Antibiotics for asymptomatic bacteriuria in pregnancy
RHL practical aspects by Tolosa JE
FIRST CONTACT (PRIMARY CARE) LEVEL
1. Educate pregnant women and their partners to contact the health facility as soon as pregnancy is diagnosed, especially if there is a history of diabetes mellitus, sickle cell disease or previous urinary tract infection.
2. In all pregnant women a test should be performed at the time of the first visit, regardless of the gestational age at which it occurs, to determine if there is asymptomatic bacteriuria.
3. If a urine culture cannot be performed, any other available test, such as a microscopic examination of the urine sediment to look for >10 leukocytes per high power field or a dipstick positive for leukocyte esterase activity or presence of nitrates, could be performed. However, health workers should know that the most adequate and desirable test is a urine culture.
4. In women at high risk for pyelonephritis, such as those with sickle cell disease, diabetes mellitus or with a history of urinary tract infections, a urine culture must be done, if necessary at a referral center.
5. Women with symptoms like increased vaginal discharge that has a bad odour, with itching or accompanied by urinary tract symptoms like dysuria, should be examined to rule out any accompanying infections.
6. If the diagnosis of asymptomatic bacteriuria is made, antibiotic treatment is indicated, based on susceptibility. Nitrofurantoin is a good choice. Note that serious side-effects can occur, such as haemolysis in the patient or fetus with glucose-6-phospate dehydrogenase deficiency. Sulfonamide or sulfonamide-containing preparations can be used, (except in the third trimester of pregnancy, due to a higher risk of fetal hyperbilirubinaemia). Broad-spectrum penicillins and cephalosporins are also effective. Tetracycline use in pregnancy is contraindicated. The optimal duration of therapy has not been determined. Practitioners should follow their current preferred practice.
7. Upon completion of therapy a follow-up urine culture is recommended to confirm cure.
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
1. To determine if there is asymptomatic bacteriuria a test should be performed in all pregnant women at the time of the first visit, regardless of the gestational age. Ideally, the test should be a urine culture. A midstream urine sample should be obtained after washing the external genitalia two or three times with a cleansing agent before voiding. The sample should be sent as soon as possible to the laboratory and if transportation is not available, it should be refrigerated at 4 °C for a maximum of 24 hours.
2. If the diagnosis of asymptomatic bacteriuria is made, antibiotic treatment is indicated, based on susceptibility. Nitrofurantoin is a good choice. Note that serious side-effects can occur, such as haemolysis in the patient or fetus with glucose-6-phospate dehydrogenase deficiency. Sulfonamide or sulfonamide-containing preparations can be used, (except in the third trimester of pregnancy, due to a higher risk of fetal hyperbilirubinaemia). Broad-spectrum penicillins and cephalosporins are also effective. Tetracycline use in pregnancy is contraindicated. The optimal duration of therapy has not been determined. Practitioners should follow their current preferred practice.
3. Upon completion of therapy a follow-up urine culture is recommended to confirm cure.
AT HOME OR IN THE COMMUNITY
Not applicable.
This document should be cited as: Jorge E. Tolosa. Antibiotics for asymptomatic bacteriuria in pregnancy RHL practical aspects (last revised: 14 January 2008). The WHO Reproductive Health Library; Geneva: World Health Organization.