect to their retrospective cohort study. 9 GDM is associated with excess gestational weight gain. This increases the risk for adverse pregnancy outcomes and may negatively impact various inflammatory processes that may occur in early gestation. While the mechanisms for the association between MVM and early gestational weight gain are unknown, Scifres et al. predicted that the “diminished early placentation seen with MVM” may impact the production of hormones that influence maternal metabolism. 9 For example, the stronger early placentation of pregnancies not associated with any pathology, may lead to the increased production of hormones that are associated with morning sickness (nausea and vomiting) common in early gestation, mitigating early gestational weight gain.

Due to the association between GDM and PEC, Xu et al. explored the placental histopathological effects of preeclamptic pregnancies complicated by GDM (PE+GDM) compared to those without GDM (PE-GDM). 10 PE+GDM placentas had significantly greater incidences of chorioamnionitis, MVM, and increased placenta weight. However, there were no significant differences regarding neonatal outcomes between the two groups.

Prospective case-control studies

Diceglie et al. reported that PHLPP1 (a phosphatase described to be involved in insulin resistance mechanisms) expression in placental tissues was increased in obese women with GDM compared to obese women without GDM. 11 There is a lack of consensus on the role of PHLPP1 in GDM and its potential role as a regulator of an insulin feedback loop absent in diabetes.

Istrate-Ofiţeru et al. investigated the association between common pregnancy morbidities, GDM and gestational hypertension (GHTN) and placental morphopathological changes that influence fetal development. 12 Both GDM and GHTN placentas had greater vascular density compared to placentas unassociated with any pathology, with the presence of chorangiosis slightly higher in GDM placentas than GHTN placentas. This study concludes that chorangiosis, a feature typical of GDM placental pathology, can also occur in pregnancies complicated with GHTN.

Nataly et al. compared pregnancy outcomes and placental pathologies of GDM pregnancies managed by diet-control (GDM1), GDM pregnancies managed by insulin, and cases that had one isolated abnormal value (OAV) regarding the OGTT. 13 The fetal to placental birth weight ratio was lower among the GDMA2 group compared to the other study groups, but there were no significant differences between groups regarding MVM, acute inflammatory, or chronic villitis lesions. Similarly, Pooransari et al. found that well-controlled GDM (by either insulin or diet) had no significant differences in placental gross morphology and pregnancy outcome compared to pregnancies not associated with any pathology. 14

Retrospective case-control studies

Aldahmash et al. found that the average placental weight of the GDM group was significantly higher than the control group. 15 Within the GDM group, common vasculopathies on the maternal side of the placenta included villous agglutination and retroplacental hemorrhage. On the fetal side, the incidence of villous fibrinoid necrosis and chorangiosis was significantly higher within the GDM group compared to the control group. Chorangiosis is the excess of blood vessels in the placental villi and impacts fetoplacental circulation, compromising placenta function and glucose metabolism.

Al-Ofi et al. discovered that the serum levels of the angiogenic biomarkers VEGF, angiopoietin-2, endoglin, and endothelin-1 were significantly higher in GDM women compared to non-GDM women. 16 The disruption of pro and anti-angiogenic biomarkers directly affect the development of feto-placental vessels and may be associated with GDM pathology. This study found that serum VEGF-A levels in GDM pregnant participants were significantly higher compared to non-GDM participants; these finds may explain the mechanisms underlying the impairments of the placental barrier in GDM that are associated with (abnormal placentation and the subsequent maternal and neonatal complications). 16

On the other hand, Goto et al. found an increased incidence of fetal vascular malperfusion among GDM placentas than non-GDM placentas. 17 However, this did not apply to maternal vascular malperfusion (MVM). While the exact mechanisms of fetal vascular malperfusion are unknown, the study’s findings suggest that maternal hyperglycemia may result in endothelial injury and dysfunction which results in the development of fetal vascular malperfusion.

