SMO 382 (D3i)

Topic6: IS THERE A BENEFIT WHEN

ANTIBIOTICS ARE PRESCRIBED FOR

ASYMPTOMATIC BACTERURIA IN PREGNANCY?

Nomsa Sibanyoni 28020864

Lerato Setlalentoa 28069201
Tanya White 28052243
Kyle Kumin 28002424
Irini Bogiages 28002368
N Nkabinde 27090360
T Tsotsetsi 27151574

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INTRODUCTION

Studies have shown that asymptomatic bacteriuria is found in 2 to 10% of all pregnancies. The prevalence of urinary

tract infection is closely related to the socio-economic status of the population. Statistically, 30% of mothers with

asymptomatic bacteriuria will develop symptomatic infection (pyelonephritis) if left untreated. Asymptomatic

bacteriuria has also been associated with low birth weight (<2500g) and pre-term delivery (<38 weeks). Based on

these studies, a review was compiled to determine the effect of antibiotic treatment on asymptomatic bacteriuria

during pregnancy. This review paid specific attention to: the development of pyelonephritis, persistent bacteriuria

during and after pregnancy and the risk of low birth weight and pre-term delivery. The review makes an attempt to

determine whether it is viable for all pregnant women to be screened and treated for asymptomatic bacteriuria. The

majority of the included studies were performed in first world countries and so the relevance (of the outcomes and

suggested protocol) to a developing country is questionable. [1,2]

RESULTS OF META-ANALYSIS

There were fourteen trials included in the meta- analysis. In 9 of the 14 trials, the control group received a placebo. In

the remaining 5 trials the control group received nothing, but the trials fails to mention whether the participants were

blind to treatment allocation. [1] Of the included trials, four main outcomes were deduced. No consistent applications

for the measured outcomes were defined. Furthermore, the included studies failed to control for socio-economic

status, smoking during pregnancy, age, parity and the presence of co-existing genital infections [2]

1) Persistent bacteriuria[2]

The administration of antibiotics proved to be beneficial in clearing persistent bacteriuria.

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 2) Development of pyelonephritis [2]

The use of antibiotics is beneficial in reducing pyelonephritis.

3) Low birth weight (<2500g) [2]

The above meta-analysis shows a benefit in the use of antibiotics regarding low birth weight neonates but the

overall relationship between asymptomatic bacteruria and low birth weight has not yet been convincingly

determined. Further research may yield more reliable results.[1,2]

4) Preterm delivery (<38 weeks gestational age) [2]

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There is no effect on the reduction of preterm delivery.

Relevance of study to conditions in South Africa

The intervention strategies proposed by the WHO, with regards to the study, will not necessarily be feasible or as

easily implemented in South-Africa as compared to develop countries. Reasons for the uncertainty of the relevance of

implementation include; lack of funds, misinformation (of both the health care worker and mother to be) and a general

lack of skills. According to the WHO all pregnant women should be screened on their first antenatal visit and a urine

culture should be performed. In South-Africa, a substantial amount of women never attend an antenatal clinic or only

visit one late into pregnancy. The cost-effectiveness of a quantitative urine culture on midstream or clean catch urine,

to be performed on every mother, has yet to be determined. Midstream urine is a labour intensive procedure as the

labia and perineum have to be cleaned according to very specific processes and the urine collecting has to be

terminated before the patient has finished voiding. If these precise procedures are not carried out, the results of the

urine culture will be insignificant. It is also difficult to follow up on patients as many women stay far from the clinics.

In some areas there may be limited access to antibiotic therapy. The above mentioned factors and inadequate

compliance to treatment will make the suggested interventions challenging and possibly unrealistic to implement. [2,3]

Conclusion

A recent prospective longitudinal study concluded a decrease in the incidence of hospitalisation for acute

pyelonephritis in pregnancy, with the administration of antibiotics and implementing the practise of screening for

asymptomatic bacteruria in pregnant women. This study showed a decline from 3- 4% to 1, 4%.[4]

The most effective time to perform the urine culture has not been determined. Despite suggestions to screen and treat

at the first prenatal visit, evidence shows that a single culture before twenty weeks may yield a false negative. There is

a need to determine the appropriate time for initial screening, when to repeat negative results, the most effective

primary treatment, when to follow up and retreatment strategies. Even though studies concluded that there is a benefit

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when antibiotics are prescribed to pregnant women with asymptomatic bacteruria, the optimal duration of treatment is

unknown. It is currently recommended that standard treatment protocol, as suggested by the WHO, be followed.

The review failed to determine the efficiency of antibiotics in preventing the recurrence of bacteruria in pregnancy.

The relationship between asymptomatic bacteruria and low birth weight has not convincingly been determined.

Evidence suggests that increasing amounts of pro-inflammatory cytokines, released by maternal or fetal monocytes or

marcophages, in response to bacteria may initiate labour. Further research may yield more convincing results.

In the studies reviewed, a diagnosis of asymptomatic bacteruria was made if the urine collected had a bacteria colony

count of more than 100 000 bacteria/ml. The gold standard for identifying asymptomatic bacteruria is quantitative

urine culture of a mid stream or clean catch urine. Rapid screening tests like urine microscopy and urine dipstick are

more cost effective but the results are less accurate. Even though evidence confirms that there is a benefit when

antibiotics are prescribed for asymptomatic bacteruria in pregnancy, the cost effectiveness of screening and treating

the entire population has yet to be determined. Based on further research, high risk population groups and the

prevalence of asymptomatic bacteruria in South Africa must be determined in order to make more informed decisions

about the benefit of implementing the proposed protocol.

Due to the overwhelming worldwide concern of increasing antimicrobial resistance it is essential that studies

determine systems to prevent inappropriate antibiotic usage. An anti-microbial susceptibility test should be conducted

in order to determine which antibiotic should be prescribed. Furthermore, the possible teratogenic properties of the

different types of antibiotics needs to be considered [1,2]

References:

1. Tolosa J.E. Antibiotics for asymptomatic bacteruria in pregnancy: RHL commentary (last revised: 14 January

2008). The WHO Reproductive Health Library; Geneva: World Health Organization.

2. Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteruria in pregnancy. Cochrane Database of Systemic

Reviews 2007, Issue 4. Art. No.: CD000490. D07:10.1002/14651858. CD 000490.pub2

Jorge E. Tolosa. Antibiotics for asymptomatic bacteriuria in pregnancy RHL practical aspects

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 (last revised: 14 January 2008). The WHO Reproductive Health Library; Geneva: World
Health Organization.

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