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Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs

Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs
Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs
Background: acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (102 or 103 or 105 CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making.

Methods: searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking.

Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ? 102 CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model.

Results: sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ? 102 CFU/ml; 55.4% at ? 103 CFU/ml and 44.8% at ? 102 CFU/ml ? 105 CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ? 102 CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ? 102 CFU/ml and 67.4% at ? 103 CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ? 102 CFU/ml and ? 103 CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ? 102 CFU/ml and ? 103 CFU/ml.

Conclusions: individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites
1471-2296
78-[14pp]
Giesen, Leonie G.M.
b351a2a4-e48b-48f2-bf37-e43dc240a68d
Cousins, Grainne
2d91bd97-feb1-46ac-9707-896cc0764c0c
Dimitrov, Borislav D.
366d715f-ffd9-45a1-8415-65de5488472f
van de Laar, Floris A.
dbbac92e-796c-4216-b663-bb9c783a78d4
Fahey, Tom
c0fd145a-af82-4c37-bce0-1c2e3e30c0f9
Giesen, Leonie G.M.
b351a2a4-e48b-48f2-bf37-e43dc240a68d
Cousins, Grainne
2d91bd97-feb1-46ac-9707-896cc0764c0c
Dimitrov, Borislav D.
366d715f-ffd9-45a1-8415-65de5488472f
van de Laar, Floris A.
dbbac92e-796c-4216-b663-bb9c783a78d4
Fahey, Tom
c0fd145a-af82-4c37-bce0-1c2e3e30c0f9

Giesen, Leonie G.M., Cousins, Grainne, Dimitrov, Borislav D., van de Laar, Floris A. and Fahey, Tom (2010) Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. BMC Family Practice, 11 (1), 78-[14pp]. (doi:10.1186/1471-2296-11-78).

Record type: Article

Abstract

Background: acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (102 or 103 or 105 CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making.

Methods: searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking.

Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ? 102 CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model.

Results: sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ? 102 CFU/ml; 55.4% at ? 103 CFU/ml and 44.8% at ? 102 CFU/ml ? 105 CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ? 102 CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ? 102 CFU/ml and 67.4% at ? 103 CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ? 102 CFU/ml and ? 103 CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ? 102 CFU/ml and ? 103 CFU/ml.

Conclusions: individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites

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Published date: 24 October 2010
Organisations: Primary Care & Population Sciences

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Local EPrints ID: 337458
URI: http://eprints.soton.ac.uk/id/eprint/337458
ISSN: 1471-2296
PURE UUID: eeb23d56-d236-41d9-842e-18efe85903ba

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Date deposited: 26 Apr 2012 10:24
Last modified: 14 Mar 2024 10:53

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Contributors

Author: Leonie G.M. Giesen
Author: Grainne Cousins
Author: Borislav D. Dimitrov
Author: Floris A. van de Laar
Author: Tom Fahey

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