Pyelonephritis

Asymptomatic bacteriuria can be found in 3% to 5% of pregnant women and up to 10% of those with sickle cell trait. Asymptomatic bacteriuria is most often caused by Escherichia coli. Antibiotic therapy is similar to that in the nonpregnant state. Cephalosporins, ampicillin, and nitrofurantoin (Mac-rodantin) are frequently used medications that are safe in pregnancy. It appears best to treat asymptomatic bacteriuria in pregnancy for 5 to 7 days. Untreated, 30% of women with asymptomatic bacteriuria will progress to pyelonephritis. Hormonal and anatomic changes of pregnancy causing hydronephrosis and hydroureter are responsible for the higher incidence of pyelonephritis in the pregnant woman. A urinary pathogen count of at least 100,000 colonies/ mL is considered significant, although pyelonephritis also occurs at counts as low as 20,000 to 50,000 (Cunningham and Lucas, 1994). Periodic cultures for screening should be performed in women with sickle cell trait, recurrent urinary tract infection, recurrent asymptomatic bacteriuria, or urine dipstick suggesting bacterial growth, such as positive nitrite.

Pyelonephritis in pregnancy requires hospitalization because of frequently associated dehydration, nausea, vomiting, and premature labor, as well as the uncommon but serious risk of endotoxic shock and endotoxin damage of alveolocapillary membranes leading to pulmonary edema and a clinical picture of adult respiratory distress syndrome (Gurman et al., 1990). Pregnant women with pyelonephritis require hospitalization for aggressive hydration and paren-teral antibiotics. Antibiotic treatment is similar to those of other-adult regimens. Intravenous antibiotic therapy with a cephalosporin or an extended-spectrum penicillin until symptoms improve and the fever has completely resolved is usually sufficient for initial therapy. Because 25% of patients with mild acute pyelonephritis who are pregnant have a recurrence, these patients should have monthly urine cultures or antimicrobial suppression with oral nitrofurantoin (Macrodantin), 100 mg daily, until 4 to 6 weeks postpartum. Fluoroquinolones should be avoided because of concerns about their teratogenic effects on the fetus. Oral antibiotics are then prescribed for 7 to 10 additional days. For seriously ill women, the addition of an aminoglycoside at the onset of therapy may be warranted until sensitivities of the offending organism are available. Renal function as well as peak and trough aminoglycoside levels should be followed.

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