Streptococcus agalactiae or group B streptococcus is a Gram-positive pathogen that is typically associated with neonatal disease and infection in pregnant women. Group B streptococcus also causes invasive infections in non-pregnant adults including urinary tract infections. The spectrum of urinary tract infections caused by group B streptococcus includes cystitis, pyelonephritis, urosepsis and asymptomatic bacteriuria, which is particularly common among elderly individuals. A rare form of invasive group B streptococcus infection in adults is secondary abscess. Here, we present the first reported case of a patient who developed an unusual, massive abdominopelvic abscess secondary to acute group B streptococcus urinary tract infection.
Pdegnancy example, about 1 in 4 babies Bladder infection in pregnancy and gbs percent who have meningitis caused by GBS develop: Cerebral palsy A group of disorders that can cause problems with brain development. Arch Med Sci. Scand J Infect Dis. To prevent group B bacteria from spreading to your baby during labor, your doctor can give you an IV antibiotic — usually penicillin or a related drug — when labor begins. Late-onset GBS can cause sepsis or meningitis. Different antibiotic regimens for Bladder infection in pregnancy and gbs asymptomatic bacteriuria in pregnancy. Please enter a valid e-mail address. One should also remember that antibiotic resistance of bacteria may differ depending on geographic area, Irosh porn stars and even hospital ward, and the information on this topic may be crucial when making therapeutic decisions.
Dogging signals. Early-onset GBS infection
Other infections are particularly troublesome for the baby. You might carry the bacteria in your body for a short time — Bladder infection in pregnancy and gbs can come and go — or you might always have it. Recurrent urinary tract infection in the female. When this occurs, the baby is at risk for health complications as well. Black celebs bulge Saf. In logistic regression analysis they found no association of exposure to the drugs and increased risk of both types of birth defects. Read this next. Antibiotic use in pregnancy. The screening is done by taking a swab of vagina and rectum culturing the samples in the lab. Pharmacoepidemiol Drug Saf.
This is a corrected version of the article that appeared in print.
- This material must not be used for commercial purposes, or in any hospital or medical facility.
- Group B strep streptococcus is a common bacterium often carried in the intestines or lower genital tract.
Urinary tract infections UTIs are common in pregnant women and pose a great therapeutic challenge, since the risk of serious complications in both the mother and her child is high. Pregnancy is a state associated with physiological, structural and functional urinary tract changes which promote ascending infections from the urethra.
Unlike the general population, all pregnant women should be screened for bacteriuria with urine culture, and asymptomatic bacteriuria must be treated in every case that is diagnosed, as it is an important risk factor for pyelonephritis in this population.
The antibiotic chosen should have a good maternal and fetal safety profile. In this paper, current principles of diagnosis and management of UTI in pregnancy are reviewed, and the main problems and controversies are identified and discussed.
Urinary tract infections UTIs in pregnant women continue to pose a clinical problem and a great challenge for physicians. That is related to profound structural and functional urinary tract changes, typical for pregnancy. This may be due to high levels of circulating progesterone [ 1 , 7 ]. Simultaneously, the enlarged uterus compresses the urinary bladder, thus increasing the intravesical pressure, which may result in vesico-ureteral reflux and urine retention in the bladder after miction, commonly observed in pregnant women.
Urinary stasis and impairment of the physiological anti-reflux mechanism create conditions favorable for bacterial growth and ascending infection. The additional predisposing factors include pregnancy-specific biochemical changes in urine, with higher amounts of glucose, amino acids and hormone degradation products, which increase urinary pH [ 7 , 8 ].
Similarly as in non-pregnant women, in pregnant women UTIs are classified either as asymptomatic bacteriuria ASB , when the infection is limited to bacterial growth in urine, or symptomatic infections acute cystitis, acute pyelonephritis , when bacteria invade urinary tract tissues, inducing an inflammatory response.
The UTIs in pregnancy are by definition considered complicated infections and require a special diagnostic approach and management. Many women acquire bacteriuria before pregnancy [ 18 , 19 ]. Other suggested risk factors for UTI during pregnancy are lower socioeconomic status, sexual activity, older age, multiparity, anatomical urinary tract abnormalities, sickle cell disease and diabetes, although the significance of some of them age, parity or sickle cell trait remains a matter of controversy [ 1 , 10 , 21 — 23 ].
