Why not unnecessary use of Fluoroquinolones when alt agents are
available?? Fluoroquinolones
(levofloxacin or moxifloxacin), bedaquiline and and linezolid are strongly
recommended for use in longer regimens, which are completed with other drugs
ranked by their relative balance of effectiveness to potential toxicity.
|
Group A :
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Group B :
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Group C :
|
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Levofloxacin (Lfx) or
Moxifloxacin (Mfx) |
Clofazimine (Cfz)
|
Ethambutol (E)
|
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Bedaquiline (Bdq)
|
Cycloserine (Cs)
or Terizidone (Trd) |
Delamanid (Dlm)
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Linezolid (Lzd)
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Pyrazinamide (Z)
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Imipenem-cilastatin (Ipm-Cln) or
Meropenem (Mpm) |
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Amikacin (Am) (or Streptomycin)
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Ethionamide (Eto) or Prothionamide (Pto)
|
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p-aminosalicylic acid (PAS)
|
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Second line drugs used to
treat rifampicin resistant and multi
drug resistant TB after December 2018
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If a plus sign is shown,
clicking on it will show more columns.
All three medicines in Group
A should be included.
In group B one or both medicines should be included
Group C medicines should be included to complete the regimen when medicines from Groups A and B cannot be used.
In group B one or both medicines should be included
Group C medicines should be included to complete the regimen when medicines from Groups A and B cannot be used.
There is some further information about this on the page on
the Treatment
of Drug Resistant TB, and there is extensive information which should
be consulted in the WHO guidelines document.
Second line drugs,
recommendations after 2016 and before 2018
In 2016 WHO changed their recommendations on the second line drugs
to be used for the treatment of drug resistant TB.2. The
second line drugs to be used for the treatment of drug resistant TB after 2016
were as follows.
|
Group A : Fluoroquinolones
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Group B : Second line
injectable drugs
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Group C : Other core
second line drugs
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Group D : Add-on drugs
(not part of the core MDR-TB regimen)
|
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Levofloxacin (Lfx)
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Amikacin (Am)
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Ethionamide/Prothionamide (Eto/Pto)
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D1 Pyrazinamide
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Moxifloxacin (Mfx)
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Capreomycin (Cm)
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Cycloserine / Terizidone (Cs Trd)
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D1 Ethambutol (E)
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Gatifloxacin (Gfx)
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Kanamycin (Km)
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Linezolid (Lzd)
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D1 High-dose isoniazid (Hh)
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(Streptomycin)
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Clofazimine (Cfz)
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D2 Bedaquiline (Bdq)
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D2 Delamanid (Dlm)
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D3 p-aminosalicylic acid PAS)
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D3 imipenem-cilastatin (lpm)
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D3 Meropenem (Mpm)
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D3 Amoxicillin-clavulanate (Amx-Clv)
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D3 Thioacetazone (T)
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Groups A, B & C are the
core second line drugs.
If a plus sign is shown,
clicking on it will show more columns.
Q.14:- How many days tr for asys bact? Only 3 days will suffice even
before C//S are awaited . The blind choice will be ether Amoxicillin, or cephalosporins.
Q.15:How to treat acute cystitis?? Wait till C.S report to arrive, Penciling,
Cephalosporin, Nitrofurantoin should be used. Till report are available
(Source: Hand book of Obstetric Medicine “ 5th Edition: Ed Catherine Nelson –Piercy:: Consultant Obstet physician & Professor of Kings College London)-low Priced
very useful book) May procure from CBC
Press: Taylors & Fancin Group. 2013 Ed, ) Original publisher Taylor &
Francis, ISNBN: 13-978-1-4987-8431-3.)
Why an old topic like UTI in preg?? : The Pathogenesis of UTI:-
Pregnant women are at increased risk for UTIs. Beginning in week 6
and peaking during weeks 22 to 24, approximately 90 percent of pregnant women
develop urethral dilatation, which will remain until delivery (hydronephrosis
of pregnancy). Increased bladder volume and decreased bladder tone, along with
decreased urethral tone, contribute to increased urinary stasis and
ureterovesical reflux.1 Additionally, the physiologic increase in plasma volume during
pregnancy decreases urine concentration. Up to 70 percent of pregnant women
develop glycosuria, which encourages bacterial growth in the urine. Increases
in urinary progestins and estrogens may lead to a decreased ability of the
lower urinary tract to resist invading bacteria. This decreased ability may be
caused by decreased urethral tone or possibly by allowing some strains of
bacteria to selectively grow.These factors may all contribute to the
development of UTIs during pregnancy.