Huynh et al. utilized multivariable logistic regression to compare placental pathologic characteristics between pregnancies complicated by T1DM, T2DM, and GDM. 18 While there were no statistically significant differences in fetal thrombotic vasculopathy, GDM placentas had significantly more villous immaturity and T2DM placentas had a significantly higher rate of fetal acute chorioamnionitis. Maturational impairments like villous immaturity are associated with increased risk of perinatal mortality and chronic fetal hypoxia; inflammatory impairments like chorioamnionitis are associated with neonatal morbidities and mortalities and preterm delivery. 19-21

Siassakos et al. aimed to study placental pathology of GDM as a risk factor of stillbirth by utilizing placental histopathology reports and clinical record analysis and focused on abnormal placental villous maturation, particularly distal villous immaturity (DVI). 22 They discovered that, despite no formal diabetes diagnosis, significantly more women with disorders of villous maturation had at least one abnormal glucose test result compared to women without disorders of villous maturation. The prevalence of a formal GDM diagnosis did not differ significantly between various histopathologies.

Weiner et al. aimed to compare placental histopathological lesions and neonatal outcomes of pregnancies complicated by GDM between singleton and dichorionic diamniotic twin pregnancies. 23 While MVM, villous immaturity, and LGA neonates were associated with singleton pregnancies, twin pregnancies resulted in significantly more NICU admissions.

Strengths and Limitations

The primary strengths of the studies included in this narrative literature review were the biochemical confirmation of GDM diagnoses by OGTT and the novelty of the groups involved such as IVF patients with GDM, PEC pregnancies complicated by GDM, macrosomic pregnancies, women with OAV, and singleton vs twin pregnancies. However, the majority of studies took place at a single center or university-affiliated hospital and acknowledged small sample size (overall and of the GDM subsample) as a limitation. Also, only 5 out of the 16 studies had blinded their pathologists to reduce potential biases, with 11 out of 16 studies either not mentioning the blinding of their pathologists or failing to include this in their methodology.

Gaps in the Research

Only 2 out of the 16 studies were conducted in the US (Scifres et al., 2017; Huynh et al., 2015) and only 2 studies looked at maternal race as a potential risk factor (Scifres et al., 2017; Huynh et al., 2015). 9,18 However, due to sample size and available data, both studies aggregated maternal races into “White”, “Black”, and “Other”, or “White” and “non-White”, respectively. Scifres et al. highlighted the need to better understand placental function in order to tailor and individualize maternal recommendations and prevent adverse perinatal outcomes. 9

Discussion and Implications for Future Placental Research

This narrative literature review on placental histopathology studies related to gestational diabetes mellitus (GDM) revealed various findings. “The placental histopathological characteristics that were significantly more frequent in pregnancies complicated by GDM included increased placental weight, incidence of chorangiosis, villous/placental immaturity, and MVM.” 18 There was variation regarding the placental histopathological characteristics: villous agglutination, retroplacental hemorrhage, villous fibrinoid necrosis, increased angiogenic biomarkers, PHLPP1 expression, FVM, increased vascular density, and chorioamnionitis.

This review reveals a lack of clarity in understanding the link between placental histopathology and GDM, emphasizing the need for further research. The studies, conducted between 2010 and 2023, highlight variations in GDM definitions, diagnostic methods, and geographical locations. Notably, research gaps exist, with limited studies in the US and minimal exploration of maternal race as a potential risk factor. The call for tailored maternal recommendations and prevention strategies arises from the diverse placental histopathological characteristics associated with GDM. Future research should focus on larger prospective studies, considering social determinants of health, non-clinical factors, and refining strategies for early detection and intervention to improve maternal and neonatal outcomes in GDM pregnancies. Social determinants of health and non-clinical factors of interest include maternal ethnicity, culture, socioeconomic status, access to care, and lifestyle factors.

Pathology plays a critical role in public health as the study of disease at the diagnostic and etiologic level. While the studies reviewed were highly laboratory and clinical-based, they provide a critical component of public health by contributing to understanding the mechanisms behind disease, surveillance, and potential strategies for early detection. 24-27 The reviewed studies emphasized the need for further research in the pathological field, particularly larger prospective studies, as well as the significance of prenatal care, perinatal glycemic control, the use of ultrasound to detect potential abnormalities, and lifestyle factors in improving maternal and neonatal outcomes in pregnancies complicated by GDM. The future of placental histopathology research offers an opportunity to investigate the social determinants of health or non-clinical factors that may underlie these histopathological characteristics. 26-30

References

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PMC10420219

Urinary Tract Infections: Prevention, Diagnosis, and Treatment

Amelia pietropaolo.

