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Meta-Analysis
. 2019 Nov 25;2019(11):CD000490.
doi: 10.1002/14651858.CD000490.pub4.

Antibiotics for asymptomatic bacteriuria in pregnancy

Fiona M Smaill  1 , Juan C Vazquez  2
Affiliations
Meta-Analysis

Antibiotics for asymptomatic bacteriuria in pregnancy

Fiona M Smaill et al. Cochrane Database Syst Rev. .

Abstract

Background: Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15% of pregnancies. If left untreated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth. This is an update of a review last published in 2015.

Objectives: To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth.

Search methods: For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 4 November 2018, and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCT) comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. Trials using a cluster-RCT design and quasi-RCTs were eligible for inclusion, as were trials published in abstract or letter form, but cross-over studies were not.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

Main results: We included 15 studies, involving over 2000 women. Antibiotic treatment compared with placebo or no treatment may reduce the incidence of pyelonephritis (average risk ratio (RR) 0.24, 95% confidence interval (CI) 0.13 to 0.41; 12 studies, 2017 women; low-certainty evidence). Antibiotic treatment may be associated with a reduction in the incidence of preterm birth (RR 0.34, 95% CI 0.13 to 0.88; 3 studies, 327 women; low-certainty evidence), and low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; 6 studies, 1437 babies; low-certainty evidence). There may be a reduction in persistent bacteriuria at the time of delivery (average RR 0.30, 95% CI 0.18 to 0.53; 4 studies; 596 women), but the results were inconclusive for serious adverse neonatal outcomes (average RR 0.64, 95% CI 0.23 to 1.79, 3 studies; 549 babies). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes, and maternal adverse effects were rarely described. Overall, we judged only one trial at low risk of bias across all domains; the other 14 studies were assessed as high or unclear risk of bias. Many studies lacked an adequate description of methods, and we could only judge the risk of bias as unclear, but in most studies, we assessed at least one domain at high risk of bias. We assessed the quality of the evidence for the three primary outcomes with GRADE software, and found low-certainty evidence for pyelonephritis, preterm birth, and birthweight less than 2500 g.

Authors' conclusions: Antibiotic treatment may be effective in reducing the risk of pyelonephritis in pregnancy, but our confidence in the effect estimate is limited given the low certainty of the evidence. There may be a reduction in preterm birth and low birthweight with antibiotic treatment, consistent with theories about the role of infection in adverse pregnancy outcomes, but again, the confidence in the effect is limited given the low certainty of the evidence. Research implications identified in this review include the need for an up-to-date cost-effectiveness evaluation of diagnostic algorithms, and more evidence to learn whether there is a low-risk group of women who are unlikely to benefit from treatment of asymptomatic bacteriuria.

PubMed Disclaimer

Conflict of interest statement

Fiona M Smaill: none known

Juan C Vazquez: none known

Figures

1
1
Study flow diagram
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study
3
3
Funnel plot of comparison: 1 Antibiotic versus no treatment for asymptomatic bacteriuria, outcome: 1.1 Development of pyelonephritis
1.1
1.1. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 1 Development of pyelonephritis.
1.2
1.2. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 2 Preterm birth < 37 weeks.
1.3
1.3. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 3 Birthweight < 2500 g.
1.4
1.4. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 4 Persistent bacteriuria.
1.5
1.5. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 5 Serious adverse neonatal outcome.
1.6
1.6. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 6 Birthweight.
1.7
1.7. Analysis
Comparison 1 Antibiotics versus no treatment for asymptomatic bacteriuria, Outcome 7 Gestational age at delivery.
See this image and copyright information in PMC

Update of

References

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