Urinary tract infections (UTIs) are frequently encountered in the
family physician's office. UTIs account for approximately 10 percent of office
visits by women, and 15 percent of women will have a UTI at some time during
their life. In pregnant women, the incidence of UTI can be as high as 8
percent.1,2 This article briefly examines the
pathogenesis and bacteriology of UTIs during pregnancy, as well as
patient-oriented outcomes. We review the diagnosis and treatment of
asymptomatic bacteriuria, acute cystitis and pyelonephritis, plus the unique
issues of group B streptococcus and recurrent infections.. Urinary tract
infections are common during pregnancy, and the most common causative organism
is Escherichia coli. Asymptomatic bacteriuria can lead to the
development of cystitis or pyelonephritis.
.
.
Diagnosis and Treatment of
UTIs:-
UTIs have three principle presentations: asymptomatic bacteriuria,
acute cystitis and pyelonephritis. The diagnosis and treatment of UTI depends
on the presentation.
ASYMPTOMATIC
BACTERIURIA
Significant bacteriuria may exist in asymptomatic patients. In the
1960s, researchers noted the subsequent increased risk of developing
pyelonephritis in patients with asymptomatic bacteriuria. Significant
bacteriuria has been historically defined as finding more than 105 colony-forming
units per mL of urine.7 Recent studies of women with acute dysuria have shown the
presence of significant bacteriuria with lower colony counts. This has not been
studied in pregnant women, and finding more than 105 colony-forming
units per mL of urine remains the commonly accepted standard. Asymptomatic
bacteriuria is common, with a prevalence of 10 percent during pregnancy.. Thus,
routine screening for bacteriuria is advocated.
Untreated asymptomatic bacteriuria leads to the development of
symptomatic cystitis in approximately 30 percent of patients and can lead to
the development of pyelonephritis in up to 50 percent. Asymptomatic
bacteriuria is associated with an increased risk of intra-uterine growth
retardation and low-birth-weight infants.9 The relatively high prevalence of asymptomatic bacteriuria
during pregnancy, the significant consequences for women and for the pregnancy,
plus the ability to avoid sequelae with treatment, justify screening pregnant
women for bacteriuria.
How to screen Asym Bacteriuia ?? SCREENING MODALITY
The American College of Obstetrics and Gynecology recommends that a
urine culture be obtained at the first prenatal visit.10 A repeat urine culture should be obtained during the third
trimester, because the urine of treated patients may not remain sterile for the
entire pregnancy. The recommendation of the U.S. Preventative Services
Task Force is to obtain a urine culture between 12 and 16 weeks of gestation
(an “A” recommendation).
By screening for and aggressively treating pregnant women with asymptomatic
bacteriuria, it is possible to significantly decrease the annual incidence of
pyelonephritis during pregnancy.8,12 In randomized controlled trials,
treatment of pregnant women with asymptomatic bacteriuria has been shown to
decrease the incidence of preterm birth and low-birth-weight infants.13
Rouse and colleagues14 performed a cost-benefit analysis of screening for bacteriuria
in pregnant women versus inpatient treatment of pyelonephritis and found a
substantial decrease in overall cost with screening. The cost of screening for
bacteriuria to prevent the development of pyelonephritis in one patient was
$1,605, while the cost of treating one patient with pyelonephritis was as much
as $2,485. Another researcher performed a similar analysis in a family practice
obstetric population and found screening for asymptomatic bacteriuria to be
cost-effective.
Q,10 How best to screen for bacteria ,Which method? At clinic or to
send to lab(high cost). Clinic method is pt friendly(need not go to Lab which
may be 1-5 km from her residence and multiple visits , But the drawback of clinic tegs for Asymp bacteriuta are the
false negative rate are high . Therefore accuracy of faster screening methods
(e.g., leukocyte esterase dipstick, nitrite dipstick, urinalysis and urine Gram
staining) has been evaluated. Time and again researchers have compared
these screening methods with urine
culture and found that while it was more cost effective to screen for
bacteriuria with the esterase dipstick for leukocytes, only one half of the
patients with bacteriuria were identified compared with screening by urine
culture. The increased number of false negatives and the relatively poor
predictive value of a positive test make the faster methods less useful; The decision about how to screen asymptomatic
women for bacteriuria is a balance between the cost of screening versus the
sensitivity and specificity of each test. The gold standard for detection of
bacteriuria is urine culture, but this test is costly and takes 24 to 48 hours
to obtain results. therefore, a urine culture should be routinely obtained in
pregnant women to screen for bacteriuria at the first prenatal visit and during
the third trimester.