1 Urology Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; moc.liamg@rteipailema

2 European Association of Urology-Young Academic Urologists (EAU-YAU) Urolithiasis and Endourology Working Group, NL-6803 AA Arnhem, The Netherlands

Urinary tract infections (UTIs) are common pathologies that can affect patients of every age and background. The role of the urological community is often to diagnose them and treat them, but also to identify strategies to prevent them. Good collaboration between urologists and microbiologists is the key to finding an effective strategy for UTI treatment. This is even more true in case of more vulnerable individuals, such as pregnant women or children. Several clinical conditions can also increase the risk of UTIs and, in some cases, can cause enhanced morbidities related to them [ 1 ]. These are often related to immunosuppression, urinary diversion, diabetes, and neurological pathologies. The prevention of UTI recurrence in these complex cases is difficult, and innovative strategies are needed in order to optimize our treatment options. Multiple previous studies have investigated the etiology of UTIs and described effective tools for their prevention and treatment [ 2 ]. The aim of this Special Issue of the Journal of Clinical Medicine , with the research topic “Urinary Tract Infection: Prevention, Diagnosis and Treatment”, is to explore different aspects of the prevention and treatment of UTIs, thereby suggesting possible solutions to tackle them in each of their manifestations. With this in mind, an overview of seven original and review articles is included in this Special Issue.

It is known that 50–60% on pregnant women can be affected by UTIs. If not correctly diagnosed and treated, this can lead to clinical issues for the mother or the fetus. Corrales et al. conducted a review of the literature, analyzing all the guidelines currently available for UTI treatment during pregnancy [ 3 ]. They also identified families of antibiotics deemed to be safe and ranked them according to their effectiveness. Screening for urinary infections is usually carried out between the 12th and 16th week of gestation in most countries. The first-line antibiotic regime varies among countries, but the most common are Nitrofurantoin, Co-amoxiclav, and first/second- or third-generation Cephalosporin class antibiotics. In cases of acute pyelonephritis, the same antibiotics are used, but with a strong preference for intravenous stewardship.

In later stages of life, pediatric patients are not often affected by urinary tract infections. However, kidney stones disease (KSD) is a known risk factor for recurrent UTIs in this age category. Recent studies have shown that Vitamin D supplementation may be a risk factor for an increased risk of kidney stones in children and, consequently, an increased incidence of UTIs [ 4 ]. Some rare clinical conditions and anatomical abnormalities can also increase the risk of infection in this population. Vesicoureteral reflux (VUR) is a rare pathological condition (1–2% of all children) that causes reflux of urine from the urinary bladder to the ureter up to the urinary collecting system. This is often cause of hospital admission in young children due to the high risk of urinary infection, fever, and pyelonephritis, which can lead to renal failure in the long term. An interesting paper by Colceriu et al. [ 5 ] describes how the inflammatory process and the immune response in this scenario can sometimes be harmful, leading to increased susceptibility to UTIs and development of tissue damage, scar tissue, and chronic kidney disease. A better understanding of the immunological mechanism of this pathology could help us to explain the cause of reflux nephropathy and to prevent and treat this rare disease.

A recent issue of the modern world related to immune system response and empirical stewardship of antibiotics is also the phenomenon of antibiotic resistance. This leads to a relevant economic and social burden, and some countries are more affected than others. Manolitsis et al. described in their paper that Greece is a country with a high incidence of multidrug-resistant bacteria due to excessive consumption of over-the-counter antibiotics, confirming the country as one of the top four antibiotic prescribers in Europe [ 6 ]. Over a time span of 2 years, 12,215 urine and blood samples from patients hospitalized in the urology department were processed by the Microbiology Laboratory. Numerous bacteria were tested, confirming a mean resistance rate of more than 22% to Escherichia Coli and of more than 46% to Klebsiella Pneumoniae. A new computerized model that uses artificial intelligence and machine learning to predict sensitivity to antibiotics will be able to shorten the speed of the diagnostic process, hence allowing for early treatment of UTIs [ 7 ]. This study will be useful for organizing stewardship programs that aim to optimize the appropriate use of available antimicrobial agents with better criteria to prevent the development of resistance.

