Treatment of UTI in women-What is indications ,Dilemmas on screening To whom to screen??

Pregancy with UTI in nonpregnant state as well as in pregancy: (preexisting or fresh infection):-An overview by Dr S K Pal (Kolkata) about the one of the most neglected topic of UTI (mostly asymptomatic) –in 5 kinds of cases who come to us as following symptoms:-When to do Urine Exam ?? like A) persistent white discharge, B) Rec white discharge) C)  those who are planning for preg D) waiting for fertility enhancing treatment) & above all routinely to all categories of preg women at booking visit??

Let us have a thread bare discussion on this very common topic. Members are requested to share their experiences please. But such investigations screening for asymptomatic bacteriuria (C/S and the appropriate drugs) :-are to be cost-effective,

Q.1:-Self criticism :-Have we, the practicing Obstetricians ever –asked ourselves about the a) relevance and b) financial feasibility of routine Urine C/s prepreg & early preg including subfertile women or women who suffering from recurrent obstinate White discharge? Have we ever thought what changes the normal vaginal flora or yourself??

Q.2: Is Urine C/S and then choiced antibiotics for Asymp is feasible/ affordable in our motherland? Ans:- Similarly,  workload of Govt hospital microbiologists and Financial commitment by average or poor women (slum dwellers) desirous of preg –the question is can they afford?? If even affordable are the ASHA workers been adequately trained in this tests?? But the fact remains that all women desirous of fertility & pregnant women should be screened for bacteriuria and subsequently treated with antibiotics such as nitrofurantoin, sulfisoxazole or cephalexin. What about ampicillin as written in Text Books?  Ampicillin should no longer be used in the treatment of asymptomatic bacteriuria because of high rates of resistance.

. Q. 3 : Tips on treating UTI (Asymp) in persistent white discharge after excluding DM, fungal infection( hanging drop prepn –Mycellium) ? Ans to Q 4:- In early preg too (booking visit) diagnosis / exclusion of Asymp bact this C/S is very essential. Agreed in preg but why urine C/S in persistent white discharge cases? The reason is ,I may be permitted to say persistent white discharge may be dribbling of few drops of urine in birth canal for days in and out à  may colonize the lower  urethra à ascending up to Cervix even  by the foreign uropathogens à altered ecosystem of vagina & pH in particular, killing natural inhabitant L bacilli. Thus, I Dr Pal , like other specialists do  feel that there is every reason  to believe that if we believe that E coli can crawl in from perineum to  lower urethra and  colonize then why not urine can drop in the birth canal and can spoil the health game of Pregancy. .

Q.5 any member like to differ? Any member having objection to the belief that urethral then why such pathogens from urine can’t go in vagina and can cause distressing whites for months and also Rec abortion /PROM .  Then what is the harm to insist on Urine RE & C/S in cases of persistent white discharge?

Q. 6: Few important tips on Urinary Tract Infections during Pregnancy which all practioner must remember. Ans to Q. 5:  Why Dr Pal is threatening us about relevance of Asymp Bacteriuria time and again? We won’t read his post onwards. That’s not cricket !!  Logic & reasoning :-Asymp Bacteriuria: prevalence at UK is7% of which 40% will develop symptomatic UTI if Asymp bact is left untreated.  But those who have already had preexisting UTI and achieved preg with UTI untreated à (i.e. UTI in nonpreg    state and had conception while Chr UTI untreated ) ===in such  women the chance of having acute infn (acute cystitis/en acute pyelonephritis) as preg advances may result into e acute cystitis will be somewhere 10 fold chance (flare of ) of acute infn both in Asymomtatic  Bact as well as more  prevalence of  & cystitis, in contrast who were treated prior to conception,.

Q: 7: Back to basics : What  is  the  Bacteriology: Varies from country, socio economic status  , ethnicity, personal hygiene, Slum dwellers  ,toilet facilities, napkin use, the basic teaching by mother about maintaing hygiene of vulva & perineum, use of tissue paper about cleaning of anal opening  after each act of defecation  counts.  I am not sure whether my granddaughters are taught about this personal, hygiene by their mothers neither I am aware of what other Lady members of this prestigious group can afford time to teach their toddlers (girls),   and personal immunity. The fact remains that the organism crawls up from perineum is the common source of Lower UTI infection.

 

Q  8:-Where from the thief entered the Bank??  Third etiology of  Asymp bact(after 1) travel of bact/cocci from unclean perineum / 2) dribbling of last few drops of urine in birth canal)   is  rough sexual intercourse more so if husband is infected,(sexual STI or nonsexual STI)

 

Q.9, Forget about Symptomatic UTI with fever, dysuria, burning sensation where diag s obvious. How best to daig nose Asymp  UTI??  Ans to Q 9:-In Asymp bact as per dictum of pathology the colony  count is > 100 000 /mL in a midstream un spun urine. But if colony count is below that the clinician may refer to another lab if she/ he wishes to be doubly sure and if acceptable and affordable by the preg woman.

 

Q. 10: Can we avoid visit to lab and how reliable is clinic test for Asymp bact ?? Ans;- Of note that tets a) Dipstick for nitrites and b)  leukocyte  esterase  are is not that helpful  in to exclude UTI, nowadays. (Source: Hand book of Obstetric Medicine “ 5^th 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.

 

Q.11. :-Which drug to choose blindly as combating common uropathogens::??  How to tr Asymp Bacteriuria: Ans;-Though science dictates that couture report will dictate us   about choice of most effective antibiotics still as an initial agent some drugs have to be used albeit empirically .Such initial   drugs before C/S report are available are the drugs likely) a) Amoxicillin (favourite drug-but repeated use in many indications-say Resp  tract  in childhood –premarital variety of infn have make this drug less effective in  child bearing age,. ), e) All kinds of Cephalosporins are al safe in first trimester, Of note that Cefadroxil or Cefetoxin 500 mg BD are  fortunately effective in most effective for most uropathogens. What about ampicillin? Unfortunately though nearly 100% safe its common use in childhood, like Amoxicillin  now resistant for common use in many diseases

Q. 12 : What about Nitrofurantoin ?? Any caution?? Ans;-Nitrofurantoin are risky in  third trimester as it cases Neonatal hemolytic anemia,

 Q. 13:  Do not get involved in atomic war with your spouse!!! A great caution (should I say a warning from Dr Pal-your elder brother) on use of Levoflaxacillin, moxifloxacin, and gatifloxacin) Even I shall not prescribe these kinds of drugs for PID including  Ofolaxacilin for UTI/ BV /PID/ wound sepsis :