The following can be used in the management of cystitis in pregnancy except –
Correct Answer: Cefpodoxime 400 mg every 12 h
Description: Ans- D Cefpodoxime 400 mg every 12 h Ref- and UTI in pregnancy is associated with significant morbidity for both mother and baby. All pregnant mothers should be screened for UTI. Untreated UTI will lead to pre-term premature rupture of membrane, maternal chorioamnionitis, intrauterine growth retardation and low birth weight baby. Early treatment with antibiotics has significantly reduced the above complications. Urine culture and sensitivity remain the gold standard in diagnosing UTI. If patients' condition are not improving despite adequate and appropriate use of antimicrobials, further investigations for underlying predisposing factors are necessary. Prophylactic antibiotic is indicated for recurrent UTI. AETIOLOGICAL AGENTS Escherichia coli (E. coli) is the major aetiological agent in causing UTI, which accounts for up to 90% of cases.1 Proteus mirabilis and Klebsiella pneumoniae are less frequent offenders. Less commonly, enterococci including Gardnerella vaginalis and Ureaplasma ureolyticum are known agents in UTIs. Gram-positive organisms are even less common in which Group B streptococcus, Staphylococcus saprophyticus and Staphylococcus haemolyticus are recognised organisms. US Food and Drug Administration (FDA) categories of medications in pregnancy Antibiotic FDA risk category Antibiotic FDA risk category Amoxicillin B Trimethoprim/sulfamethoxazol C Cephalosporins B Ciprofloxacin C Piperacillin/tazobactam B Levofloxacin C Daptomycin B Imipenem/cilastatin C Azithromycin B Linezolid C Erythromycin B Clarithromycin C Meropenem B Spiramycin C Clindamycin B Gentamycin C Nitrofurantoin B Amikacin D Vankomycin iv. B Tobramycin D Metronidazol iv. B Netilmycin D Trimethoprim C Tetracyclines D A - Well-controlled studies available in humans with no adverse effects observed in human pregnancies; B - No adverse effects in well-controlled studies of human pregnancies with adverse effects seen in animal pregnancies OR no adverse effects in animal pregnancies without well-controlled human pregnancy data available; C - Human data lacking with adverse pregnancy effects seen in animal studies OR no pregnancy data available in either animals or humans; D - Adverse effects demonstrated in human pregnancies; benefits of drug use may outweigh the associated risks. Common antibiotic choices for UTI in pregnancy1 Antibiotic Recommended dosage Pregnancy Risk category Nitrofurantoin 50 to 100mg 6 hourly B Cephalexin 250mg 6 hourly B Ampicillin 250mg 6 hourly B Amoxycillin- clavulanic acid 250mg 6 hourly B Amoxycillin 500mg 8 hourly B Trimethoprim-sulfamethoxazole 160mg 12 hourly C Category B: Animal studies do not demonstrate foetal risk but no controlled study in humans. Category C: No controlled study in humans available, animals' study revealed adverse foetal effects. Diagnosis and treatment of asymptomatic bacteriuria (ASB) and acute cystitis/urethritis in Pregnancy (doses for normal renal function) Asymptomatic bacteriuria Acute cystitis/urethritis Screening (obligatory) 1st prenatal visit or 12-16 HBD First line treatment Amoxicillin 500 mg every 8-12 h - for 3-7 days For 7 days Cephalexin 500 mg every 12/6 h - for 3-7 days For 7 days FDA cat. B Amoxicillin/clavulanic acid 500 mg every 12 h - for 3-7 days For 7 days Nitrofurantoin 100 mg every 12 h - for 5-7 days* For 7 days Cefuroxime 250 mg, every 12 h - for 3-7 days For 7 days Cefpodoxime 100 mg every 12 h FDA cat. C Trimethoprim with sulfamethoxazole 960 mg every 12 h for 5 days For 7 days *Treatment limited to the 2nd and 3rd trimester (except last 2 weeks); should not be used in the 1st trimester if other first line agents may be administered. Maternal and foetal complications of asymptomatic bacteriuria in pregnancy.9,10 Maternal complications Foetal complications Hypertension Intrauterine growth retardation Pre-eclampsia retardation Anaemia Intrauterine death Chorioamnionitis Low birth weight Symptomatic acute cystitis Acute pyelonephritis Prematurity PHYSIOLOGICAL CHANGES OF PREGNANCY AND ITS ASSOCIATION WITH URINARY TRACT INFECTIONS Pregnancy increases the risk of UTIs. At around 6th week of pregnancy, due to the physiological changes of pregnancy the ureters begin to dilate. This is also known as "hydronephrosis of pregnancy", which peaks at 22-26 weeks and continues to persist until delivery.1 Both progesterone and estrogens levels increase during pregnancy and these will lead to decreased ureteral and bladder tone. Increased plasma volume during pregnancy leads to decrease urine concentration and increased bladder volume.1 The combination of all these factors lead to urinary stasis and uretero-vesical reflux. Glycosuria in pregnancy is also another well-known factor which predisposes mothers to UTI.
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