Posted 01-04-20
Drug selection of Acute UTI in pregancy??
Q.1:What are the different
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 : Prtevalence , Treatemnet 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.
UTI Q7: 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 of acute pyelonephritis 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.
Very uncommon complications of UTI in pregancy:-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%.
Management of the pregnant woman with acute pyelonephritis
6 Hospitalization
7 Urine culture; blood culture if
overtly septic
8 Haemogram, serum creatinine and
electrolytes
9 Monitor vital signs frequently,
including urinary output with indwelling bladder catheter
10 Intravenous crystalloid to establish
urinary output to &50 ml/h
11 Intravenous antimicrobial therapy
12 Chest x-ray if there is dyspnea or
tachypnea
13 Repeat hemogram and creatinine in 48
hours
14 Switch to oral antimicrobials when
afebrile
15 Discharge when afebrile 24 hours,
give antimicrobial therapy for 7 to 10 days
16 Urine culture 1 to 2 weeks after
antimicrobial therapy completed
How
to diagnose Cystitis ?? Cystitis typically is characterized by dysuria, urgency and frequency with
minimal manifestations. Infection is confirmed by pyuria, hematuria and
bacteriuria. The upper urinary tract may also become involved by ascending
infection, either with or without concomitant cystitis.
•
Kidney changes in pregancy :-What are the Structural changes:
During pregnancy,
the kidneys increase 1 to 1.5 cm in length and 30% in volume. The collecting
system expands more than 80%, with greater dilation on the right side.
• Mild right-sided physiologic
hydronephrosis is seen as early as 6 weeks of gestation. Renal volume returns
to normal within the first week postpartum, but hydronephrosis and hydroureter
may not normalize until 3 to 4 months after delivery. Elective pyelography
should, therefore, be deferred until at least 12 weeks postpartum.
• These structural changes increase the
risk of pyelonephritis in the setting of asymptomatic bacteriuria or urinary
tract infections.
•
Renal filtration: Blood volume expansion during pregnancy increases renal
plasma flow by 50% to 80%, which in turn results in an increased glomerular
filtration rate (GFR). Increased GFR can be seen within 1 month after
conception, peaking at 40% to 50% above prepregnancy levels by the end of the
first trimester.
• Elevated GFR increases creatinine
clearance, so formulas for GFR based on age, height, and weight do not apply;
creatinine clearance must be calculated with a 24-hour urine collection in
pregnancy.
• Increased GFR results in lower mean
serum blood urea nitrogen (BUN) and serum creatinine during pregnancy (8.5 and
0.46 mg/dL, respectively). A serum creatinine which may be considered normal
outside of pregnancy may suggest renal insufficiency in pregnancy.
•
Renal tubular function: Decreased tubular resorption in pregnancy increases
urinary excretion of electrolytes, glucose, amino acids, and protein.
• Increased calcium clearance is
balanced by increased gastrointestinal (GI) tract absorption. Ionized calcium
remains stable despite decreased total serum calcium because of the lower serum
albumin concentration.
• Physiologic hyponatremia occurs, with
plasma sodium concentration falling by 5 mEq/L during pregnancy. Sodium levels
return to baseline by 1 to 2 months postpartum.
• Urinary excretion of glucose
increases 10- to 100-fold, and glucosuria is observed routinely in normal
pregnancy. Increased urinary glucose increases the risk of bacteriuria and
urinary tract infections.
• Renal resorption of bicarbonate
decreases to compensate for the respiratory alkalosis of pregnancy, lowering
serum bicarbonate by about 5 mEq/L in pregnancy.
•
Routine assessment of renal function: Proteinuria should be assessed at
every prenatal visit. A urine dipstick value > 1 + should prompt further
evaluation by clean-catch urine sample for culture and microscopy. If
proteinuria persists despite negative culture, further evaluation is warranted
and may include either a 24-hour urine protein collection or a random protein
to creatinine ratio. A 24-hour total urine protein exceeding 150 mg is
abnormal.
• Patients with chronic hypertension,
diabetes, preexisting renal disease, or other diseases may have abnormal levels
of proteinuria prior to pregnancy and should undergo a baseline 24-hour urine
protein collection early in pregnancy.
•
Serum
creatinine persistently >0.9 mg/dL should prompt investigation for intrinsic
renal disease. The presence of comorbidities should be assessed and further evaluation
should be considered. Renal biopsy during pregnancy should be considered when
the results will change management before delivery.
Urinary Tract Disorders in Pregnancy Urinary tract infections (UTIs) are common in pregnancy. Urinary
stasis secondary to hydroureter and hydronephrosis, bladder trauma due to
compression or edema, vesicoureteral reflux, and increased glucosuria may all
contribute to the increased risk of infection. Women with two or more UTIs or a
diagnosis of pyelonephritis during pregnancy should be considered for daily
suppressive antibiotic therapy until delivery.