The pathogens responsible for infections during pregnancy are similar to those in the general population. The Cochrane Library meta-analysis revealed that antibiotic treatment was effective in reducing the incidence of low-birth-weight infants but not of preterm deliveries [ 27 ].
However, the authors stressed the poor methodological quality of the available studies, their different design, lack of sufficient information about the randomization methods, different definitions used, low statistical power and some substantial biases, urging caution in drawing conclusions. A good example of these problems is presented by the Cardiff Birth Survey [ 33 ]. In a prospectively studied large cohort of 25 pregnancies, several demographic, social and medical factors including bacteriuria were significantly associated with preterm birth in the initial univariable analyses.
However, after adjustments for other medical factors, bacteriuria retained an association of only borderline significance, and after further adjustment for demographic and social factors, the relationship completely disappeared. Two separate multiple logistic regression analyses revealed that spontaneous and indicated preterm births have different overall profiles of risk factors, and only the last of them was associated with bacteriuria.
Maternal GBS bacteriuria in a pregnant woman is considered a marker for genital tract colonization with this organism which poses a significant risk of preterm rupture of the membranes, premature delivery and early-onset severe neonatal infection [ 1 , 24 , 26 , 35 — 37 ].
They may develop various complications, such as acute kidney injury, anemia, hypertension, preeclampsia, sepsis and septic shock, hemolysis, thrombocytopenia, and acute respiratory distress syndrome, particularly if treatment is initiated too late [ 17 , 27 , 38 — 44 ].
A number of observational studies have demonstrated the relationship between maternal symptomatic UTI and the risk of premature delivery and lower birth weight [ 28 — 30 , 46 ]. However, again, a substantial heterogeneity between these studies, together with many possible biases, makes it difficult to establish the overall contribution of UTI to preterm birth [ 48 ].
A rare but severe complication is the transmission of the infection onto the newborn baby [ 49 ]. Very often the transmitted infection originates from a heavily colonized birth canal, usually with GBS [ 26 ].
Nearly all antimicrobials cross the placenta, and some of them may exert teratogenic effects. A — Well-controlled studies available in humans with no adverse effects observed in human pregnancies; B — No adverse effects in well-controlled studies of human pregnancies with adverse effects seen in animal pregnancies OR no adverse effects in animal pregnancies without well-controlled human pregnancy data available; C — Human data lacking with adverse pregnancy effects seen in animal studies OR no pregnancy data available in either animals or humans; D — Adverse effects demonstrated in human pregnancies; benefits of drug use may outweigh the associated risks.
However, this study has been criticized for several significant limitations including recall bias women were asked about antibiotic use after pregnancy and it was not confirmed by medical records , inability to determine whether the birth defect was due to the antibiotic itself, the infection for which the antibiotic was prescribed, or other confounding factors.
Recently Nordeng et al. Among pregnancies between and , women filled prescriptions for nitrofurantoin in the first trimester. The same concerns other antimicrobials with very high protein binding e. Nitrofurantoin can be theoretically associated with a risk of fetal or neonatal hemolytic anemia if the mother has glucosephosphate deficiency, and although this complication in pregnancy has not been reported, the drug should be used with caution, particularly in areas of disease prevalence [ 10 , 58 , 59 ].
The rate of major congenital malformations did not differ between the group exposed to quinolones in the first trimester and the control group 2. A systemic review of prospective, controlled studies showed that the use of fluoroquinolones during the first trimester of pregnancy does not appear to be associated with an increased risk of major malformations recognized after birth, stillbirths, preterm births or low birth weight [ 64 ]. However, in some cases of complicated symptomatic UTI, resistant to other antibiotics, their benefits may outweigh the risks [ 60 ].
Although these drugs are used in pregnancy relatively often, the data on their embryotoxicity and teratogenicity are limited. No significant teratogenic effect of erythromycin was identified in a Hungarian case-control study, a nationally based registry of cases with congenital abnormalities [ 69 ].
The main limitations of this data set were: a relatively low response rate, retrospective collection of data recall bias , inability to exclude the effect of other drugs, and a restriction of the study to the second and third trimester.
