A 33-year-old woman, gravida 3 para 2, at 31 weeks gestation comes to the emergency department due to fever, nausea, vomiting, and right flank pain. The patient has no chronic medical conditions and her pregnancy has been uncomplicated. She is admitted to the hospital for acute pyelonephritis and started on intravenous ceftriaxone. Forty-eight hours later, the patient feels better and has become afebrile. She is able to eat a normal diet and has had no nausea or vomiting for the past day. Current temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, and pulse is 76/min. Fetal heart tones are 130/min. The abdomen is nontender and there is no costovertebral angle tenderness. Urine culture from the day of hospital admission grows Escherichia coli with the following sensitivities: Which of the following is the most appropriate oral antibiotic therapy for this patient at this time?

Question

A 33-year-old woman, gravida 3 para 2, at 31 weeks gestation comes to the emergency department due to fever, nausea, vomiting, and right flank pain.  The patient has no chronic medical conditions and her pregnancy has been uncomplicated.  She is admitted to the hospital for acute pyelonephritis and started on intravenous ceftriaxone.  Forty-eight hours later, the patient feels better and has become afebrile.  She is able to eat a normal diet and has had no nausea or vomiting for the past day.  Current temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, and pulse is 76/min.  Fetal heart tones are 130/min.  The abdomen is nontender and there is no costovertebral angle tenderness.  Urine culture from the day of hospital admission grows Escherichia coli with the following sensitivities:  Which of the following is the most appropriate oral antibiotic therapy for this patient at this time?

Quizplus · Accepted Answer

11ec25c8_da07_21e1_bc81_69e0237fe4d0_MD0003_00 Pregnant patients are at increased risk for acute pyelonephritis due to pregnancy-related urinary tract changes (eg, ureteral dilation) that enable bacteria to ascend to the kidney. Most cases are caused by Escherichia coli (70%), but Klebsiella pneumoniae and group B Streptococcus are also common. Because pyelonephritis increases the risk for maternal and obstetric complications (eg, acute respiratory distress syndrome, preterm labor), initial treatment of pyelonephritis during pregnancy requires hospitalization, urine culture with sensitivities, and broad-spectrum intravenous antibiotics (eg, ceftriaxone). The treatment course for pyelonephritis (regardless of pregnancy status) typically requires 5-14 days to completely eliminate bacteria from both the upper (eg, kidney, renal collecting ducts) and lower urinary tract (Choice D). Following initial treatment with broad-spectrum antibiotics, patients who show clinical improvement (ie, no fever for 48 hours) are typically at low risk for disease progression and/or complications (eg, renal abscess); therefore, these patients can transition to oral antibiotics to complete the treatment course. The choice of oral antibiotic during pregnancy is guided by fetal safety profile and urine culture sensitivity testing. Generally, penicillins, cephalosporins, and fosfomycin are safe during all trimesters. Therefore, the most appropriate therapy for this patient with cephalexin-sensitive Escherichia coli is oral cephalexin. Following completion of treatment, pregnant patients also require a repeat urine culture (due to a high risk for persistent bacteriuria) and daily antibiotic prophylaxis (eg, cephalexin, nitrofurantoin) for the remainder of the pregnancy to prevent recurrence. (Choice B) Ciprofloxacin, a fluoroquinolone, can be used to treat acute complicated urinary tract infections in nonpregnant patients; however, it is generally avoided during pregnancy because its fetal effects are not well studied. In addition, this patient's urine culture shows resistance to ciprofloxacin. (Choices C and E) Nitrofurantoin and trimethoprim-sulfamethoxazole are commonly used to treat acute cystitis during pregnancy; however, both achieve poor concentration in the kidneys and are therefore inadequate for the treatment of pyelonephritis. In addition, trimethoprim-sulfamethoxazole is generally avoided near term gestation because of the risk for neonatal kernicterus. Educational objective: Pregnant patients with acute pyelonephritis initially require intravenous broad-spectrum antibiotics (eg, ceftriaxone). Those with symptomatic improvement (ie, afebrile for 48 hours) can be transitioned to oral antibiotics, which are chosen based on fetal safety profile and urine culture sensitivity testing. Penicillins, cephalosporins (eg, cephalexin), and fosfomycin are safe during all trimesters. References: Treatments for symptomatic urinary tract infections during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/21249652) Interventions for preventing recurrent urinary tract infection during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26221993)

A 33-Year-Old Woman, Gravida 3 Para 2, at 31 Weeks