Diagnosis & treatment of acute UTI in pregnancy

Q.1:Kinds of UTI in pregancy?? Ans:-Urinary infections are the most common bacterial infections encountered during pregnancy. They are of three types: one is A) asymptomatic bacteriuria, which has a prevalence of 2% to 7% depending on the population studied; and secondly symptomatic infections that include B) cystitis C) pyelonephritis.

Q.2: What causes urinary infection more prone in pregancy?? Ans:-Normal pregnancy-induced urinary stasis and vesico ureteral reflux predispose to these infections. The invading organisms are those from the normal perineal flora, and about 10% of women have perineal coloniza­tion with strains of E. coli that have adhesins such as S- or P-fimbriae. These appendages enhance bacterial virulence, and indeed, 90% of E. coli isolates from women with acute pyelonephritis have these fimbriae.  One note of caution!! If there is nonsignificant growth in MSU or say mixed growth may not be accepted by the concerned clinician .But many of favour initiating prophylaxis  therapy if C/S report exhibit such doubtful growth  .Ideally such dubious C/S report should be repeated,

Q. 3: Why it is important to treat asymtomatic bacteriuria, in pregancy?? Ans:-Because one-fourth of pregnant women with untreated asymptomatic bacteriuria go on to develop acute pyelonephritis. This is the rationality of early prenatal screening for ASB (asymptomatic bacteriuria) , AS such, routine Urine RE & C/S is recommended even in first antenatal visit though cost of such tets in our country is very high. However, when the colony count exceeds 1,00,000/ml of unspun urine then eradication of offending bacteria is recommended . I personally have no knowledge on the dipstick culture technique which I was told is less costly and seems to be reasonable accurate.

Q. 4 : ABC of  acute pyelonephritis??  The incidence of acute pyelonephritis during pregnancy is reported to be as high as 4%. .Pyelonephritis is more common after mid­pregnancy and it is right-sided in about half of cases and bilateral in another fourth. The onset is usually abrupt with fever, shaking chills and pain in one or both lumbar regions. There may be anorexia, nausea and vomiting. Tenderness usually can be elicited by percussion in one or both costovertebral angles.

Q.5: How best to select drugs for ASB?? Bacteriuria or cystitis is treated as per Urine C/S though initially many of us empirically initiate therapy if there too many pus cells in routine examination. Asymptomatic bacteriuria. Many of us use any one of the five known antibiotics for 3 days only and insist on monthly follow up ( about 15% will have rec UTI inspite of early diagnosis  & apt treatement in first trimester). However, as soon as routine report is available and diagnosis of ASB is reasonably certain.  One of the commonly known antimi­crobial regimens that include single-dose or better still 3-day treatment with 1) ampicillin or 2) amoxicillin; 3) one kind of  cephalosporins (say cefadroxil BD) or 4) nitrofurantoin 100 mg TDS for 3- 5 days(to be avoided in third trimester). ; or trimethoprim-sulfamethoxazole.  Trimethpoprim is a  good agent(septran) but should not be  uesd in first trimester.

. 7: What is the recurrence rate of ASB/ acute Cystitis / acute Pyelonephritis ?? Ans; Regardless of the regimen chosen, the recurrence rate is about 30% after completion of any of these regimens. For women with a recurrent infection, a second course with the same or another one of these agents is given. For women with persistent bacteriu­ria, or those with frequent recurrences, suppressive therapy for the remain­der of pregnancy can be given with nitrofurantoin, 100 mg at bedtime.

1    Q. 9:- How best to treat of acute Pyelonephritis?? Ans: Better to adnit her > Hospitalization>) Hydration with intravenous crystalloid solutions and B) parenteral antimicrobials is the cornerstone of therapy and is begun promptly at diagnosis. Intravenous antimicrobial therapy Switch to oral antimicrobials when afebrile/ . In addition:- Rpt Urine culture; blood culture if overtly septic,Haemogram, serum creatinine and electrolytes, Monitor vital signs frequently, including urinary output with indwelling bladder catheter Intravenous crystalloid to establish urinary output to &50 ml/h

2    Chest x-ray if there is dyspnea or tachypnea

3    Repeat hemogram and creatinine in 48 hours

4     Discharge when afebrile 24 hours, give antimicrobial therapy for 7 to 10 days

5     Urine culture 1 to 2 weeks after antimicrobial therapy completed

: - A Therapy is empirical, and ampicillin plus gentamicin; cefazolin or ceftriaxone; or an extended-spectrum beta-lactam have been found to be 95% effective in randomized trials.

Can there be worsening in spite of I V antibiotics and admission?? Ongoing surveillance in an acute care unit is recommended in order to recognize worsening of sepsis syn­drome. To do so, frequent determinations of vital signs and urinary output are monitored. Clinical response is usually relatively prompt and clinical symptoms usually resolve within 2 days and 95% of women are afebrile by 72 hours. However , for those who do not respond promptly and appropriately, consideration is given for urinary tract obstruction, usually from stone disease, and imaging studies may be indicated. At discharge, oral antimicrobial therapy is given for 7 to 10 days.

Rare & rare in mid/ late trimester : Pyrexia or evidence of sepsis without pyrexia(unexplained shock like syndrome) –The rare cause is  antepartum pyelonephritis are caused by the sepsis syndrome. Between 5 and 20% of women will manifest reversible acute kidney injury manifest by elevated serum creat­inine levels. In some of these, it may be necessary to modify dosing with potentially nephrotoxic antimicrobials such as amnioglycosides.

Rare and Rare:   Up to 5 to 10% of women with acute pyelonephritis develop varying degrees of acute respiratory distress syndrome. In some of these, tracheal intubation with mechanical ventilation is lifesaving.

Rare & Rare : can irritable uterus or increased tonicity or say painful ut contraction in early third trimester be due to Acute severe UTI(acute pyelonephritis)?? Ans; Not impossible.  After midpregnancy, septicemia may cause uterine activity, but caution is urged for co-administration of tocolytics that may increase the risk of permeability pulmonary edema. Finally, persistence of the sepsis syndrome should prompt a search for ureteral obstruction as well as for a perinephric phlegmon or abscess. Endotoxin-induced hemolysis causes anemia in about a third of women.

Q. 14: How common is recurrence?? Ans:-Recurrent covert bacteriuria develops in about a third of women following treatment for pyelonephritis. Because a third of these will again develop recur­rent symptomatic infection, then asymptomatic bacteriuria is treated again as described above. Unless urine culture surveillance is performed to ensure urine sterility, then nitrofurantoin, 100 mg at bedtime, is given for the remainder of the pregnancy.

The urinary sediment usually contains many leu­kocytes, frequently in clumps, and numerous bacteria. E. coli strains are isolated from urine cultures in 75 to 80% of women with pyelonephri­tis. The other isolates include Klebsiella, Enterobacter or Proteus species or group B streptococci. Women with acute pyelonephritis usually appear quite ill, and bacteremia is confirmed in 15 to 20%.