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Cousins G, Dimitrov BD , Van de Laar FA, Fahey T

Systematic review and meta -analysis on diagnostic accuracy of signs & symptoms predicting uncomplicated urinary tract infection in women Giesen LGM Erasmus student Sept – Dec 2009 RCSI, Dublin. Cousins G, Dimitrov BD , Van de Laar FA, Fahey T. Outline. Background/ Rationale Methods

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Cousins G, Dimitrov BD , Van de Laar FA, Fahey T

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  1. Systematic review and meta-analysis on diagnostic accuracy of signs & symptoms predicting uncomplicated urinary tract infection in women Giesen LGM Erasmus student Sept – Dec 2009 RCSI, Dublin Cousins G, Dimitrov BD, Van de Laar FA, Fahey T

  2. Outline • Background/ Rationale • Methods • Results • Conclusion

  3. Background • Prevalence • 5% asymptomatic • 50% symptomatic • Pathogens • Reference standard • Midstream urine culture • Thresholds >10², >10³, >105 CFU/ml

  4. Diagnosis UTI Diagnosis Dipstick testing Culture urine Signs & symptoms

  5. Diagnosis UTI Diagnosis Dipstick testing Culture urine Signs & symptoms

  6. Rationale • Bent 2002 • Meta-analysis of 9 studies • Reference standard > 104 CFU/ml • Significant symptoms & signs • What can we add? • 9 additional studies • European guidelines • Consideration of heterogeneity

  7. Diagnostic accuracy signs & symptoms Signs & symptoms Dysuria Frequency Urgency Hematuria Fever Flank pain Absence vaginal discharge & irritation Reference test : Urine culture > 10² CFU/ml >10³ CFU/ml >105 CFU/ml

  8. Methods – Identification of studies

  9. Methods • Quality assessment (QUADAS) • Meta-analysis • Derivation of summary statistics of each study (2x2 tables) • Pooling the summary statistics across studies • Examine the pattern of variability (heterogeneity) observed in the results

  10. Derivation of summary statistics Specificity: 60/154 = 39.0% + LR = sens/ (1- spec) = 72.8/ (1-39.0) = 1.19 Sensitivity: 185/254 = 72.8%

  11. Results: 16 studiesQuality assessment Time periodindex and reference test Blinding Contamination reported Pt selected consecutively Data included 95%CI

  12. Results: Meta-analysis (> 102)

  13. Pretest & posttest probability Posttest Probability 52,4% Frequency LR+ = 1.10 56.5% Dysuria LR+ = 1.30 Pretest Probability = 50% Hematuria LR+ = 1.72 63.2% Nocturia LR+ = 1.30 56.5% Urgency LR+ = 1.22 55.0% Vaginal discharge LR+ = 0.65 39.4%

  14. Heterogeneity - threshold effect (> 102)

  15. Heterogeneity frequency - threshold effect

  16. Heterogeneity 102 CFU/ml 103 CFU/ml 105 CFU/ml I-square = 84.9% I-square = 85.2% I-square = 68.1% Figures: sensitivity frequency

  17. Conclusions • 5 symptoms increase the probability of UTI when present (frequency/ dysuria/ hematuria/ nocturia/ urgency) • Vaginal discharge decreasedprobability of UTI • However only modest ability to ‘rule in’ or ‘rule out’ UTI • High pre-testprobability

  18. Conclusions • Importance of considering heterogeneity • Variations in diagnosticthreshold • Patientselection/ setting • Future directions • Combinations of symptoms – clinicalpredictionrule • Severitiy of symptoms

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