Critical Appraisal Topics
Title: no difference of empiric antibiotic choice in pregnant women with acute
pyelonephritis
Clinical bottom line:
Empiric antibiotic use of acute pyelonephritis in pregnancy could be cefazolin or cefazolin +
GM or ceftriaxon. The clinical choice should be revised according to the culture result.
Citation/s:
Obstetrics & Gynecology Volume 92, Issue 2, August 1998, Pages 249-253 A randomized trial of
three antibiotic regimens for the treatment of pyelonephritis in pregnancy
Lead author's name and fax:
DeborahA Wing MD, ColleenM Hendershott MD, Laurie Debuque RN, and LynnaeK Millar MD
Clinical Scenario & PICO Question:
情境重點簡述：
22 歲越南新娘，懷孕約妊娠 30 週。懷孕以來有規則接受產檢，過程中並沒有異常發現。在 3
月 14 日當日忽然發生右側腰痛而至急診求診，經由一連串檢查發現，白血球上升(WBC
11300/ul,seg 80%)。尿液檢查發現膿尿和菌尿。腎臟超音波有雙側水腎。入院診斷為泌尿道感
染併左側急性腎盂腎炎。
懷孕婦女的泌尿道感染與一般泌尿道感染在抗生素上的選擇有何不同，對胎兒會有影響嗎？
P:
pregnant women with acute pyelonephritis
I/E and C :
1) intravenous (IV) ampicillin and gentamicin,
2) IV cefazolin, or
3) intramuscular ceftriaxone
O:
persistent or recurrent infection and obstetric complications
Type of Question: therapy
Search Terms & Strategy:
Database: Pubmed
Key words & Search stratedy: （建議進入 clinical query 搜尋 , 另外 pyelonephritis 是否有同義
字？ Urninary tract infection 是否同義或包含 pyelonephritis？）




#6 and #7 8
#7Search pregnancy 655767
#6Search acute pyelonephritis ceftriaxon 45
#3Search acute pyelonephritis cefazolin and gentamicin 4
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 #2Search acute pyelonephritis cefazolin 15
 #1Search acute pyelonephritis 3174
The Study: Level of Evidence: Ib
 179 pregnant women < 24 GA who had acute pyelonephritis were randomized to
1) intravenous (IV) ampicillin and gentamicin,
2) IV cefazolin, or
3) intramuscular ceftriaxone.
 All participants then completed 10-day courses of oral cephalexin after primary treatment.
 A urine culture was performed on admission and 5–14 days after completion of therapy.
 Surveillance for persistent or recurrent infection and obstetric complications continued until
delivery.
 On the basis of a two-sided hypothesis test and with α = .025, 60 subjects were needed in
each group for statistical power greater than 80% to detect a difference between ceftriaxone
and other antibiotics if hospital length of stay differed by 1 or more days.
The Evidence:
1.
no statistically significant differences in length of hospitalization, hours until becoming
afebrile, days until resolution of costovertebral angle tenderness, infecting organism.
no statistically significant differences in birth outcomes between the three groups
Escherichia coli was the most common uropathogen isolated (137 of 179, 76.5%). Blood
cultures were positive for organisms in 15 cases (8.4%).
There are no significant differences in clinical response to antimicrobial therapy or birth
outcomes among subjects treated with ampicillin and gentamicin, cefazolin, or ceftriaxone for
acute pyelonephritis in pregnancy before 24 weeks’ gestation.
2.
3.
4.
Comments:
1. 由上面這篇 paper 雖然最符合我們的答案，但因為年代久遠實在還必須考慮的年這些年來
抗藥性的問題。底下有一些近期 review article 分可解決我們的問題。

2008 research article
1) a prospective cohort study of pregnant women with pyelonephritis All patients received
ampicillin and gentamicin.
2) 440 cases 72 % (316 cases) had urine cultures with identification of organism and antibiotic
sensitivities. Fifty-one percent of uropathogens were ampicillin resistant. The patients
with ampicillin-resistant organisms were more likely to be older and multiparous.
3) no significant differences in hospital course (length of stay, days of antibiotics, ECU
admission, or readmission).
4) ampicillin resistant organisms did not have higher complication rates (anemia, renal
dysfunction, respiratory insufficiency, or pretermbirth).
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 2007 retrospective article：
1) 7034 pregnant, 94 cases of acute antepartum pyelonephritis (incidence: 1.3%).
2) Maternal mean age for the infection was 22 ± 3.41 years.
3) Acute pyelonephritis was most frequently occurred in nulliparous women (75%), and in the
second trimester (60%).
4) The incidences of low-birthweight babies (14%) and preterm babies (7.81%) in the cases with
acute antepartum pyelonephritis were not significantly different compared to that of all births
in our hospital during the same period (13% and 8%, respectively;P> 0.05).
5) Ceftriaxone, because of its safety and negligible side-effect, should be the drug of choice for
acute antepartum pyelonephritis

2004 Review article
1) equally effective based on the incidences of clinical cure, recurrence, preterm delivery, PPROM
and length of hospitalization
2) IV antimicrobial therapy should be initiated empirically and continued until the patient becomes
afebrile for 48 hours with the resolution of symptoms.
3) Conversion to oral antibiotics to complete a course lasting 10–14 days
4) The antibiotic(s) may be revised based on culture and sensitivities, and potentially changed to
contain an aminoglycoside.
References: 證據等級的判定需要修正
1.
Laura G. Greer, ScottW. Roberts, Jeanne S. Sheffield, Vanessa L. Rogers, James B. Hill,Donald D. Mcintire,
and George D.Wendel Jr Ampicillin Resistance and Outcome Differences in Acute Antepartum Pyelonephritis
Infectious Diseases in Obstetrics and Gynecology Volume 2008, Article ID 891426, 5 pages . (prospective
cohort study LoE: 2)
2.
Paban SHARMA and Laxmi THAPA, Acute pyelonephritis in pregnancy: A retrospective study, Australian
and New Zealand Journal of Obstetrics and Gynaecology 2007;47:313–315 ( retrospective study LoE: 3)
3. Jennifer Le, Gerald G Briggs, Anna McKeown, and Gerardo Bustillo Urinary Tract Infections During
Pregnancy Ann Pharmacother 2004;38:1692-701. (LoE: 1a)
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科部會議名稱：「一般內科 EBM 個案討論會」
舉行日期時間：3/24/2009, 0730-0830）
報告者：姓名：林佩萱
Code: 139293
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Email: 139293@cch.org.tw