However, in a large prospective observational study, performed in women exposed to macrolides during the first trimester, Bar-Oz et al. Recently, Lin et al. In logistic regression analysis they found no association of exposure to the drugs and increased risk of both types of birth defects.
So further studies are needed before the macrolides become accepted for wide use. Until then, this group of antibiotics should be reserved for the treatment of serious or life-threatening conditions, unresponsive to standard antibiotic therapy.
The study sought follow-up information for children at age 7 in the UK using a parent-report postal questionnaire. The cause of this neurological dysfunction is unclear, but it could be a result of subclinical perinatal infection as well as a direct effect of the antibiotics on the fetal brain or cerebral blood flow.
Alternatively the antibiotic might have negatively influenced microbial colonization of newborn children, with long-lasting consequences. There are some suggestions that antibiotics alter immune tolerance by changing the fetal gut flora, thus contributing to the substantial increase in the incidence of asthma, allergies, autoimmune diseases, autism, ADHD and other chronic conditions [ 73 — 75 ]. The main conclusion from all these interesting studies is that we should be very cautious in prescribing antibiotics to pregnant women in the absence of proven benefit e.
Given the evidence that effective antimicrobial therapy of ASB in pregnancy significantly reduces the risk of pyelonephritis and possibly also adverse fetal outcomes, routine screening for the presence of clinically significant bacteriuria in all pregnant women has become necessary.
A question which remains unanswered is: should women in whom no ASB was detected upon the first examination have additional screening in later pregnancy? McIsaac et al. A total of 49 cases of ASB were detected prevalence 4. In a much smaller Turkish study, ASB prevalence distribution in the first, second, and third trimesters was 0.
That suggests that many women with no bacteriuria in their initial examination in the first trimester may develop bacteriuria during the later trimesters. The authors of these studies conclude that it would be prudent to screen pregnant women for bacteriuria also in the second and third trimesters [ 78 , 79 ]. However, until large, prospective, randomized clinical trials RCTs are available and a clear benefit of this routine additional screening is observed, no recommendation can be made for or against it.
The presence of ASB in a pregnant woman is an absolute indication for initiation of the treatment. Management of ASB in pregnancy consists of short-term, usually 5—7 days, oral antibiotic therapy [ 76 ]. Basic principles of management are presented in Table II.
In the face of the rapidly developing antibiotic resistance, the current position is that the treatment should be based on microbial sensitivity testing.
Kashanian et al. Out of 10 cultures in which E. All pregnant women with ASB should have periodic screening after therapy, since as many as one third of them experience a recurrent infection [ 58 , 76 ]. Follow-up cultures should be obtained 1—2 weeks after treatment and then repeated once a month [ 58 , 76 ].
In case of persistent or recurrent bacteriuria, longer antibiotic therapy using the same agent e. Subsequent treatment courses are administered until the bacterial counts drop to non-significant levels [ 56 ]. If bacteriuria persists despite repeated courses of therapy, as well as in women with additional risk factors e. Patients with recurrences associated with sexual activity may be offered postcoital prophylaxis a single antibiotic dose e.
The remaining women may be given small doses of antibacterial agents e. In this group the follow-up urine culture is performed only at the beginning of the third trimester. In case of significant bacteriuria, prophylactic doses should be replaced by another course of antimicrobials, based on susceptibility testing [ 56 ].
The optimal duration of treatment is unknown, but longer courses 5—7 days of the therapy are generally suggested [ 12 , 55 , 58 , 86 ]. In women receiving chronic immunosuppression, management discussed in the section on ASB should be followed. Besides ASB, the other risk factors of acute pyelonephritis include: mother's age, nulliparity, sickle cell anemia, diabetes, nephrolithiasis, illicit drug use, history of pyelonephritis and maternal urinary tract defects [ 2 , 8 , 24 , 58 ].
Nearly one in five of pregnant women with pyelonephritis has septicemia at diagnosis [ 3 , 8 , 17 , 40 ]. Hill et al. Numbers of preterm births and small-for-gestational-age infants were not increased as compared with expected rates in this hospital.