Accuracy of Screening Tests for Asymptomatic Bacteriuria
The rightsholder did not grant rights to reproduce
this item in electronic media. For the missing item, see the original print
version of this publication.
TREATMENT
of UTI in pregnacy:
Pregnant women should be treated when bacteriuria is identified. The
choice of antibiotic should address the most common infecting organisms (i.e.,
gram-negative gastrointestinal organisms). The antibiotic should also be safe
for the mother and fetus. Historically, ampicillin has been the drug of choice,
but in recent years E. coli has become
increasingly resistant to ampicillin. Ampicillin
resistance is found in 20 to 30 percent of E. coli cultured from urine in the out-patient setting.
Nitrofurantoin is a good choice because of its high urinary
concentration. Alternatively, cephalosporins are well tolerated and adequately
treat the important organisms. Fosfomycin (Monurol) is a new antibiotic that is
taken as a single dose. Sulfonamides can be taken during the first and second
trimesters but, during the third trimester, the use of sulfonamides carries a
risk that the infant will develop kernicterus, especially preterm infants.
Other common antibiotics (e.g., fluoroquinolones and tetracycline) should not
be prescribed during pregnancy because of possible toxic effects on the fetus.
Antibiotic Choices for Treatment of UTIs During Pregnancy
|
ANTIBIOTIC
|
PREGNANCY CATEGORY
|
DOSAGE
|
|
1)Cephalexin (Keflex)
|
B
|
250 mg two or four times daily
|
|
2) Erythromycin
|
B
|
250 to 500 mg four times daily
|
|
3) Nitrofurantoin (Macrodantin)
|
B
|
50 to 100 mg four times daily
|
|
4) Sulfisoxazole (Gantrisin)
*—Contraindicated in pregnant women at term.
|
C*
|
1 g four times daily
|
|
5) Amoxicillin-clavulanic acid (Augmentin)
|
B
|
250 mg four times daily
|
|
6) Fosfomycin (Monurol)
|
B
|
One 3-g sachet
|
|
7) Trimethoprim-sulfamethoxazole (Bactrim)
Avoid during first trimester and at term.
|
C†
|
160/180 mg twice daily
|
*—Contraindicated in pregnant women at term.
†—Avoid during first trimester and at term.
Information from Duff P. Antibiotic selection for infections in
obstetric patients. Semin Perinatol 1993;17:367–78, and Krieger JN.
Complications and treatment of urinary tract infections during pregnancy. Urol
Clin North Am 1986;13:685–93.
How many days tr?? A seven- to 10-day course of antibiotic treatment
is usually sufficient to eradicate the infecting organism(s). Some authorities
have advocated shorter courses of treatment—even single-day therapy.
Conflicting evidence remains as to whether pregnant patients should be treated
with shorter courses of antibiotics. Masterton21 demonstrated a cure rate of 88 percent with a single 3-g dose
of ampicillin in ampicillin-sensitive isolates. Several other studies have
found that a single dose of amoxicillin, cephalexin (Keflex) or nitrofurantoin
was less successful in eradicating bacteriuria, with cure rates from 50 to 78
percent. Fosfomycin is effective when taken as a single, 3-g sachet.
Other antibiotics have not been extensively researched for use in
UTIs, and further studies are necessary to determine whether a shorter course
of other antibiotics would be as effective as the traditional treatment length.1 After patients have completed the treatment regimen, a repeat
culture should be obtained to document successful eradication of bacteriuria.10
Acute Cystitis
Acute cystitis is distinguished from asymptomatic bacteriuria by the
presence of symptoms such as dysuria, urgency and frequency in afebrile
patients with no evidence of systemic illness. Up to 30 percent of patients
with untreated asymptomatic bacteriuria later develop symptomatic cystitis.
6Over a six-year period, Harris and Gilstrap25 found that 1.3 percent of obstetric patients who delivered at
a single hospital developed acute cystitis with no symptoms of pyelonephritis.