In the urological field, most urinary infections are associated with indwelling devices such as catheters, ureteric stents, and different urinary diversion systems. Catheter-related UTIs are very common, and they are often responsible for high morbidity and costs to the health system worldwide [ 8 ]. Jo et al. described that E. Coli was the most common species causing UTIs in patients without indwelling catheters, while in catheterized patients, Enterobacter and Enterococcus species were mostly isolated. However, the study showed no difference in resistance rates between the two groups of patients (catheterized vs. not catheterized). Interestingly, in both groups of patients, Fosfomycin had a success rate higher than 50% for UTIs. According to this study, Fosfomycin should therefore be considered as the primary antibiotic for catheterized patients [ 9 ].

Unfortunately, in cases of multidrug-resistant recurrent UTIs, no alternative solutions are available to prevent patient morbidity. Intravesical antibiotics have already been identified as a valid alternative to oral or systemic antibiotics for recurrent infection refractories [ 10 ]. A recent systematic review by Ong et al. described the effectiveness of using intravesical Aminoglycoside instillations (IVA) for either treatment or prophylaxis of refractory UTIs, achieving successful outcomes in around 80% of patients [ 11 ]. The review takes into account 584 patients who underwent intravesical administration of Gentamicin, Amikacin, Tobramycin, Garamycin, Netilmicin, or Neomycin. Moreover, some studies assessed the use of an intravesical Aminoglycoside in combination with Polymyxin. Most patients were affected by neurogenic bladder, or had urinary diversion or indwelling and intermittent catheters. A success rate of 80% was observed in patients who had IVA alone, and this rate was 79.5% in cases of IVA in combination with Polymixin. The side effects were low and patients’ compliance was excellent, with 6.3% discontinuation reported. The paper described how IVA treatment can effectively solve the issue of multi-resistant organisms in the short term thanks to the avoidance of oral intravenous antibiotics. However, to date, no guidelines are available due to the lack of standardization of doses and administration methods.

As previously mentioned, a strong relationship exists between KSD and UTIs, and indeed, stone formers are at a higher risk of developing UTIs over their lifetimes [ 12 ]. For this reason, patients with recurrent UTIs and concomitant KSD may benefit from surgical treatment of the stones [ 13 ]. The original paper by Ripa et al. analyzed data of 178 consecutive patients with recurrent UTIs, sepsis, or pyelonephritis who underwent ureteroscopy and laser lithotripsy (FURSL) as a treatment for their urinary stones over a 10-year period. The study showed that 88.8% of the patients were infection-free after the treatment [ 14 ]. The overall rate of early post-operative UTI recurrences was 6.2%, with a gradual increase over time, mostly related to stone recurrence. Older or diabetic patients tended to have lower chances of being infection-free after the stone treatment. The outcomes of the paper suggest that stone-free status after FURSL could help to reduce UTI recurrence in the majority of patients.

In rare cases, FURSL itself can be followed by infectious complications. The main reason for these rare, but morbid, events can be related to the intrarenal pressure developed during the procedure, which can be a cause of pyelo-venous backflow and bacteremia leading to sepsis [ 15 ], with potentially fatal consequences [ 16 ]. Villa et al. carried out an original study to identify possible correlations between the use of a ureteric access sheath (UAS) and post-operative infection during FURSL. The UAS is a useful tool utilized during FURSL to reduce intrarenal pressure and to improve both the removal of fragments and the visibility by promoting a constant outflow from the renal cavities [ 17 ]. In their study, Villa et al. analyzed 451 surgical FURSL procedures [ 18 ]. In the first 24 hours after surgery, fever, sepsis, and septic shock was described in 52 (11.5%), 10 (2.2%), and 6 (1.3%) cases, respectively. Patients’ comorbidities were positively associated with a 10% higher risk of infectious complications, including sepsis and septic shock ( p < 0.01). However, according to the study, the use of UAS effectively reduced the risk of septic shock ( p < 0.04), but not necessarily the risk of fever or sepsis.

