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ACOG Pub Review > CC#4: Urinary Tract Infections in Pregnant Individuals > Flashcards

CC#4: Urinary Tract Infections in Pregnant Individuals Flashcards

1
Q

Entities that comprise UTI (3)

A

ASB, symptomatic acute cystitis, pyelo

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2
Q

Percentage of pregnancies affected by UTI of some sort

A

~8%

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3
Q

Most common bacterial pathogen isolated from pregnant pts w/ UTI

A

E. coli

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4
Q

Pregnancy risks associated w/ presence of UTI (2)

A

PTD, LBW

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5
Q

Potential serious maternal complications of pyelo (3)

A

Sepsis, DIC, ARDS

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6
Q

Percentage of pregnant pts in whom ASB is identified

A

2-10%

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7
Q

Percentage of pregnant pts in whom acute cystitis is diagnosed; percentage of pregnant pts in whom pyelo is diagnosed

A

~1-2%; ~1-2%

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8
Q

When is pyelo most likely to occur?

A

2nd tri

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9
Q

Anatomic/Physiologic changes during pregnancy that can predispose pts to UTIs

A

Progesterone-induced ureteral dilation and mechanical compression of ureter by gravid uterus > increased residual volume in bladder and urinary stasis > VUR > increased risk of bacterial colonization and ascending infection

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10
Q

When should screening for ASB be performed; how should screening for ASB be performed?

A

At an early prenatal visit; w/ UCx

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11
Q

Why is screening for ASB indicated?

A

Because it has been shown to be associated w/ a decrease in pyelo

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12
Q

Are routine UDips at each PNV beneficial?

A

No (and also not sufficiently sensitive to detect ASB)

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13
Q

Reason that routine UDips are not beneficial/sensitive

A

Both midstream and midstream clean-catch specimens commonly have at least moderate contamination in pregnant pts (and because of increased risk of culture contamination w/ advancing gestational age, attempts at repeat collection may be futile)

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14
Q

Is additional screening indicated after initial negative screening UCx; why?

A

No; residual risk of pyelo is low

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15
Q

Maternal condition that may benefit from more frequent UTI screening; maternal conditions that do not merit additional screening for ASB beyond initial screen (2)

A

SCT; DM, SCI

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16
Q

Reason additional screening is not recommended for pts w/ SCI (3)

A

ASB seems to be protective against symptomatic UTI, tx can precipitate symptomatic UTI, tx can contribute to antimicrobial resistance

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17
Q

At what cutoff is ASB clinically significant; what do lower levels represent?

A

CFU >100,000 (ie 10^5); contamination from vulva/vagina

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18
Q

General tx recs for ASB

A

5-7 day course of abx that has demonstrated efficacy against most common bacteria in ASB/UTI (ie E. coli, Proteus, Klebsiella)

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19
Q

Abx exception to 5-7 day course rec for tx of ASB

A

Fosfomycin (has good efficacy as single-dose tx for both ASB and symptomatic acute cystitis)

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20
Q

When should tx be started for ASB?

A

Once bacteriuria is confirmed (and then altered if abx sensitivities show that isolated bacteria are not sensitive to initial choice of tx)

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21
Q

When should GBSbu be treated; what do lower levels indicate?

A

If CFU >100,000; do not require tx but should be noted as indication for intrapartum GBS ppx

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22
Q

Components of normal vulvovaginal flora that should not be treated (3)

A

Lactobacilli, Corynebacteria, coagulase-neg Staph)

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23
Q

Is TOC or repeat screening indicated s/p tx of ASB?

A

Evidence does not make rec

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24
Q

Common presenting sxs of acute cystitis (4)

A

Dysuria, hematuria, frequency, nocturia (which frequently overlap w/ common pregnancy sxs)

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25
Q

Most useful tool for triage of UTI sxs

A

UA

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26
Q

Definition of pyuria on UA

A

> 5 WBC/HPF, or presence of leuk esterase

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27
Q

Sensitivity of pyuria on UA; general specificity of pyuria on UA

A

97%; lower (because WBCs could be contaminants of vulva/vagina)

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28
Q

Specificity of nitrites on UA; general sensitivity of nitrites on UA

A

94-98%; lower (because not all bacteria produce nitrites)

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29
Q

NPV of UA w/ neither leuk esterase nor nitrites present

A

78-98%

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30
Q

Can UTI be excluded if UDip is entirely normal?

A

Yes

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31
Q

When can abx tx be initiated for symptomatic acute cystitis?

A

In presence of positive UA, for symptomatic relief

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32
Q

Situation in which empiric tx may be considered for symptomatic acute cystitis

A

When urine specimens cannot be collected and pt described new-onset dysuria and frequency

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33
Q

Should UCx be obtained in suspected symptomatic acute cystitis; why?

