“Urielle’s urine”
RDU on UTI Pregnant
Group 1
Achondo, Acttanasiri, Agraan, Alingayao, Angkaw, Anzures, Apalisok,
Araya, Arenque, Arocena, Asuncion, Avaiya, Avena, Badiola
Learning Objectives
1.
Diagnose the case presented
2.
Create a concept map explaining the pathophysiology of the case
3.
Formulate the therapeutic objectives and treatment
4.
Justify the drug you choose for the case
5.
Create a prescription appropriate for the patient
6.
Plan your counseling technique for the patient
The students should have a prior knowledge on:
1.
Basic Pharmacology on Antimicrobials
2.
Principles of Rational Drug Use
3.
Pathophysiology of infection in pregnant women
4.
Principles of Prescription Writing
5. If available, include Clinical Practice Guidelines, WHO guidelines, JNCs, GINA, Different local
disciplines.
Case
Urielle, a 24 year old primigravid, on her 12th weeks age of gestation, consulted her OB-GYN for
the first time. A Urinalysis was requested on her. She is wondering about the request because
she could not remember any manifestations pertaining to the Urinary system. Though hesitant,
she still complied. There are no associated signs and symptoms like pain and fever. Her Past
medical history and family history were all unremarkable.
Urinalysis result:
color: yellow
PMN: 12-17/ hpf
glucose: (-)
protein (-)
bacteria: few
epithelial cells: few
A urine culture and sensitivity was further requested which revealed presence of > 100,000
colonies of Escherichia coli / ml of urine.
Questions
1. What is your diagnosis?
2.
How will you explain, in a concept map form, what is happening to Urielle?
3.
What are your therapeutic objectives in managing her condition?
4.
How will you manage her both pharmacologically and non-pharmacologically?
5. How will you select your drug for Urielle on the basis of comparing efficacy, suitability,
safety and cost?
6.
What is the drug that you are to give her?
7.
How will you counsel her about the complete drug information?
8.
When will you ask her for follow-up?
Salient Features
●
●
●
●
●
24 year old
Primigravid, 12 weeks AOG
Asymptomatic
Urinalysis result:
- PMN of 12-17/ hpf (leukocyturia)
Urine culture and sensitivity result:
- >100 000 colonies of e.coli/ ml of urine
Definition of Terms
Primigravid – An individual pregnant for the first time (webster) or has been pregnant one time.
Age of gestation – Common term used during pregnancy to describe how far along the pregnancy is,
usually measured in weeks and taken from the first day of the woman’s last menstrual cycle to the current
date. (medline)
Urinalysis – usually done via midstream clean catch, usually includes physical, chemical and microscopic
examination. Besides noting for color and odor, it also includes noting bilirubin, blood, glucose, ketones,
leukocyte esterase, nitrites, protein, specific gravity and urobilinogen.
Definition of Terms
Urine culture and sensitivity – Used to diagnose a urinary tract infection and to identify the bacteria or
yeast causing the infection (portea)
Escherichia coli – part of Enterobacteriaceae, gram negative rod which usually resides in the intestinal
tract of humans and animals. It is part of the normal microbiota and incidentally cause disease. ( Jawetz)
What is your diagnosis? Basis?
Pregnant Uterine, G1P0, 8 weeks AOG, UTI, Asymptomatic bacteriuria, due
coli
BASIS:
-Pregnant at 8 weeks AOG
-presence of > 100,000 colonies of Escherichia coli / ml of urine.
-no associated signs and symptoms
to E.
Definition of asymptomatic bacteriuria (ASB)
ASB in pregnancy is the presence of
>100,000 CFU/mL of the same uropathogen in
two consecutive midstream urine specimens or
≥100 CFU/mL of a single uropathogen in one
catheterized
urine
specimen.
Symptoms
attributable to urinary infection should be absent.
Strong recommendation, High quality of evidence
*In settings where obtaining two consecutive
urine cultures is not feasible, or is difficult, one
urine culture is an acceptable alternative for the
diagnosis of ASB in pregnancy. Weak
recommendation, Low quality of evidence
IMMUNOLOGIC
Suppression of
various humoral and
cell-mediated
immunologic factors
CONCEPT
MAP
encourage the growth of
both commensal and
non-commensal
microorganisms
Most
common is
E.Coli
BACTERIURIA
PREGNANCY
Enhances
asymptomatic to
symptomatic
bacteriuria
Prenatally, routine urine
culture screening
X
Pyelonephritis,
prematurity,
low-birth
weight, higher
fetal mortality
Asymptomatic bacteriuria among pregnant women. Paul Erhunmwunse Imade, MSc, FIMLS:
© North American Journal of Medical Sciences
What are your therapeutic objectives in managing her
condition?
1.
2.
3.
4.
To eradicate bacteria (Escherichia coli)
To prevent complications
To prevent maternal and fetal complications
To prevent the recurrence
How will you manage her both pharmacologically and
non-pharmacologically?