TREATMENT
In general, treatment of pregnant patients with acute cystitis is
initiated before the results of the culture are available. Antibiotic choice,
as in asymptomatic bacteriuria, should focus on coverage of the common
pathogens and can be changed after the organism is identified and sensitivities
are determined. A three-day treatment course in nonpregnant patients with acute
cystitis has a cure rate similar to a treatment course of seven to 10 days, but
this finding has not been studied in the obstetric population.1 Patients treated for a shorter time frame are more likely to
have a recurrence of the infection. In the pregnant patient, this higher rate
of recurrence with shorter treatment periods may have serious
consequences. ble 217 lists oral
antibiotics that are acceptable treatment choices. Group B streptococcus is
generally susceptible to penicillin, but E. coli and other
gram-negative rods typically have a high rate of resistance to this agent.
Diag and Tr of Pyelonephritis
Acute pyelonephritis during pregnancy is a serious systemic illness
that can progress to maternal sepsis, preterm labor and premature delivery. The
diagnosis is made when the presence of bacteriuria is accompanied by systemic
symptoms or signs such as fever, chills, nausea, vomiting and flank pain.
Symptoms of lower tract infection (i.e., frequency and dysuria) may or may not
be present. Pyelonephritis occurs in 2 percent of pregnant women; up to 23
percent of these women have a recurrence during the same pregnancy. Early,
aggressive treatment is important in preventing complications from
pyelonephritis. Hospitalization, although often indicated, is not always
necessary. However, hospitalization is indicated for patients who are
exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and
who are having contractions. A randomized study of 90 obstetric inpatients with
pyelonephritis compared treatment with oral cephalexin to treatment with
intravenous cephalothin (Keflin) and found no difference between the two groups
in the success of therapy, infant birth weight or preterm deliveries.
Further support for outpatient therapy is provided in a randomized
clinical trial that compared standard inpatient, intravenous treatment to
outpatient treatment with intramuscular ceftriaxone (Rocephin) plus oral
cephalexin.. Response to antibiotic therapy in each group was similar,
with no evident differences in the number of recurrent infections or preterm
deliveries.
Antibiotic therapy (and intravenous fluids, if hospitalization is
required) may be initiated before obtaining the results of urine culture and
sensitivity. Several antibiotic regimens may be used. A clinical trial
comparing three parenteral regimens found no differences in length of
hospitalization, recurrence of pyelonephritis or preterm
delivery. Patients in this trial were randomized to receive treatment with
intravenous cefazolin (Ancef), intravenous gentamycin plus ampicillin, or
intramuscular ceftriaxone.
Parenteral treatment of pyelonephritis when ?? Ans:-Parenteral
treatment of pyelonephritis should be continued until the patient becomes
afebrile. Most patients respond to hydration and prompt antibiotic treatment
within 24 to 48 hours. The most common reason for initial treatment failure is
resistance of the infecting organism to the antibiotic. If fever continues or
other signs of systemic illness remain after appropriate antibiotic therapy,
the possibility of a structural or anatomic abnormality should be investigated.
Persistent infection may be caused by urolithiasis, which occurs in one of
1,500 pregnancies, or less commonly, congenital renal abnormalities or a
perinephric abscess.
What are the diagnostic tests of
UTI , Asympp UTI in particular?? ? Diagnostic tests may include
renal ultrasonography or an abbreviated intravenous pyelogram. The indication
to perform an intravenous pyelogram is persistent infection after appropriate
antibiotic therapy when there is the suggestion of a structural abnormality not
evident on ultrasonography.30Even the low-dose radiation involved in an intravenous pyelogram,
however, may be dangerous to the fetus and should be avoided if possible.
Special Tr of Group B Streptococcal
Infection
Group B streptococcal (GBS) vaginal colonization is known to be a
cause of neonatal sepsis and is associated with preterm rupture of membranes,
and preterm labor and delivery. GBS is found to be the causative organism in
UTIs in approximately 5 percent of patients. Evidence that GBS bacteriuria
increases patient risk of preterm rupture of membranes and premature delivery
is mixed.34 A randomized, controlled trial35 compared the treatment of GBS bacteriuria with penicillin to
treatment with placebo. Results indicated a significant reduction in rates of
premature rupture of membranes and preterm delivery in the women who received
antibiotics. It is unclear if GBS bacteriuria is equivalent to GBS vaginal
colonization, but pregnant women with GBS bacteriuria should be treated as GBS
carriers and should receive a prophylactic antibiotic during labor.