A

Ideally, yes; to confirm dx and direct abx therapy

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34
Q

Cutoff at which tx is indicated in symptomatic acute cystitis

A

Reasonable to treat CFU as low as 100 of a single organism (unlike in ASB) if sxs are present

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35
Q

Sensitivity of UDip w/ leuks; specificity of UDip w/ leuks; PPV of UDip w/ leuks; NPV of UDip w/ leuks

A

72-97%; 41-86%; 43-56; 82-91

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36
Q

Sensitivity of UDip w/ nitrites; specificity of UDip w/ nitrites; PPV of UDip w/ nitrites; NPV of UDip w/ nitrites

A

19-48%; 92-100%; 50-83; 70-88

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37
Q

Sensitivity of UDip w/ leuks or nitrites; specificity of UDip w/ leuks or nitrites; PPV of UDip w/ leuks or nitrites; NPV of UDip w/ leuks or nitrites

A

46-100%; 42-98%; 52-68; 78-98

38
Q

Sensitivity of UDip w/ protein >3+; specificity of UDip w/ protein >3+

A

96%; 87%

39
Q

Sensitivity of UDip w/ protein >1+; specificity of UDip w/ protein >1+

A

91-100%; 65-99%

40
Q

Sensitivity of microscopy w/ >5 WBC/HPF; specificity of microscopy w/ >5 WBC/HPF; PPV of microscopy w/ >5 WBC/HPF; NPV of microscopy w/ >5 WBC/HPF

A

90-96%; 47-50%; 56-59; 83-95

41
Q

Sensitivity of microscopy w/ >5 RBC/HPF; specificity of microscopy w/ >5 RBC/HPF; PPV of microscopy w/ >5 RBC/HPF; NPV of microscopy w/ >5 RBC/HPF

A

18-44%; 88-89%; 27; 82

42
Q

Sensitivity of microscopy w/ bacteriuria; specificity of microscopy w/ bacteriuria; PPV of microscopy w/ bacteriuria; NPV of microscopy w/ bacteriuria

A

46-58%; 89-94%; 54-88; 77-86

43
Q

How does PPV change in a low-prevalence population; how does NPV change in a low-prevalence population?

A

Decreases; increases

44
Q

General tx recs for acute cystitis

A

5-7 day course of abx (w/ poss modification based on UCx sensitivities)

45
Q

Macrobid tx regimen for ASB and acute cystitis

A

100mg PO q12h x5-7 days

46
Q

Considerations for macrobid tx for UTI in pregnancy (2)

A

Reasonable to offer in 1st tri only if no appropriate alternative available, avoid for pyelo 2/2 inability to reach therapeutic levels in kidney

47
Q

Keflex tx regimen for ASB and acute cystitis

A

250-500mg PO q6h x5-7 days

48
Q

ASB/acute cystitis tx recs for pts w/ low-risk beta-lactam allergy; ASB/acute cystitis tx recs for pts w/ high-risk beta-lactam allergy

A

Tx w/ cephalosporins appropriate; alternative regimen recommended

49
Q

Bactrim tx regimen for ASB and acute cystitis

A

800/160mg PO q12h x5-7 days

50
Q

Considerations for Bactrim tx for UTI in pregnancy (2)

A

Reasonable to offer in 1st tri only if no appropriate alternative available, avoid initiating prior to UCx results available in areas w/ >20% resistance to Bactrim

51
Q

Fosfomycin tx regimen for ASB and acute cystitis

A

3g PO once

52
Q

Consideration for fosfomycin tx for UTI in pregnancy

A

Avoid for pyelo 2/2 inability to reach therapeutic levels in kidney

53
Q

Amoxicillin tx regimens for ASB and acute cystitis (2)

A

500mg PO q8h x5-7 days, 875mg PO q12h x5-7 days

54
Q

Consideration for amoxicillin/amoxicillin-clavulanate tx for UTI in pregnancy

A

High degree of resistance in E. coli, so avoid if initiating tx before UCx results available

55
Q

Amoxicillin-clavulanate tx regimens for ASB and acute cystitis (2)

A

500mg PO q8h x5-7 days, 875mg PO q12h x5-7 days

56
Q

Reasonable first-line option for tx of lower UTIs; advantages of this med (3)

A

Macrobid; low resistance rates, effective against many pathogens common in pregnancy, achieves therapeutic levels in bladder

57
Q

Reason why Macrobid and Bactrim are ideally avoided in 1st tri (unless no appropriate alternatives available)

A

Some data suggest poss congenital anomalies

58
Q

Pts in whom Macrobid should be avoided; why?

