Table 2 Definition of malnutrition and urinary tract infections across included studies

Cross-sectional studies

Philips I et al. 1968 [41]

Marasmus or kwashiorkor

Severe malnutrition, including kwashiorkor (84%) and marasmus (16%).

urine bag or suprapubic aspiration (if specimen using bag is contaminated)

Culture (details not specified)

Not specified

Brooke O. G et al. 1973 [57]

Protein-energy malnutrition

Severe malnutrition (100%)

Sterile urine bags or suprapubic tap

microscopy and culture (details not specified)

> 10000 organisms/ml of urine confirmed by suprapubic tap (if a bad specimen was initially used)

Buchanan N et al. 1973 [35]

Kwashiorkor, marasmic kwashiorkor, marasmus or underweight for age (below the third percentile)

Severe malnutrition including Kwashiorkor: 46.7%), marasmic Kwashiorkor (23.3%), Marasmus (20%) and Underweight for age (10%)

Midstream urine or sterile urine bags

Uricult dip-slide (nutrient agar on one side and McConkey’s agar on the other side, with 13 cm² areas for each medium) incubated at 37 °C for 16–24 h.

> 10⁵ organisms/ml of urine

Morehead D et al. 1974 [53]

Kwashiorkor, marasmus or marasmic kwashiorkor

Moderate/severe malnutrition including marasmus: (22.9%) marasmic kwashiorkor (51.4%) and Kwashiorkor (25.7%).

Suprapubic tap or urethral catheterization

Plating on sheep blood and McConkey agar within one hour of the collection (or immediately put in a refrigerator to be plated within 24 h) and Gram staining of urine samples

> 10⁵ organisms/ml of urine

Brown KH et al. 1981 [52]

Marasmus, marasmic kwashiorkor or kwashiorkor

Severe malnutrition including marasmus (57.1%), marasmic kwashiorkor (28.6%) and kwashiorkor (14.3%).

Suprapubic aspiration or freshly voided specimen

Microscopy and culture (details not specified)

≥10⁵ colonies/ml of urine (mid-stream) or ≥ 1 organism (suprapubic aspiration)

Morton RE et al. 1982 [40]

Kwashiorkor or marasmus

Severe malnutrition, including kwashiorkor (52.3%) and marasmus (47.7%).

Suprapubic aspiration and mid-stream urine.

Culture using McConkey and blood agar for 18 h

Any growth from suprapubic aspiration or ≥ 10⁵ from mid-stream urine

Berkowitz FE 1983 [15]

Marasmus, marasmic kwashiorkor and kwashiorkor

Severe malnutrition including kwashiorkor (68%), marasmus (12%) and marasmic Kwashiorkor (20%).

Suprapubic aspiration

Microscopy and culture (details not specified).

≥One organism/ml of urine

Oyedeji G 1989 [39]

Marasmus, kwashiorkor or marasmic kwashiorkor, plus at least one feature of the disease compelling hospitalization (severe dermatoses with extensive wet areas, severe edema, intractable diarrhea, intolerance of oral fluids and feeds, hypothermia and severe mental apathy)

Severe malnutrition, including kwashiorkor (67.1%) and marasmic Kwashiorkor (32.9%).

mid-stream urine or suprapubic tap

microscopy, culture (details not specified) and sensitivity

Not specified

Isaack H et al. 1992 [44]

Marasmus, marasmic kwashiorkor or kwashiorkor

Severe malnutrition including marasmus (55.5%), kwashiorkor (23.8%) and marasmic kwashiorkor (20.7%).

Not specified

Urine culture using Mc Conkey’s and blood agar

Not specified

Kala UK et al. 1992 [13]

Underweight, marasmus, kwashiorkor or marasmic kwashiorkor

All forms of malnutrition including underweight (29.3%), marasmus (13.3%), kwashiorkor (41.3%) and marasmic kwashiorkor (16%)

Suprapubic aspiration

Dip-slide cultures (Uricult®-Boehringer Mannheim and incubated at 37 degrees C for 24-48 h) and microscopy

Presence of any growth on dip-slide culture

Ighogboja et al. 1993 [38]

Marasmus, kwashiorkor or Marasmic-kwashiorkor

Severe malnutrition, including marasmic kwashiorkor (46.2%), kwashiorkor (29.2%) and marasmus (24.6%).

Mid-stream urine or suprapubic tap

Microscopy, culture (medium not specified) and sensitivity

Not specified

Shimeles D et al. 1994 [16]

Marasmus, Marasmic-Kwashiorkor or Kwashiorkor

Severe malnutrition, including marasmus (48.9%), kwashiorkor (18.9%) and marasmus (32.2%).

Suprapubic aspiration or sterile bags

Microscopy and culture (details not specified)

Not specified

Reed P et al. 1995 [14]

Nutritional dwarfism, kwashiorkor, marasmus or Marasmic Kwashiorkor

All including kwashiorkor (53.7%), nutritional dwarfism (32.8%), marasmus (8.2%) and marasmic kwashiorkor (5.2%).