Recurrence and Prophylaxis
The majority of UTIs are caused by gastrointestinal organisms. Even
with appropriate treatment, the patient may experience a reinfection of the
urinary tract from the rectal reservoir. UTIs recur in approximately 4 to 5
percent of pregnancies, and the risk of developing pyelonephritis is the same
as the risk with primary UTIs. A single, postcoital dose or daily suppression
with cephalexin or nitrofurantoin in patients with recurrent UTIs is effective
preventive therapy. A postpartum urologic evaluation may be necessary in
patients with recurrent infections because they are more likely to have
structural abnormalities of the renal system. Patients who are found to have
urinary stones, who have more than one recurrent UTI or who have a recurrent
UTI while on suppressive antibiotic therapy should undergo a postpartum
evaluation.
Outcomes
The maternal and neonatal complications of a UTI during pregnancy
can be devastating. Thirty percent of patients with untreated asymptomatic
bacteriuria develop symptomatic cystitis and up to 50 percent develop
pyelonephritis. Asymptomatic bacteriuria is also associated with
intrauterine growth retardation and low-birth-weight infants. Schieve and
associates conducted a study involving 25,746 pregnant women and found
that the presence of UTI was associated with premature labor (labor onset
before 37 weeks of gestation), hypertensive disorders of pregnancy (such as
pregnancy-induced hypertension and preeclampsia), anemia (hematocrit level less
than 30 percent) and amnionitis . While this does not prove a cause and
effect relationship, randomized trials have demonstrated that antibiotic
treatment decreases the incidence of preterm birth and low-birth-weight
infants.13 A risk of urosepsis and chronic pyelonephritis was also found.40In addition, acute pyelonephritis has been associated with anemia.
Comparison of Adverse Outcomes in Pregnant Patients Who Developed
UTI During Pregnancy and Those Who Did Not
|
OUTCOME
|
ODDS RATIO
|
95% CONFIDENCE
INTERVAL
|
||
|
Perinatal
|
||||
|
Low birth weight (weight less than 2,500 g [5
lb, 8 oz])
|
1.4
|
1.2 to 1.6
|
||
|
Prematurity (less than 37 weeks of gestation at
delivery)
|
1.3
|
1.1 to 1.4
|
||
|
Preterm low birth weight (weight less than 2,500
g and less than 37 weeks of gestation at delivery)
|
1.5
|
1.2 to 1.7
|
||
|
Maternal
|
||||
|
Premature labor (less than 37 weeks of gestation
at delivery)
|
1.6
|
1.4 to 1.8
|
||
|
Hypertension/preeclampsia
|
1.4
|
1.2 to 1.7
|
||
|
Anemia (hematocrit level less than 30%)
|
1.6
|
1.3 to 2.0
|
||
|
Amnionitis (chorioamnionitis, amnionitis)
|
1.4
|
1.1 to 1.9
|
||
UTI = urinary tract infection.
Information from Pfau A, Sacks TG. Effective prophylaxis for
recurrent urinary tract infections during pregnancy. Clin Infect Dis
1992;14:810–4.
Neonatal outcomes that are associated with UTI include sepsis and
pneumonia (specifically, group B streptococcus infection).31,42 UTI increases the risk of low-birth-weight infants (weight
less than 2,500 g [5 lb, 8 oz]), prematurity (less than 37 weeks of gestation
at delivery) and preterm, low-birth-weight infants (weight less than 2,500 g
and less than 37 weeks of gestation at delivery).
Final Comment
UTIs during pregnancy are a common cause of serious maternal and
perinatal morbidity; with appropriate screening and treatment, this morbidity
can be limited. A UTI may manifest as asymptomatic bacteriuria, acute cystitis
or pyelonephritis. All pregnant women should be screened for bacteriuria and
subsequently treated with appropriate antibiotic therapy. Acute cystitis and
pyelonephritis should be aggressively treated during pregnancy. Oral
nitrofurantoin and cephalexin are good antibiotic choices for treatment in
pregnant women with asymptomatic bacteriuria and acute cystitis, but parenteral
antibiotic therapy may be required in women with pyelonephritis.
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