Outpatient treatment of pyelonephritis in pregnancy: a randomized controlled trial

doi:10.1016/S0029-7844(95)80016-6

Obstetrics & Gynecology

Volume 86, Issue 4, Part 1, October 1995, Pages 560-564

https://doi.org/10.1016/S0029-7844(95)80016-6 Get rights and content

Objective:

To compare the safety and efficacy of outpatient and inpatient treatment of pyelonephritis in pregnancy.

Methods:

We performed a randomized controlled trial of pregnant women with pyelonephritis before 24 weeks' estimated gestational age, comparing inpatient and outpatient treatment. Sixty inpatients received cefazolin intravenously until afebrile for 48 hours, and 60 outpatients received two injections of ceftriaxone intramuscularly. All patients completed a 10-day course of oral cephalexin. We performed a urine culture 5–14 days after completion of therapy.

Results:

The two groups were similar with respect to age, parity, temperature, estimated gestational age, initial white blood cell count, and incidence of bacteremia. Escherichia coli was the major uropathogen isolated (86% of cultures, 95 of 111). Twelve percent (13 of 111) of bacteria were resistant to cefazolin. Eleven outpatients and 12 inpatients had positive urine cultures after therapy (relative risk 0.9, 95% confidence interval 0.4–1.9). Three patients in each group had recurrent pyelonephritis. We switched six inpatients to gentamicin because of a worsening clinical picture (two) or a prolonged febrile course (four); no outpatients required a change in antibiotic (Fisher exact test, P = .03). One preterm delivery occurred in an inpatient with recurrent pyelonephritis.

Conclusion:

Outpatient antibiotic therapy is effective and safe in selected pregnant women with pyelonephritis.

References (11)

SafrinS et al.
Pyelonephritis in adult women: Inpatient versus outpatient therapy
Am J Med
(1988)
WardG et al.
Treatment of pyelonephritis in an observation unit
Ann Emerg Med
(1991)
TowersCV et al.
Pulmonary injury associated with antepartum pyelonephritis: Can patients at risk be identified?
Am J Obstet Gynecol
(1991)
StammWE et al.
Urinary tract infections: From pathogenesis to treatment
J Infect Dis
(1989)
PinsonAG et al.
Oral antibiotic therapy for acute pyelonephritis: A methodologic review of the literature
J Gen Intern Med
(1992)

There are more references available in the full text version of this article.

Cited by (82)