• Asymptomatic bacteriuria (ASB) is the presence of bacteria within
the urinary tract, excluding the distal urethra, without signs or symptoms of
infection. ASB is associated with low-birth-weight infants and preterm
delivery, and its treatment in pregnancy is indicated. The prevalence of ASB
during pregnancy ranges from 2% to 7%. If left: untreated, 20% to 30% of ASB in
pregnant women progresses to pyelonephritis; treatment reduces this to 3%.
•
• Screening for bacteriuria with a
urine culture is recommended at the first prenatal visit. Women with sickle
cell trait have a twofold increased risk of ASB and can be screened every
trimester. °A clean-catch urine culture with >100,000 colonics/mL or
catheterized urine
culture
with >100 colonics/mL warrants treatment.
° Escherichia coli accounts for 75% to 90% of
infections. Klebsiella,
Proteus, Pseudomonas, Enterobacter, and coagulase-negative Staphylococcus are other common pathogens.
Initial therapy is usually empiric
and may be altered based on urine culture sensitivities. Repeat urine culture
is obtained 1 to 2 weeks after treatment and again each trimester. If
bacteriuria persists after two or more treatment courses, suppressive therapy
should be considered for the remainder of the pregnancy.
• Acute cystitis occurs in approximately 1% to 3% of pregnant women. Symptoms include urinary frequency,
urgency, dysuria, hematuria, and/or suprapubic discomfort. Empiric treatment
regimens arc the same as for ASB. If possible, a urine culture should be sent
prior to initiating antibiotic therapy.
• Chlamydial Urethritis is usually caused by Chlamydia trachomatis, and it should be suspected in
patients with symptoms of acute cystitis and a negative urine culture. Mucopurulent
cervicitis may also be present. The treatment of choice is azithromycin 1 g as
a single oral dose for both the patient and her partner. A test of cure should
be sent 3 to 4 weeks after treatment.
is the leading cause of septic shock in pregnancy.
Complications include preterm labor, preterm premature rupture of membranes
(PPROM), bacteremia, sepsis, acute respiratory distress syndrome, and hemolytic
anemia. Prompt diagnosis and treatment of pyelonephritis in pregnancy are
crucial.
•
Symptoms include fever, chills, flank pain, nausea,
and vomiting. Frequency, urgency, and dysuria are variably present.
Symptoms include fever, chills, flank pain, nausea,
and vomiting. Frequency, urgency, and dysuria are variably present.
•
Pyelonephritis
is a clinical diagnosis. Urine culture, complete blood count (CBC), serum
creatinine, and electrolytes should be obtained at admission. Blood cultures
need not be routinely performed in pyelonephritis and can be reserved for
severely ill patients.
Pyelonephritis
is a clinical diagnosis. Urine culture, complete blood count (CBC), serum
creatinine, and electrolytes should be obtained at admission. Blood cultures
need not be routinely performed in pyelonephritis and can be reserved for
severely ill patients.
•
Treatment
includes administration of intravenous (IV) broad-spectrum antibiotics,
hydration, and antipyretics. Transition
to an oral regimen is appropriate after an afebrile period of greater than 48
hours. Antibiotic regimen should be chosen based on urine culture sensitivities.
Oral therapy is continued to complete a 14-day antibiotic course. Daily
suppressive therap is then initiated for the remainder of pregnancy due to the
recurrence risk of approximately 20%.Cefazolin or ceftriaxone are
commonly used and are equivalent to ampicillin plus gentamicin. For penicillin allergy,
clindamycin plus gentamicin is appropriate. Fluoroquinolones are generally
avoided during pregnancy.
• Pregnant women with pyelonephritis
are at significant risk for developing acute respiratory distress syndrome.
They should be closely monitored for evidence of respiratory symptomatology
with provision of respiratory support as needed.
Amoxicillin, 3 g Ampicillin, 2 g Cephalexin, 2 g Nitrofurantoin,
200 mg Sulfisoxazole, 2 g
Trimethoprim-sulfamethoxazole,
320/1,600 mg
Amoxicillin,
250-500 mg tid
Ampicillin,
250 mg qid
Cephalexin,
250-500 mg qid
Nitrofurantoin,
100 mg bid
Sulfisoxazole,
1 g then 500 mg qid
Trimethoprim-sulfamethoxazole,
320/1,600 mg bid
Nitrofurantoin,
100 mg qhs
Ampicillin,
250 mg po qd
Trimethoprim-sulfamethoxazole,
160/800 mg qd
tid, three times a day; qid, four
times a day; bid, twice a day; qhs, at bedtime; po, by mouth; qd, every day.
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