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Learning outcomes
Level 2 case study: You will be able to:
Scenario
A 30-year-old pregnant woman presents to your pharmacy with a new prescription for cefalexin
500 mg three times a day for one week. She is worried about possible effects on the developing
baby.
Questions
2b. What are the presenting features, signs and symptoms of UTI?
4a. Which antibiotics used to treat UTI can be safely prescribed in pregnancy?
4b. Which antibiotics used to treat UTI can be used with caution during pregnancy?
4c. Which antibiotics used to treat UTI should be avoided or are contraindicated during
pregnancy?
5a. How would you counsel the patient on the medication she has been prescribed?
5b. What nutritional advice could you offer the patient to aid a healthy pregnancy?
General references
Answers:
Urinary tract infections are usually caused by bacteria from the gastrointestinal tract; Escherichia
coli accounts for about 90% of UTIs acquired in the community.
Other organisms responsible for UTIs are Staphylococcus species, Proteus mirabilis, Enterococci
and Candida albicans. Candida albicans UTI is rarely found in patients within the community
setting but is common in hospital patients with risk factors such as indwelling catheters,
immunosuppression, diabetes mellitus and those on antibiotic treatment.
• dysuria
• frequency of urination
• haematuria
• back pain
• flank/loin tenderness
• no vaginal irritation or discharge.
Before initiating treatment it is important that a sample of urine be sent for culture and
sensitivities. A mid-stream urine sample (MSU) and clean catch urine are the most commonly
collected specimens and are recommended for routine use. The first part of the voided urine is
discarded and without interrupting the flow approximately 10 mL is collected in a sterile
container.
Empirical treatment is then initiated with trimethoprim, nitrofurantoin or cefalexin.
Once the sensitivity of the cultured organism is known treatment can be adjusted
accordingly.
A repeat urine culture should be done at approximately 7 days after the completion of
treatment to confirm eradication of the bacteria has been achieved.
Symptoms of pain and raised temperature due to infection may be treated with
paracetamol.
Urine cultures should be repeated monthly throughout the rest of the pregnancy to
screen for asymptomatic infection.
4b Which antibiotics used to treat UTI can be used with caution during pregnancy?
Trimethoprim can be used during pregnancy except in women with a known folate deficiency or
those who are taking folate antagonists, because it may limit availability of folic acid to the fetus
and impair normal development. There is equivocal evidence to suggest that folate
supplementation reduces the risk of neural tube defects in offspring of pregnant women treated
with trimethoprim. Therefore, folate supplementation is recommended in all women treated with
trimethoprim during the first trimester as a precautionary measure. Trimethoprim should not be
used if the woman has recently had a course (some clinicians recommend avoiding repeating
treatment with trimethoprim within three months) or if the woman has a history of recurrent
infections resistant to this drug.
Co-amoxiclav can be separated into amoxicillin (see above 4a) and clavulanic acid; no adverse
effects in newborn or fetus attributed to the combination of amoxicillin and clavulanic acid
during pregnancy. Nitrofurantoin is effective against most UTIs. It should not be prescribed if
the mother is glucose-6-phosphate dehydrogenase (G6PD) deficient. Nitrofurantoin can
otherwise be used in pregnancy, but may cause haemolysis in a G6PD-deficient infant if used
close to term. Nitrofurantoin is thus contraindicated in pregnant women during the third
trimester. For most people the standard tablet formulation is suitable. The microcrystalline
capsules and the twice-daily modified-release formulation may be better tolerated if nausea is
troublesome and are offered as alternatives.
4c Which antibiotics used to treat UTI should be avoided or are contraindicated during
pregnancy?
Quinolones are contraindicated during all stages of pregnancy due to the risk of arthropathy.
5a How would you counsel the patient on the medication she has been prescribed?
5b What nutritional advice could you offer the patient to aid a healthy pregnancy?
A healthy diet during pregnancy helps reduce the risk of having an infant of low birth weight
who is at increased risk of poor health. A good diet contains a wide variety of foods including
bread, cereals, pasta, rice and potatoes; fruit and vegetables; lean meat; fish and pulses; and
reduced fat milk and dairy products. Listeriosis is a rare but serious disease if it occurs in
pregnancy. Some cases of listeria have been associated with food. Foods such as Brie,
Camembert and blueveined cheeses, pâté and undercooked meat, eggs and poultry should be
avoided. Fruit, vegetables and salads should be washed thoroughly.