Urinary tract infections in pregnancy
2023, Clinical Microbiology and Infection
Urinary tract infections (UTIs) are the most common infection among pregnant women and have been associated with maternal and foetal complications. Antimicrobial exposure during pregnancy is not without risk. International guidelines recommend a single screen-and-treat approach to asymptomatic bacteriuria (ASB); however, this approach has been questioned by recent studies.
The aim of this narrative review was to assess the pathophysiology, current risk factors and management of UTI during pregnancy, its impact on pregnancy outcomes, and to develop recommendations on the best use of antimicrobials.
PubMed, Cochrane database, and ClinicalTrials.gov.
Owing to the physiological changes related to pregnancy, pregnant women are at higher risk of UTI. All types of UTIs combined have been estimated to affect approximately 2% to 15% of women. ASB affects 2% to 7% of pregnant women. Recent studies do not provide good-quality evidence for an association between ASB and acute pyelonephritis if ASB is untreated. There is low-to-moderate–quality evidence that treatment of ASB results in a reduction in the incidence of low birth weight and preterm birth, which justifies screening practices for ASB with only a single urine culture in the first trimester. If the clinician opts for treatment, a short course of β-lactams, nitrofurantoin, or fosfomycin should be favoured. Studies on cystitis during pregnancy are limited. Acute pyelonephritis has been shown to be associated with increased maternal complications and in some studies has also been associated with preterm delivery and low birth weight. Preferred antimicrobials for the management of pyelonephritis are amoxicillin combined with an aminoglycoside, third-generation cephalosporins, or carbapenems. Studies on recurrent UTIs during pregnancy are limited, making it difficult to draw conclusions regarding prophylactic measures.
Further research is required to understand the true incidence of ASB-related complications and the benefit and modalities of screening for ASB and to further explore prophylactic measures.
Clinical findings predictive of maternal adverse outcomes with pyelonephritis
2022, American Journal of Obstetrics and Gynecology MFM
Citation Excerpt :
Our study supported the use of laboratory findings as a means to discriminate women at risk of adverse outcomes associated with pyelonephritis. The ability to use presenting signs and symptoms to formulate a leading etiology and management plan is important when some consider outpatient therapy in select women.1,12,13 This became potentially more relevant during the start COVID-19 pandemic when many specialties, as our own, were prioritizing decreased hospital admissions.18–23
Pyelonephritis, a leading cause of infection during pregnancy, is associated with increased maternal adverse outcomes. Therefore, early recognition and intervention of pyelonephritis are important. Early recognition of pyelonephritis has historically been dependent on fever and costovertebral angle tenderness. However, the reliability of these findings to distinguish women who will develop maternal adverse outcomes is limited.
This study aimed to identify clinical variables on presentation that are predictive of maternal adverse outcomes associated with pyelonephritis during pregnancy.
A retrospective cohort study of pregnant women admitted with pyelonephritis at a single hospital from October 1, 2015, to July 31, 2021, was conducted. The primary outcome was a composite maternal adverse outcome consisting of any of the following: maternal intensive care unit admission, surgical intervention, hypotension requiring vasopressors, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, altered mental status, dialysis, organ failure, venous thromboembolism, or maternal death. Differences in maternal characteristics and clinical signs and symptoms on admission were stratified by the presence or absence of a maternal adverse outcome. Categorical variables were analyzed using the Fisher exact test. Continuous data were analyzed with Wilcoxon rank-sum test. Sensitivity and specificity and likelihood ratios with 95% confidence intervals were calculated for the detection of maternal adverse outcomes by specified admission physical examination and laboratory findings.
Of 97 women that met the inclusion criteria, 28 (28.9%) had maternal adverse outcomes. Moreover, 50 of 97 women (51.5%) had fever on presentation, with no difference between cohorts recognized. Admission vital signs were not significantly different between cohorts. Costovertebral angle tenderness was present in 78 of 97 women (80.4%) on presentation, with no difference between cohorts. Compared with women without a maternal adverse outcome, women with maternal adverse outcomes were more likely to have leukocytosis (18/28 [64.3%] vs 20/69 [29.0%]), thrombocytosis (3/28 [10.7%] vs 5/69 [7.2%]), bandemia (8/28 [28.6%] vs 7/69 [10.1%]), and an abnormal serum potassium (20/28 [71.4%] vs 32/63 [50.8%]).
Admission vital signs may not reliably identify women with pyelonephritis at risk of maternal adverse outcomes. Laboratory studies, particularly a complete blood count and electrolytes, may provide a means of distinguishing those at risk of maternal adverse outcomes.
Impact of revised susceptibility breakpoints on bacteremia of Klebsiella pneumoniae: Minimum inhibitory concentration of cefazolin and clinical outcomes
2016, Journal of Microbiology, Immunology and Infection
Citation Excerpt :
The dose and frequency of the regimen varied widely among the studies.18–21 Data about the correlation of MIC and cephalosporin dose from clinical trials are also lacking.18–21 We therefore conducted this study to evaluate the MIC distribution of cefazolin among K. pneumoniae isolates, to analyze the correlation of MICs and the clinical outcomes of patients with K. pneumoniae bacteremia, and to analyze the impact of cefazolin breakpoint changes of CLSI in 2011 on treatment.
The Clinical and Laboratory Standards Institute (CLSI) revised the susceptibility breakpoints of cephalosporins for Enterobacteriaceae in 2010 and 2011. However, there is a lack of clinical data about the correlation of minimum inhibitory concentrations (MICs) and clinical outcome. Data for the distribution of MICs and clinical outcomes were analyzed in this study to evaluate the impact of changes in the CLSI breakpoints on the treatment of Klebsiella pneumoniae bacteremia.
Ninety-seven bacteremic K. pneumoniae isolates from Taichung Veterans General Hospital, Taichung, Taiwan were collected for study during the period 2009–2011. The cefazolin MIC was determined by the broth microdilution method according to the recommendations of the CLSI. The MIC distribution of cefazolin and the clinical responses to definitive cefazolin treatment were analyzed.
The modal cefazolin MIC among the 97 isolates was 1 μg/mL and accounted for 73 (75.3%) isolates. There were 18 (18.6%) isolates with a cefazolin MIC of 2 μg/mL. The conventional dosage regimens of cefazolin (1 g every 6 hours or 8 hours) achieved a clinical cure in 70 (97.2%) of 72 patients in the group with a cefazolin MIC ≤1 μg/mL and in 14 (87.5%) of 16 patients in the group with a cefazolin MIC of 2 μg/mL. With the conventional dose, the cumulative clinical cure rate for K. pneumoniae bacteremia with cefazolin MIC ≤2 μg/mL was 95.5% (84/88 patients).
The conventional cefazolin dose still can result in satisfactory clinical cure rates for bacteremic episodes due to K. pneumoniae with cefazolin MIC ≤2 μg/mL, the revised susceptible breakpoint of CLSI 2011.
Urinary Tract Infection and Bacteriuria in Pregnancy
2015, Urologic Clinics of North America
Citation Excerpt :
Historically, these regimens have resulted in 95% or better response rates within 72 hours,17,35,120,133,135,136 although resistance to ampicillin alone approaches 50% in contemporary studies.133 No single-treatment regimen has been proven to be superior to others,17,35,133,135,136 and individual treatments should be tailored to local antibiograms and susceptibility patterns. There are no organizational guidelines on the duration of treatment of pyelonephritis in pregnant women; however, most recommend a treatment course of 7 to 14 days,16,17,35,132,133 in line with IDSA recommendations for nonpregnant patients.11
Diagnosis and management of urinary tract infection in the emergency department and outpatient settings
2014, Infectious Disease Clinics of North America
Clinical Practice Guideline for complicated urinary tract infection
2023, Infectio

View all citing articles on Scopus

: Supported by a grant from Hoffman-La Roche, Inc.

View full text

Outpatient treatment of pyelonephritis in pregnancy: a randomized controlled trial

Objective:

Methods:

Results:

Conclusion:

Am J Med

Ann Emerg Med

Am J Obstet Gynecol

Urinary tract infections: From pathogenesis to treatment

J Infect Dis

Oral antibiotic therapy for acute pyelonephritis: A methodologic review of the literature

J Gen Intern Med