Sunday, January 28, 2018

UTI in pregnancy: nitrofurantoin and trimethoprim-sulfamethoxazole overprescribed despite potential risks.


Nitrofurantoin and trimethoprim-sulfamethoxazole were commonly prescribed for pregnant women during first trimester in 2014, despite the potential risk associated with these antibiotics, reports the results of analysis of large insurance database by Center for Disease Control(CDC). These findings were reported in the Morbidity and Mortality Weekly Report(MMWR) by CDC issued January 12, 2018.

Pregnant women are routinely screened for UTI in pregnancy and receive antibiotics if they screen positive, because of foreseen serious complication later in pregnancy like pyelonephritis, preterm labor, low birth weight, and sepsis.

ACOG recommends to being selective in prescribing antibiotics during first trimester because of potential of birth defects with certain antibiotics. ACOG recommends that nitrofurantoin and trimethoprim-sulfamethoxazole should only be prescribed in early pregnancy when other antibiotics are found ineffective.

CDC gathered data of about 482,917 pregnancies from Truven Health MarketScan Commercial Database and analyzed it for prescription filled for antibiotics during the first trimester.

All pregnant women between aged 15–44 years with a diagnosis of a UTI from 90 days before LMP through the end of pregnancy were identified to be included in the study. UTI was defined according to the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9 CM) diagnosis code or presence of cystitis with an outpatient prescription filled.

Women with recurrent UTI or those who were admitted were excluded from study.

The data showed that 34,864 (7.2%) pregnant women had an initial outpatient UTI claim 90 days before or during pregnancy.  UTI was most common during the first trimester (40%) and least common in the third trimester of pregnancy.

Types of antibiotics prescribed differed according to pregnancy status of women, with fluoroquinolones and sulfonamides more commonly prescribed to women within 90 days before their LMP while nitrofurantoin, cephalosporins and penicillins were the drugs of choice during pregnancy.

The most common antibiotics prescribed during the first trimester were nitrofurantoin (34.7%), ciprofloxacin (10.5%), cephalexin (10.3%), and trimethoprim-sulfamethoxazole (7.6%).

This report has its own limitations because UTI was identified only based on codes and not lab reports, some women may have other concomitant infections for which these antibiotics were prescribed, the MarketScan sample was a convenient sample hence could not be generalized to whole of US populations and out of pocket payee women were not included in the study.

Inspite of these limitations,  the report shows that it is important for all healthcare providers to be aware of antibiotic recommendations in pregnancy and be aware that they are prescribing for two in women who are pregnant or who might get pregnant in coming months.   





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