A

G6PD deficiency; use can be associated w/ pulm toxicity and hemolytic anemia

59
Q

Is single-dose fosfomycin as effective as other longer tx regimens?

A

Yes

60
Q

Appropriate surveillance strategies s/p tx for acute cystitis (2)

A

Repeat UCx in 1-2 weeks s/p abx tx, clinical monitoring (w/ UCx only if sxs recur)

61
Q

Definition of recurrent UTI; percentage of pregnancies this occurs in

A

2+ UTIs diagnosed during pregnancy; 4-5% of pregnancies

62
Q

Abx ppx strategies for recurrent UTI in pregnancy (2)

A

Continuous, postcoital

63
Q

How to administer postcoital abx ppx

A

Abx taken only before or after vaginal intercourse (shown to have decrease in adverse events related to abx use)

64
Q

How to administer continuous abx ppx

A

Abx taken once daily

65
Q

Common continuous suppressive abx regimens (2)

A

Macrobid 100mg PO daily, Keflex 250-500mg PO daily

66
Q

Definition of pyelo

A

Infection of kidney thought to arise from ascending bacteria from bladder to upper urinary tract

67
Q

Presenting signs/sxs of pyelo (5)

A

Fever, N/V, flank pain, CVA tenderness, renal US abnormalities

68
Q

Poss CBC findings during pyelo (4)

A

Elevated WBC, bandemia, thrombocytopenia, anemia

69
Q

CBC finding highly correlated w/ adverse outcomes (ie ICU admission)

A

Abnormalities in multiple cell lines

70
Q

Common pyelo presentation that should prompt timely abx tx

A

Abnormal UA w/ fever, flank pain, CVA tenderness

71
Q

Poss alternative presentations of pyelo (4)

A

Preterm ctxs/PTL, sepsis, acute renal insufficiency, ARDS

72
Q

Ddx for pyelo-like sxs in pregnancy (4)

A

Nephrolithiasis, renal abscess, urosepsis w/o pyelo, chorio

73
Q

Recommended labs when evaluating pt w/ suspected pyelo (3)

A

Midstream/catheterized urine specimen for UA, microscopy, UCx prior to initiation of abx (though tx should not be delayed while awaiting UCx results)

74
Q

Are BCx clinically useful in setting of suspected pyelo?

A

No

75
Q

Initial inpatient management principles in tx of pyelo (2)

A

Fluid hydration, IV abx

76
Q

What factors determine initial abx regimen for pyelo (2)?

A

Local susceptibility data, recent abx use by pt

77
Q

First-line abx for pyelo (2)

A

Broad spectrum beta-lactams w/ consideration of adding aminoglycosides (ie ampt + gent), or single-agent cephalosporins (ie Rocephin or cefepime)

78
Q

Pyelo tx recs for pts w/ low-risk beta-lactam allergy; pyelo tx recs for pts w/ high-risk beta-lactam allergy

A

Tx w/ cephalosporins appropriate; alternative regimen such as aztreonam an ID consult should be pursued

79
Q

Amp + gent regimen for tx of pyelo

A

Amp 2g IV q6h + gent 1.5mg/kg IV q8h (or 5mg/kg IV q24h)

80
Q

Rocephin regimen for tx of pyelo

A

1g IV q24h

81
Q

Cefepime regimen for tx of pyelo

A

1g IV q24h

82
Q

Aztreonam regimen for tx of pyelo

A

1g IV q8-12h

83
Q

Percentage of pyelo pts w/ clinical improvement (afebrile >24h and improvement in sxs) within 48-72h after initiating IV abx

A

75-95%

84
Q

Further evaluation principle for pts not demonstrating clinical improvement within 72h

A

R/o bacterial resistance and/or other urinary tract pathology

85
Q

Most common reason for pyelo tx failure

A

Abx resistance

86
Q

Ongoing tx recs after clinical improvement of pyelo w/ IV abx

A

Transition to appropriate PO abx (based on UCx sensitivity) for 14-day abx course

87
Q

Is repeat UCx indicated after completion of abx for pyelo?

A

Yes, to confirm no residual infection

88
Q

What should be pursued if antimicrobial-resistant organisms are identified?

A

ID consult in order to determine abx course and duration of tx

89
Q

Percentage of pts who experience recurrence of pyelo prior to delivery

A

25%

90
Q

Suppression abx regimens s/p pyelo tx (2); recommended duration of tx

A

Macrobid 100mg PO daily, Keflex 250-500mg PO daily; until 4-6 weeks PP

91
Q

Lab testing consideration for pts w/ recurrent pyelo in pregnancy

A

Routine monthly UCx

ACOG Pub Review (12 decks)

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