Basic principles of management are presented in Table III. According to the IDSA guidelines, all suspected cases of pyelonephritis should be hospitalized at least for the initial 48 h of treatment [ 76 ]. However, some authors believe that in carefully selected cases, when a definite diagnosis of pyelonephritis can be made and a strict medical follow-up is possible, outpatient treatment may be attempted [ 38 , 88 , 89 ]. Appropriate hydration of the patient is a very important part of the treatment regardless of the setting.
Beside urine and blood culture, recommendations include basic laboratory analyses complete blood counts, electrolytes, creatinine, liver parameters, coagulation profile and an ultrasound scan, which usually reveals dilation of pyelocalyceal systems and allows exclusion of other causes of the symptoms e.
In all patients, regardless of whether they are hospitalized, antibiotics should be given parenterally, for at least the first 48 h until the resolution of fever. Forty-eight hours after resolution of symptoms, administration may be switched to the oral route.
Antibiotic therapy is usually continued for 10—14 days, although its optimum duration has never been established. Unfortunately, there are not sufficient data available to recommend the specific treatment regimens in pregnant women.
Then upon detection of bacteriuria, prophylaxis is replaced by regular treatment [ 56 ]. In the aforementioned prospective study by Hill et al. Only 12 of them 2. However, again, this regimen is not supported by evidence obtained in RCTs. Due to the potential risk to mother and fetus, detection and effective treatment of UTIs remains an important clinical problem.
It is advisable to assess risk factors for UTI in pregnancy, bearing in mind that some diagnostic procedures are not feasible and advisable to perform i. Unfortunately, in contrast to the overall population, available data are scant, and the management guidelines were published several years ago and were largely opinion-based. The development of new recommendations requires well-planned, extensive studies, that would answer the still open questions regarding the frequency of screening and follow-up examinations, purposefulness of prophylaxis, safety of hitherto insufficiently studied or new antibiotics in pregnancy, and choice of optimum treatment regimens.
If possible, any antibiotic use should be avoided in the first trimester, as this is the period of fetal organogenesis and nervous system development, with the highest risk of teratogenic effects of drugs. Another disturbing problem, particularly in the aspect of fetal safety associated with therapeutic limitations, is the observed rapid development of antibiotic resistance.
Recently Nordeng et al. A good example of these problems is presented by the Cardiff Birth Survey [ 33 ]. This content does not have an English version. Nearly all antimicrobials cross the placenta, and some of them may exert teratogenic effects. Recently, Lin et al. During pregnancy, your immune system changes so that it can protect both you and your baby from disease. Infections in Pregnancy: Bacterial Vaginosis.
Bladder infection in pregnancy and gbs. Introduction
Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems
This is a corrected version of the article that appeared in print. JOHN E. See related patient information handout on urinary tract infections during pregnancy , written by the authors of this article.
Asymptomatic bacteriuria can lead to the development of cystitis or pyelonephritis. All pregnant women should be screened for bacteriuria and subsequently treated with antibiotics such as nitrofurantoin, sulfisoxazole or cephalexin. Ampicillin should no longer be used in the treatment of asymptomatic bacteriuria because of high rates of resistance.
Pyelonephritis can be a life-threatening illness, with increased risk of perinatal and neonatal morbidity. Recurrent infections are common during pregnancy and require prophylactic treatment. Pregnant women with urinary group B streptococcal infection should be treated and should receive intrapartum prophylactic therapy. Urinary tract infections UTIs are frequently encountered in the family physician's office. UTIs account for approximately 10 percent of office visits by women, and 15 percent of women will have a UTI at some time during their life.
In pregnant women, the incidence of UTI can be as high as 8 percent. We review the diagnosis and treatment of asymptomatic bacteriuria, acute cystitis and pyelonephritis, plus the unique issues of group B streptococcus and recurrent infections.
Pregnant women are at increased risk for UTIs. Beginning in week 6 and peaking during weeks 22 to 24, approximately 90 percent of pregnant women develop ureteral dilatation, which will remain until delivery hydronephrosis of pregnancy. Increased bladder volume and decreased bladder tone, along with decreased ureteral tone, contribute to increased urinary stasis and ureterovesical reflux.