Therapeutic Objectives
Pharmacologic Treatment
Non-Pharmacologic
Treatment
To eradicate bacteria (E. coli)
Give oral antibiotics
Adequate fluid intake
Good hygiene practices
To prevent maternal and fetal
complications
Give oral antibiotics
Adequate fluid intake
Good hygiene practices
To prevent recurrence
Behavioral methods:
●
Avoid baths
●
Wash hands before using the toilet
●
Wipe front-to-back after urinating or
defecating
●
Use liquid soap to prevent colonization
●
Use washcloths to clean the perineum
●
Clean the urethral meatus first when
bathing
How will you select your drug for Urielle on the basis of
comparing efficacy, suitability, safety and cost?
Drug
Nitrofurantoin
Efficacy
Safety
Suitability
Cost
A urinary antiseptic.
Category B
100 mg QID x 7 days
100 mg capsule 29.00 php
Bacterial flavoproteins
reduce nitrofurantoin into
highly reactive compounds
which inactivate or alter
ribosomal proteins and
other bacterial
macro-molecules →
bacterial protein synthesis,
aerobic metabolism, DNA
and RNA synthesis and
cell wall synthesis are
inhibited.
Anorexia , nausea,
vomiting
Well absorbed after
ingestion
29.00 php x 4 = 116 x 7
May cause hemolytic
anemia, anophthalmia ,
hypoplastic left heart
syndrome, ASD and cleft
lip and palate.
Must be taken with food to
improve absorption and to
increase GI tolerance.
May be given on the
second trimester up to 32
weeks AOG.
= 812.00 php
Drug
Co-Amoxiclav
Amoxicillin + Clavulanic
acid
Efficacy
β-lactamase-producing
strains including resp tract,
genitourinary & abdominal
infections; cellulitis, animal
bites, severe dental
infection w/ spreading
cellulitis
Safety
Hypersensitivity reactions
& GI disturbances.
Prolonged bleeding time,
Dizziness, headache,
Increased AST & ALT,
serum bilirubin & alkaline
phosphatase;
Category B
Suitability
625mg tablet BID x 7 days
May be taken with or
without food: Best taken at
the start of meals for
better absorption & to
reduce GI discomfort
Cost
625mg tablet 36.75php
36.75 x 14 = 514.50php
Drug
Cephalexin
Efficacy
effective against
most gram-positive
bacteria
It inihibits cross
linking reaction
between N-acetyl
muramicacid and
N-acetylglucosamin
e in the cell wall
effective against
gram-positive
bacteria
Safety
Category B
Safe to use in
any trimester
Doesn't show
any birth defect
in neonate
upset stomach,
diarrhea, and
vomiting.
Suitability
Dose: 500mg BID
for 7 days for UTI
before meal
Cost
P 2.60 / tablet
36.4 total
Drug
Fosfomycin
trometamol
Efficacy
Synthetic, broad spectrum,
bactericidal antibiotic
It inhibits the very early stage
of bacterial cell wall synthesis
due to its inactivation of the
enzyme enolpyruvate
transferase, thereby
irreversibly blocking the
condensation of uridine
diphosphate-N-acetylglucosa
mine with p-enolpyruvate.
Active against both
Gram-positive and Gram
negative
organisms
Safety
Category B
Safe to use in any
trimester.
Most common
side effects
include: diarrhea,
vaginal itching or
pain, nausea,
headache,
dizziness,
weakness and
indigestion.
Suitability
Used as a single
3-g dose for
treatment of
uncomplicated
UTIs in women.
Can be taken with
or without food.
Cost
Monurol
granules
P 439.6 /
sachet
How will you select your drug for Urielle on the basis of
comparing efficacy, suitability, safety and cost?
Drug
Efficacy
Safety
Suitability
Cost
TOTAL
Nitrofurantoin
++++
+++
++
+
10
Co-Amoxiclav
++++
+++
++
++
11
Cephalexin
+++
++
+
++++
10
Fosfomycin
++++
+++
++
++++
13
What is the drug that you are to give her?
Dispense: 1 sachet
Label: Should be taken orally 1 hr before or 2 hr after meals. Dissolve
the contents of a single-dose sachet in 90-120 mL of water. Do not use
hot water. Should be taken immediately after dissolving in water for
Urinary tract infection.
How will you counsel her about the complete drug
information?
Cephalexin falls into category B. Studies in animals have failed to
demonstrate a risk to the unborn baby and there are no well-controlled
studies in pregnant women.
Reassure that the p drug is safe to use in any trimester. But it may still
exhibit common side effects such as upset stomach, diarrhea, vomiting,
stomach cramps, fever, mild skin rash.
Advise her to be vigilant if any serious adverse reaction such as
hypersensitivity may happen; seek medical attention if symptoms persist.
When will you ask her for follow-up?
Seven days after the antibiotic course.
The studies show that three days of antibiotic treatment for urinary tract infection is
as effective as seven or ten days. But recurrent infections in pregnant women are
tend to occur and may have serious consequences therefore a longer course of
antibiotics is used to avoid relapse. And post-treatment urine culture should be
obtained to confirm eradication of bacteriuria in pregnant women.
References