Suprapubic aspiration

Dipstick urinalysis for leukocytes and nitrites using Combur-9 strips (Boehringer Mannheim); Culture in cystine lactose electrolyte deficient medium, blood agar and McConkey agar (Bio Lab media, Merck Ltd., Johannesburg) incubated at 37 degrees overnight; Antimicrobial Sensitivity using Kirby-Bauer disk-diffusion method.

Any growth from suprapubic aspiration

Ekanem EE et al. 1997 [37]

Kwashiorkor, marasmus or marasmic-kwashiorkor

Severe malnutrition including kwashiorkor (51.9%), marasmus (25.9%) and marasmic-kwashiorkor (22.2%)

Not specified

Urine culture (medium not specified)

Not specified

Caksen H et al. 2000 [46]

Weight for age below the 90th percentile (Grade I: 76–90% or Grade II: 61–75% or Grade III: < 60%)

Mild to severe malnutrition (100%)

Not specified

microscopy and culture (details not specified)

≥10⁵ colonies/ml of urine with the same organism

Rabasa AI et al. 2002 [11]

Marasmus, marasmic kwashiorkor and kwashiorkor

Severe malnutrition including marasmus (67%), marasmic kwashiorkor (13.4%) and kwashiorkor (19.6%).

Suprapubic aspiration

Culture on McConkey’s agar, cysteine lactose electrolyte deficient medium and incubated 18-24 h at 37.1 °C and sensitivity using the disc method

≥One organism/ml of urine.

Russell B et al. 2004 [55]

Weight loss resulting in downwards crossing of two major percentile lines or no weight gain (weight and weight for age z-score)

Mild/ moderate/ severe (76% gained no weight in the past 2–3 months, and 24% crossed down two major percentile lines)

Not specified

Not specified

Not specified

Noorani N et al. 2005 [43]

Kwashiorkor, marasmus or marasmic-kwashiorkor

Severe malnutrition including kwashiorkor (22%), marasmus (66%), and marasmic-kwashiorkor (12%)

Suprapubic aspiration

Urine culture using CLED medium incubated overnight and sensitivity using diffusion technique

Not specified

Bachou H et al. 2006 [42]

Presence of edema and/or weight for height z score > −3 of the NCHS/WHO reference values

Severe malnutrition including severe wasting (45.4%) and edematous malnutrition (54.6%)

Not specified

Urine culture and sensitivity

Not specified

Okomo UA et al. 2011 [19]

Very low weight for height (below −3z scores of the median NCHS/WHO growth standards, visible severe wasting, or the presence of nutritional edema.

Severe acute malnutrition (32.1% had edema with or without weight for height below -3SD)

Suprapubic aspiration (if < 12 months) or urethral catheterization or clean-catch sample (children > 12 months or in cases of dry suprapubic tap).

Microscopy, culture (cysteine lactose electrolyte deficient (CLED) agar incubated overnight at 37 degrees) and sensitivity

≥10⁵ colonies/ml of urine (mid-stream) or ≥ 1 organism/ml of urine (suprapubic aspiration)

Suliman OSM et al. 2011 [45]

Kwashiorkor, marasmus or marasmic-kwashiorkor

Severe malnutrition including marasmus (46.9%), marasmic-kwashiorkor (34.7%) and kwashiorkor (18.4%)

Not specified

Urine microscopy, culture, and sensitivity

≥Five pus cells/HPF and/or positive cultures

Page A et al. 2013 [13]

Weight-for-height < 3z scores of the median WHO growth standards and/or mid-arm circumference, 110 mm and/or bipedal edema. Complicated malnutrition if accompanied by anorexia and/or Kwashiorkor with bilateral pitting edema and/or another severe condition.

Severe malnutrition with 15.4% being edematous

Foley catheter

Dipstick urinalysis, Culture using CHRO Magar inoculation plate and sensitivity using Kirby Bayer disk diffusion method on Mueller-Hinton agar.

Single pathogen ≥10⁴/ml (Escherichia coli) or ≥ 10⁵/ml (others) regardless of the number of leukocytes in urine OR bacteriuria ≥10³/ml (Escherichia coli) or 10⁴/ml (others in the presence of at least 10⁴ leukocytes/ml in the urine

Sameen I and Moorani N 2014 [50]

Weight for height Z scores (below -3 SD with or without bilateral pitting edema and any of the following: anorexia, severe anemia, high fever, severe dehydration, and systemic infection.