Up to 70 percent of pregnant women develop glycosuria, which encourages bacterial growth in the urine. Increases in urinary progestins and estrogens may lead to a decreased ability of the lower urinary tract to resist invading bacteria. This decreased ability may be caused by decreased ureteral tone or possibly by allowing some strains of bacteria to selectively grow.
The organisms that cause UTIs during pregnancy are the same as those found in nonpregnant patients. Escherichia coli accounts for 80 to 90 percent of infections. Other gram-negative rods such as Proteus mirabilis and Klebsiella pneumoniae are also common. Gram-positive organisms such as group B streptococcus and Staphylococcus saprophyticus are less common causes of UTI.
Group B streptococcus has important implications in the management of pregnancy and will be discussed further. Less common organisms that may cause UTI include enterococci, Gardnerella vaginalis and Ureaplasma ureolyticum.
UTIs have three principle presentations: asymptomatic bacteriuria, acute cystitis and pyelonephritis. The diagnosis and treatment of UTI depends on the presentation. In the s, Kass 6 noted the subsequent increased risk of developing pyelonephritis in patients with asymptomatic bacteriuria. Asymptomatic bacteriuria is common, with a prevalence of 10 percent during pregnancy. Untreated asymptomatic bacteriuria leads to the development of symptomatic cystitis in approximately 30 percent of patients and can lead to the development of pyelonephritis in up to 50 percent.
The American College of Obstetrics and Gynecology recommends that a urine culture be obtained at the first prenatal visit. By screening for and aggressively treating pregnant women with asymptomatic bacteriuria, it is possible to significantly decrease the annual incidence of pyelonephritis during pregnancy. Rouse and colleagues 14 performed a cost-benefit analysis of screening for bacteriuria in pregnant women versus inpatient treatment of pyelonephritis and found a substantial decrease in overall cost with screening.
Wadland and Plante 15 performed a similar analysis in a family practice obstetric population and found screening for asymptomatic bacteriuria to be cost-effective. The decision about how to screen asymptomatic women for bacteriuria is a balance between the cost of screening versus the sensitivity and specificity of each test. The accuracy of faster screening methods e. The increased number of false negatives and the relatively poor predictive value of a positive test make the faster methods less useful; therefore, a urine culture should be routinely obtained in pregnant women to screen for bacteriuria at the first prenatal visit and during the third trimester.
The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. Pregnant women should be treated when bacteriuria is identified Table 2 17 , The antibiotic should also be safe for the mother and fetus. Historically, ampicillin has been the drug of choice, but in recent years E.
Alternatively, cephalosporins are well tolerated and adequately treat the important organisms. Fosfomycin Monurol is a new antibiotic that is taken as a single dose. Sulfonamides can be taken during the first and second trimesters but, during the third trimester, the use of sulfonamides carries a risk that the infant will develop kernicterus, especially preterm infants.
Other common antibiotics e. Information from Duff P. Antibiotic selection for infections in obstetric patients. Semin Perinatol ;—78, and Krieger JN. Complications and treatment of urinary tract infections during pregnancy. Urol Clin North Am ;— A seven- to day course of antibiotic treatment is usually sufficient to eradicate the infecting organism s.
Some authorities have advocated shorter courses of treatment—even single-day therapy. Conflicting evidence remains as to whether pregnant patients should be treated with shorter courses of antibiotics. Masterton 21 demonstrated a cure rate of 88 percent with a single 3-g dose of ampicillin in ampicillin-sensitive isolates. Several other studies have found that a single dose of amoxicillin, cephalexin Keflex or nitrofurantoin was less successful in eradicating bacteriuria, with cure rates from 50 to 78 percent.
Other antibiotics have not been extensively researched for use in UTIs, and further studies are necessary to determine whether a shorter course of other antibiotics would be as effective as the traditional treatment length.
Acute cystitis is distinguished from asymptomatic bacteriuria by the presence of symptoms such as dysuria, urgency and frequency in afebrile patients with no evidence of systemic illness. Up to 30 percent of patients with untreated asymptomatic bacteriuria later develop symptomatic cystitis.
Antibiotic choice, as in asymptomatic bacteriuria, should focus on coverage of the common pathogens and can be changed after the organism is identified and sensitivities are determined. A three-day treatment course in nonpregnant patients with acute cystitis has a cure rate similar to a treatment course of seven to 10 days, but this finding has not been studied in the obstetric population.