As Guest Editor, I would like to thank all the authors for their high-quality contributions, which shine new light on the topic of the prevention and treatment of urinary tract infections. I warmly thank the reviewers for their time in professionally reviewing the papers and raising important comments and queries. Special thanks to the JCM editorial team and Shirley Chen for their collective support, perseverance, and assistance.

Conflicts of Interest

The author declares no conflict of interest.

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Urinary Tract Infections in Pregnant Individuals
Summary: Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies 1 2. These infections represent a spectrum, from asymptomatic bacteriuria, to symptomatic acute cystitis, to the most serious, pyelonephritis. The presence of UTIs has been associated with adverse pregnancy ...
Which Antibiotic for Urinary Tract Infections in Pregnancy? A
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).
Urinary Tract Infection in Pregnancy and Its Effects on Maternal and
Introduction. Urinary tract infections (UTI) continue to be one of the most common medical conditions complicating pregnancy, with a prevalence of approximately 20% [].A UTI is diagnosed when there is an overgrowth of bacteria in the urinary tract (≥105 counts/mL of urine), irrespective of the presence of clinical symptoms [].UTI include a spectrum of disorders, ranging from those affecting ...
Urinary Tract Infection and Associated Factors among Pregnant Women
The changes in the urinary tract and immunological changes associated with pregnancy, along with an already short urethra predispose women to UTI [3, 4]. Maternal UTI is the commonest nonintestinal infection in pregnant women globally, and it is a major health problem affecting up to 20% of expectant mothers [ 5 , 6 ].
Which Antibiotic for Urinary Tract Infections in Pregnancy? A ...
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).
Global prevalence of urinary tract infection in pregnant mothers: a
Urinary tract infection (UTI) is a prevalent infection during pregnancy that can lead to complications for both the mother and the foetus. The objective of this systematic review and meta-analysis is to determine the global prevalence of UTIs (both symptomatic and asymptomatic) during pregnancy, based on previous studies in this area.
Urinary tract infections in pregnancy
Urinary tract infections (UTIs) are the most common infection among pregnant women and have been associated with maternal and foetal complications. Antimicrobial exposure during pregnancy is not without risk. International guidelines recommend a single screen-and-treat approach to asymptomatic bacteriuria (ASB); however, this approach has been questioned by recent studies.
Diagnostic work-up of urinary tract infections in pregnancy: study
Introduction. The prevalence of urinary tract infections (UTIs) during pregnancy reported in literature varies between 2.3% and 15%.1-5 It is hypothesised that anatomical changes during pregnancy such as dilatation of the ureters, decreased ureteral tone and increased bladder volume contribute to urinary stasis and ureterovesical reflux increasing the risk of a UTI.6-8 Besides the ...
Which Antibiotic for Urinary Tract Infections in Pregnancy? A ...
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).
Urinary Tract Infection in Pregnancy and Its Effects on ...
Background A urinary tract infection (UTI) is a common medical condition complicating pregnancy with adverse maternal and perinatal outcomes. This study aimed to assess any adverse maternal and perinatal morbidity related to UTI in pregnancy, focusing on identifying common uropathogens and their antibiotic sensitivity and resistance patterns.
Urinary tract infections and asymptomatic bacteriuria in pregnancy
Without treatment, as many as 20 to 35 percent of pregnant women with asymptomatic bacteriuria will develop a symptomatic urinary tract infection (UTI), including pyelonephritis, during pregnancy [ 6,7 ]. This risk is reduced by 70 to 80 percent if bacteriuria is eradicated (see 'Rationale for treatment' below).
Urinary tract infections in pregnancy
Urinary tract infections (UTIs) are the most common bacterial infection in pregnancy and have been estimated to affect 2% to 15% of the pregnant population, although recent data suggest that this may be higher. Using data from the National Birth Defects Study population (41 869 women), Johnson et al. [ 1] found that 11% to 26% of women reported ...
Urinary Tract Infection in Pregnancy