Severe malnutrition including severe wasting (80.8%) and edematous malnutrition (19.2%)

Not specified

Urine culture and sensitivity

Not specified

Ahmed M et al. 2015 [18]

Weight-for-height < 3 SD of the z score according to WHO Classification (Mild (−1 SD) or moderate (−2 SD) or severe (−3SD)

All. Mild (36.6%), moderate (19.2%) and severe (44.3%)

Mid-stream urine (if > 24 months) or suprapubic aspiration (if < 24 months)

Culture (cysteine lactose electrolyte deficient agar (CLED), MacConkey and blood agar plates (Oxoid UK) incubated at 37 degrees for 24 h. Drug susceptibility using disc diffusion method

Any growth from suprapubic aspiration or ≥ 10⁵/ml of mid-stream urine

Anjum M et al. 2016 [51]

Presence of bilateral pitting edema or weight for height z score > − 3 of the NCHS/WHO reference values

Severe malnutrition including marasmus (82%) and edematous malnutrition (18%)

Not specified

Microscopy and culture

Not specified

Thuo N et al. 2017

Pedal edema (kwashiorkor or marasmic kwashiorkor) or weight for height Z score ≤ − 3 or mid-arm circumference < 11 cm (if length > 65 cm)

Severe (36% with edema)

Mid-stream urine

Microscopy, culture in cystine lactose electrolyte deficient agar at 37 degrees and sensitivity

Growth of a single pathogen at ≥50 colony forming units/μl

Case-control studies

Buchanan N et al. 1971 [34]

Atrophic malnutrition or kwashiorkor

Moderate/severe malnutrition including kwashiorkor: (33.3%) and atrophic malnutrition: (66.7%)

midstream urine or sterile urine bags or suprapubic aspiration

Uricult dip-slide (nutrient agar on one side and McConkey’s agar on the other side, each medium covering 13 cm² slide area) incubated at 37 °C for 16–24 h. Confirmation using conventional pour plate method for suprapubic urine specimen

> 10⁵ organisms/ml of urine

Freyre EA et al. 1973 [56]

Marasmus, Marasmic Kwashiorkor or Kwashiorkor

Severe malnutrition including marasmus (39%), kwashiorkor (20%) and marasmic kwashiorkor (41%).

Sterile plastic urine collector

Culture using the Henrich method

≥10⁵ colonies/ml of urine

Bodaghi E et al.1978 [54]

Less than 75% standard weight for age (Grade I: 70–75%; Grade II: 60–70%; Grade III: 50–60%; Grade IV: 40–50%)

Mild /moderate /severe including Grade I (20%), Grade II (20%), Grade III (33%) and Grade IV (27%)

Sterile urine bags

Culture on blood, nutrient and eosin methylene blue agar media

2–3 consecutive specimen revealing 10⁵ colonies/ml of urine with the same organism of the same serotype

Banarpurmath C et al. 1994

Weight for age of < 60% (Grade I: 71–80% or Grade II: 61–70% or Grade III: 51–60% or Grade IV: < 50%)

Severe malnutrition including Grade III (70.5%) and Grade IV (29.5%).

Suprapubic aspiration (children < 3 years old) and mid-stream urine (> 3 years)

Direct microscopic examination, gram stain, and culture (details not specified)

≥10⁵ colonies/ml of urine (mid-stream) or ≥ 1 organism (suprapubic aspiration)

Jeena PM et al. 1995 [36]

Protein-energy malnutrition defined according to conventional clinical features

All (groups not specified)

Urethral catheterization, suprapubic aspiration or clean-catch sample

microscopy, culture, and sensitivity

≥10⁵ colonies/ml of urine (mid-stream or clean catch) or > 10³ organisms (suprapubic aspiration);

Caksen H et al. 2001 [47]

Weight for age below the 90th percentile (Grade I: 76–90% or Grade II: 61–75% or Grade III: < 60%)

Mild to severe malnutrition (combined Grade I-III: 31%)

Sterile urine bags

Urine microscopy and culture (sheep agar and eosin methylene blue agar plates incubated at 35 °C for 24–48 h)

Two consecutive specimens revealing 10⁵ colonies/ml of urine with the same organism

Bagga A et al. 2003 [4]

< 80% weight for age (Grade I: 71–80% or Grade II: 61–70% or Grade III: 51–60% or Grade IV: < 50%)

Moderate/ severe, including Grade II (49.1%), Grade III (45.5%) and Grade IV (5.4%).

Suprapubic tap or clean-catch

Microscopy (WBC counting using a Neubauer counting chamber; and Gram staining) and culture

Any growth on urine specimen collected by suprapubic aspiration or > 10⁵ organisms/ml of clean-catch urine

Gopal G and Premalatha R 2014 [49]

Less than 70% of the expected weight for age (Grade II: 60–69.9% or Grade III: 50–59.9% or Grade IV: < 50%)

Moderate to severe malnutrition including Grade II (34%), Grade III (37%) or Grade IV (29%) malnutrition

Suprapubic aspiration (if < 36 months) and clean catch (if ≥36 months)

Urine microscopy and culture (culture medium not specified)

> 5 pus cells/high power field or a positive urine culture