In the pregnant patient, this higher rate of recurrence with shorter treatment periods may have serious consequences. Table 2 17 , 18 lists oral antibiotics that are acceptable treatment choices.
Group B streptococcus is generally susceptible to penicillin, but E. Acute pyelonephritis during pregnancy is a serious systemic illness that can progress to maternal sepsis, preterm labor and premature delivery. The diagnosis is made when the presence of bacteriuria is accompanied by systemic symptoms or signs such as fever, chills, nausea, vomiting and flank pain. Symptoms of lower tract infection i. Pyelonephritis occurs in 2 percent of pregnant women; up to 23 percent of these women have a recurrence during the same pregnancy.
Early, aggressive treatment is important in preventing complications from pyelonephritis. Hospitalization, although often indicated, is not always necessary. However, hospitalization is indicated for patients who are exhibiting signs of sepsis, who are vomiting and unable to stay hydrated, and who are having contractions. A randomized study of 90 obstetric inpatients with pyelonephritis compared treatment with oral cephalexin to treatment with intravenous cephalothin Keflin and found no difference between the two groups in the success of therapy, infant birth weight or preterm deliveries.
Further support for outpatient therapy is provided in a randomized clinical trial that compared standard inpatient, intravenous treatment to outpatient treatment with intramuscular ceftriaxone Rocephin plus oral cephalexin.
Several antibiotic regimens may be used. A clinical trial comparing three parenteral regimens found no differences in length of hospitalization, recurrence of pyelonephritis or preterm delivery. Parenteral treatment of pyelonephritis should be continued until the patient becomes afebrile.
If fever continues or other signs of systemic illness remain after appropriate antibiotic therapy, the possibility of a structural or anatomic abnormality should be investigated. Persistent infection may be caused by urolithiasis, which occurs in one of 1, pregnancies, 30 or less commonly, congenital renal abnormalities or a perinephric abscess. Diagnostic tests may include renal ultrasonography or an abbreviated intravenous pyelogram. The indication to perform an intravenous pyelogram is persistent infection after appropriate antibiotic therapy when there is the suggestion of a structural abnormality not evident on ultrasonography.
Group B streptococcal GBS vaginal colonization is known to be a cause of neonatal sepsis and is associated with preterm rupture of membranes, and preterm labor and delivery. The majority of UTIs are caused by gastrointestinal organisms. Even with appropriate treatment, the patient may experience a reinfection of the urinary tract from the rectal reservoir. UTIs recur in approximately 4 to 5 percent of pregnancies, and the risk of developing pyelonephritis is the same as the risk with primary UTIs.
A single, postcoital dose or daily suppression with cephalexin or nitrofurantoin in patients with recurrent UTIs is effective preventive therapy. The maternal and neonatal complications of a UTI during pregnancy can be devastating. Thirty percent of patients with untreated asymptomatic bacteriuria develop symptomatic cystitis and up to 50 percent develop pyelonephritis.
While this does not prove a cause and effect relationship, randomized trials have demonstrated that antibiotic treatment decreases the incidence of preterm birth and low-birth-weight infants.
Low birth weight weight less than 2, g [5 lb, 8 oz]. Preterm low birth weight weight less than 2, g and less than 37 weeks of gestation at delivery. Premature labor less than 37 weeks of gestation at delivery. Effective prophylaxis for recurrent urinary tract infections during pregnancy.
Clin Infect Dis ;—4. Neonatal outcomes that are associated with UTI include sepsis and pneumonia specifically, group B streptococcus infection. UTIs during pregnancy are a common cause of serious maternal and perinatal morbidity; with appropriate screening and treatment, this morbidity can be limited. A UTI may manifest as asymptomatic bacteriuria, acute cystitis or pyelonephritis.
All pregnant women should be screened for bacteriuria and subsequently treated with appropriate antibiotic therapy. Acute cystitis and pyelonephritis should be aggressively treated during pregnancy.
Oral nitrofurantoin and cephalexin are good antibiotic choices for treatment in pregnant women with asymptomatic bacteriuria and acute cystitis, but parenteral antibiotic therapy may be required in women with pyelonephritis.