Consensus for the treatment of upper urinary tract infections during pregnancy
DOI:
https://doi.org/10.18597/rcog.3984Keywords:
Pyelonephritis, antibiotic, antimicrobial resistance, urinary infectionAbstract
Objectives: To generate evidence-based recommendations through formal consensus regarding the treatment of upper urinary tract infections during gestation.
Materials and methods: Experts in microbiology, public health, internal medicine, infectious diseases, obstetrics, maternal fetal medicine and obstetric and gynecological infections participated in the consensus development group. The group also included professionals with training in clinical epidemiology, systematic data search, and representatives from the Health Secretariat and the Bogota Obstetrics and Gynecology Association. The participants disclosed their conflicts of interest. Starting with a clinical question, outcomes were graded and a systematic search was conducted in the Medline via PubMed, Embase, Lilacs, and Bireme databases. The search was expanded to include institutional repositories and antimicrobial resistance surveillance systems, with no language or date restrictions. The search was updated on October 1, 2022. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to assess the quality of the evidence and determine the strength of the recommendations. Finally, the RAND/UCLA (Research and Development/University of California Los Angeles) methodology was applied for the formal consensus. This document was reviewed by academic peers before publication.
Results: The following are the consensus recommendations.
Recommendation 1. The initial management of pregnant women with upper urinary tract infections (UTIs) should be approached in a hospital setting.
Recommendation 2. The use of second generation cephalosporins is the suggested first option for empirical antimicrobial management in pregnant women with upper UTI in order to improve the rates of clinical and microbiological cure.
Recommendation 3. Because of the risk-benefit balance, the use of aminoglycosides is suggested as a second option for empirical antimicrobial treatment in pregnant women presenting with upper UTIs in the second and third trimester.
Recommendation 4. The use of third-generation cephalosporins is suggested as the third option for empirical antimicrobial treatment in pregnant women with upper UTIs given that the risk of inducing microbial resistance is high with this group of antibiotics.
Recommendation 5. The use of carbapenems is suggested as a first option in pregnant women with upper UTIs and a history of infections caused by microorganisms with resistance to third or fourth-generation cephalosporins.
Recommendation 6. The use of aminoglycosides or fourth-generation cephalosporins is suggested as a second option in pregnant women with upper UTIs and a history of infection caused by microorganisms with resistance to third-generation cephalosporins, taking risk-benefit into account.
Recommendation 7. The use of piperacillin/tazobactam is suggested as a third option in pregnant women with upper UTIs and a history of infection caused by microorganisms with resistance to third or fourthgeneration cephalosporins.
Recommendation 8. Getting a urine culture is recommended in pregnant women with upper UTIs before initiating empirical antimicrobial treatment.
Recommendation 9. In pregnant women with upper UTIs, it is suggested to modify therapy in accordance with the results of the sensitivity test when the culture report shows resistance to the antimicrobial agent initiated empirically.
Recommendation 10. In pregnant women hospitalized due to upper UTIs, it is suggested to switch to oral antimicrobial therapy after at least 48 hours of modulation of the systemic inflammatory response and the clinical signs of infection, and when tolerance to oral intake is adequate.
Recommendation 11. In pregnant women with upper UTIs with no complications secondary to the primary infection, it is recommended to administer antibiotic therapy for a period of 7 to 10 days.
Conclusions: It is expected that with this Colombian upper UTI consensus variability in clinical practice will be reduced. It is recommended that groups doing research in maternal fetal medicine assess the implementation and effectiveness of these recommendations.
Author Biographies
Juan Sebastián Molina-Muñoz, Universidad Nacional de Colombia, Bogotá (Colombia).
Médico cirujano, Universidad Nacional de Colombia; especialista en Epidemiología de la Fundación del Área Andina; especialista en Obstetricia y Ginecología, Universidad Nacional de Colombia, Bogotá (Colombia).
Jimena Cuadrado-Angulo, Universidad Nacional de Colombia, Bogotá (Colombia).
Médica cirujana, Universidad Nacional de Colombia; especialista de Obstetricia y Ginecología, Universidad Nacional de Colombia, Bogotá (Colombia).
Carlos Fernando Grillo-Ardila, Universidad Nacional de Colombia, Bogotá (Colombia).
Médico cirujano; especialista en Obstetricia y Ginecología; magíster en Epidemiología Clínica. Profesor Departamento de Ginecología y Obstetricia, Universidad Nacional de Colombia, Bogotá (Colombia).
Edith Angel-Müller, Universidad Nacional de Colombia, Bogotá (Colombia).
Médica cirujana; especialista en Obstetricia y Ginecología; Fellow en Infectología Ginecoobstétrica. Profesora Departamento de Ginecología y Obstetricia, Universidad Nacional de Colombia, Bogotá (Colombia).
Jorge Alberto Cortés, Universidad Nacional de Colombia, Bogotá (Colombia).
Médico cirujano; especialista en Medicina interna; Fellow en infectología. Profesor del departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá (Colombia).
Aura Lucía Leal-Castro, Universidad Nacional de Colombia, Bogotá (Colombia).
Médica; especialista en Microbiología y Parasitología Médicas; magíster en Epidemiología y control de infecciones. Profesora asociada al Departamento de Microbiología de la Facultad de Medicina, Universidad Nacional de Colombia, Bogotá (Colombia).
Maria Teresa Vallejo-Ortega, Instituto Nacional de Cancerología, Bogotá (Colombia).
Médica cirujana; magíster en epidemiología clínica, Universidad Nacional de Colombia; médico especialista, grupo de investigación clínica y epidemiología del cáncer, Instituto Nacional de Cancerología, Bogotá (Colombia).