Urinary tract infections (UTIs) are frequently encountered in pregnant women. Pyelonephritis is the most common serious medical condition seen in pregnancy. Thus, it is crucial for providers of obstetric care to be knowledgeable about normal findings of the urinary tract, evaluation of abnormalities, and treatment of disease. Fortunately, UTIs in pregnancy are most often easily treated with ...
Global prevalence of urinary tract infection in pregnant mothers: a
Meta-regression of the effect of sample size on the prevalence of urinary tract infection during pregnancy. N. Salari, Y. Khoshbakht, M. Hemmati et al. Public Health 224 (2023) 58 e 65 63
A systematic review of non-antibiotic measures for the prevention of
Urinary tract infections (UTIs) are common in pregnancy and account for the highest proportion of primary care antibiotic prescriptions issued to pregnant women in the UK. ... safety of these measures in pregnancy have not been addressed and therefore the aim of this study was to systematically review the literature to identify and evaluate ...
Urinary tract infections in pregnancy
search terms were 'urinary tract infection', 'pyelonephritis', 'asymptomatic bacteriuria', and 'pregnancy'. Relevant references discovered during the literature search were also reviewed. Pathophysiology Physiological changes related to increased levels of progester-one place pregnant women at the risk of developing UTI. High
(PDF) Urinary Tract Infections During Pregnancy
OBJECTIVE: To provide a comprehensive review of urinary tract infections (UTIs) during pregnancy. All aspects of UTIs, including. epidemiology, pathogenesis, resistance, clinical features ...
Characteristics of women with urinary tract infection in pregnancy
INTRODUCTION. Urinary tract infection (UTI) is the most common bacterial infection in pregnancy. 1 In pregnancy, the definition of UTI often includes symptomatic infections of the bladder (cystitis) or kidney (pyelonephritis) as well as asymptomatic bacteriuria, the presence of bacteria in the urine without symptoms. Review articles cite a prevalence of 2-10% for asymptomatic bacteriuria, 1 ...
Global prevalence of urinary tract infection in pregnant ...
Objective: Urinary tract infection (UTI) is a prevalent infection during pregnancy that can lead to complications for both the mother and the foetus. The objective of this systematic review and meta-analysis is to determine the global prevalence of UTIs (both symptomatic and asymptomatic) during pregnancy, based on previous studies in this area.
PDF Urinary Tract Infection in Pregnancy: Review of Clinical Management
Pregnancy is a period that asymptomatic bacteriuria has a different meaning: indication for treatment is required as well as prevents recurrence of UTI during pregnancy is essential given the severity of possible complications. This review summarizes epidemiology, clinical features and clinical management of this important infection in pregnancy.
Bacterial profile and prevalence of urinary tract infections in
Background Given the physiological changes during pregnancy, pregnant women are likely to develop recurrent urinary tract infections (UTIs) and pyelonephritis, which may result in adverse obstetric outcomes, including prematurity and low birth weight preeclampsia. However, data on UTI prevalence and bacterial profile in Latin American pregnant women remain scarce, necessitating the present ...
Prevalence of Urinary Tract Infection and Its Associated Factors among
Objective. Urinary tract infection (UTI) is the most common bacterial infections during pregnancy. It is associated with different maternal and neonatal adverse outcomes such as low birth weight, preterm birth, still birth, preeclampsia, maternal anemia, sepsis, and amnionitis, even when the infection is asymptomatic.
Gestational Diabetes Mellitus and Associated Placental Histopathology
By Mal Go Illustration by Taimi Xu Abstract This narrative literature review explores the relationship between Gestational Diabetes Mellitus (GDM) and placental histopathology. The placenta, a crucial fetal organ, plays a vital role in maternal-fetal exchanges during pregnancy. GDM, a common complication affecting 2 to 10 percent of pregnancies in the US, is characterized […]
Urinary Tract Infections: Prevention, Diagnosis, and Treatment
It is known that 50-60% on pregnant women can be affected by UTIs. If not correctly diagnosed and treated, this can lead to clinical issues for the mother or the fetus. Corrales et al. conducted a review of the literature, analyzing all the guidelines currently available for UTI treatment during pregnancy . They also identified families of ...

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Global prevalence of urinary tract infection in pregnant mothers: a systematic review and meta-analysis

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