References
Foxman B. Urinary tract infection syndromes: Occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin North Am. 2014;28(1):1-13. https://doi.org/10.1016/j.idc.2013.09.003
Johnson CY, Rocheleau CM, Howley MM, Chiu SK, Arnold KE, Ailes EC. Characteristics of women with urinary tract infection in pregnancy. J Womens Health. 2021;30(11):1556-64. https://doi.org/10.1089/jwh.2020.8946
Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database of Systematic Reviews. 2015. https://doi.org/10.1002/14651858.CD000490.pub3
Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. Eur J Clin Invest. 2008;38 Suppl 2:50-7. https://doi.org/10.1111/j.1365-2362.2008.02009.x
Chu CM, Lowder JL. Diagnosis and treatment of urinary tract infections across age groups. Am J Obstet Gynecol. 2018;219(1):40-51. https://doi.org/10.1016/j.ajog.2017.12.231
Grette K, Cassity S, Holliday N, Rimawi BH. Acute pyelonephritis during pregnancy: A systematic review of the aetiology, timing, and reported adverse perinatal risks during pregnancy. J Obstet Gynaecol. 2020;40(6):739-48. https://doi.org/10.1080/01443615.2019.1647524
Wing DA, Fassett MJ, Getahun D. Acute pyelonephritis in pregnancy: An 18-year retrospective analysis. Am J Obstet Gynecol. 2014;210(3):219.e1-6. https://doi.org/10.1016/j.ajog.2013.10.006
Cuadrado J, Molina J, Angel E. Perfil de resistencia antimicrobiana en gestantes colombianas con infección urinaria alta: revisión sistemática de alcance. XXXIII Congreso Nacional de Obstetricia y Ginecología [Internet]. 2022; Medellín, Colombia. Disponible en: https://revista.fecolsog.org/index.php/rcog/issue/download/385/58
Ferreira FE, Olaya SX, Zúñiga P, Angulo M. Infección urinaria durante el embarazo, perfil de resistencia bacteriana al tratamiento en el Hospital General de Neiva, Colombia. Rev Colomb Obstet Ginecol. 2005;56(3):239-43. https://doi.org/10.18597/rcog.532
Quintero JF. Perfil de resistencia antimicrobiana en infección del tracto urinario de embarazadas atendidas en una institución de la ciudad de Cartagena entre los años 2018 y 2019 [tesis de especialización; Internet]. [Cartagena]: Universidad de Cartagena; 2020. Disponible en: https://hdl.handle.net/11227/11060
Nocua LC, Cortés JA, Leal AL, Arias GF, Ovalle MV, Saavedra SY, et al. Susceptibilidad antimicrobiana de enterobacterias identificadas en infección urinaria adquirida en la comunidad, en gestantes en nueve hospitales de Colombia. Rev Colomb Obstet Ginecol. 2017;68(4):275-84. https://doi.org/10.18597/rcog.928
Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. Lancet. 2022;399(10325):629-655. https://doi.org/10.1016/S0140-6736(21)02724-0
Centro de Estudios e Investigación en Salud de la Fundación Santa Fe de Bogotá. Guía metodológica para la elaboración de Guías de Práctica Clínica con Evaluación Económica en el Sistema General de Seguridad Social en Salud Colombiano [Internet]. 2013. Disponible en: https://www.iets.org.co/Archivos/62/Gu%C3%ADa%20Metodol%C3%B3gica%20Elaboraci%C3%B3n%20de%20GPC%20con%20Evaluaci%C3%B3n%20Econ%C3%B3mica%20en%20el%20Sist%20Seguridad%20Social%20y%20Salud-Versi%C3%B3n%20final%20completa.PDF
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane Handbook for Systematic Reviews of Interventions. John Wiley & Sons; 2019. 739 p. https://doi.org/10.1002/9781119536604
Vallejo MT, Sánchez R, Feliciano JE, García MJ, Gutiérrez MP, Merchán RA. Manual para la elaboración de protocolos clínicos en el Instituto Nacional de Cancerología [Internet]. 2016. Disponible en: https://isbn.cloud/9789588963150/manual-para-la-elaboracion-de-protocolos-clinicos-en-el-instituto-nacional-de-cancerologia/
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017 Sep 21;358:j4008. https://doi.org/10.1136/bmj.j4008
McMaster University and Evidence Prime. GRADEpro GDT: GRADEpro Guideline Development Tool [Internet]. Disponible en: https://gradepro.org
Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database Syst Rev. 2011;(1):CD002256. https://doi.org/10.1002/14651858.CD002256.pub2
Vidal L, Gafter A, Borok S, Fraser A, Leibovici L, Paul M. Efficacy and safety of aminoglycoside monotherapy: Systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother. 2007;60(2):247-57. https://doi.org/10.1093/jac/dkm193
Tan X, Pan Q, Mo C, Li X, Liang X, Li Y, et al. Carbapenems vs alternative antibiotics for the treatment of complicated urinary tract infection: A systematic review and network meta-analysis. Medicine. 2020;99(2):e18769. https://doi.org/10.1097/MD.0000000000018769
Van Dorsten JP, Lenke RR, Schifrin BS. Pyelonephritis in pregnancy. The role of in-hospital management and nitrofurantoin suppression. J Reprod Med [Internet]. 1987;32(12):895-900. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/3430498
van Nieuwkoop C, van der Starre WE, Stalenhoef JE, van Aartrijk AM, van der Reijden TJK, Vollaard AM, et al. Treatment duration of febrile urinary tract infection: A pragmatic randomized, double-blind, placebo-controlled non-inferiority trial in men and women. BMC Med. 2017;15(1):70. https://doi.org/10.1186/s12916-017-0835-3
How to Cite
Downloads
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Funding data
| Article metrics | |
|---|---|
| Abstract views | |
| Galley vies | |
| PDF Views | |
| HTML views | |
| Other views | |
