Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks.

OBJECTIVE: To compare outpatient to inpatient management of acute pyelonephritis in pregnancy beyond 24 weeks' gestation. METHODS: Ninety-two gravidas past 24 weeks' gestation, randomized to outpatient or inpatient therapy, received two 1-g doses of intramuscular ceftriaxone at 24-hour intervals while hospitalized, then were discharged and reevaluated within 48-72 hours or remained hospitalized until afebrile for 48 hours. Subjects received oral cephalexin after initial treatment. Urine cultures were done on admission and 5-14 days after therapy. Surveillance continued until delivery. We anticipated that 15% of outpatients and 0.01% of inpatients would require changes in antibiotic therapy. RESULTS: Twenty-one percent of women evaluated were excluded. Thirteen of 46 (28%) outpatients' hospitalization exceeded 24 hours. Six outpatients (13.0%) and one inpatient did not respond to initial therapy and were treatment failures (relative risk [RR] 1.82, 95% confidence interval [CI] 1.00, 3.31). Within 2 weeks of initial therapy, seven of 81 (8.6%) subjects had positive urine cultures, four outpatients versus three inpatients (P > .999). Eleven of 84 (13.1%) deliveries for which birth data were available occurred preterm (six of 41 outpatients versus five of 43 inpatients) (RR 1.14, 95% CI 0.61, 2.11). CONCLUSION: There were no significant differences in clinical responses or birth outcomes of inpatients or outpatients treated for acute pyelonephritis after 24 weeks' gestation if they completed their assigned protocols. Thirty percent of outpatients were unable to, and most women with acute pyelonephritis in the third trimester were not candidates for outpatient therapy.

Serial betamethasone administration: effect on maternal salivary estriol levels.

OBJECTIVE: Maternal salivary estriol levels are an indirect measure of fetal adrenal activity, which may be affected by administration of betamethasone. The objective was to compare sequential salivary estriol levels in patients receiving serial betamethasone therapy with those of healthy pregnant patients. STUDY DESIGN: Ten patients at high risk for preterm delivery were asked to obtain salivary specimens before and 1 to 2 days after each administration of weekly betamethasone treatments between 24 and 32 weeks' gestation. These values were compared with those of specimens obtained throughout gestation in healthy women who were not delivered preterm. Unconjugated salivary estriol was measured with a sensitive and specific enzyme-linked immunoassay (Biex, Inc, Dublin, Calif). RESULTS: The effect of betamethasone on salivary estriol levels did not change with time, showing an average of 23.1% drop from pretreatment to posttreatment levels but rebounding to the same starting level before the next dose. When weekly pretreatment values were looked at across time, the geometric mean of the individual patients' slopes did not differ significantly from no change. The same was true of the posttreatment values. The rate of change with advancing gestation was compared between 182 control subjects and the 10 study subjects. The average change was +8.8% per week in the control subjects and -1.3% per week in the study patients (P =.003). CONCLUSIONS: Maternal administration of betamethasone significantly suppressed salivary estriol levels. These levels returned to pretreatment values each week before the next dose; however, the rise normally associated with advancing gestational age was not observed.

A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy.

OBJECTIVE: To compare the effectiveness of three antibiotic regimens for the treatment of acute pyelonephritis in pregnancy. METHODS: One hundred seventy-nine pregnant women earlier than 24 weeks' gestation who had acute pyelonephritis were randomized to 1) intravenous (i.v.) ampicillin and gentamicin, 2) i.v. 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 alpha = .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. RESULTS: The treatment groups were similar in age, parity, temperature, gestational age, and initial white blood cell count. There were no statistically significant differences in length of hospitalization, hours until becoming afebrile, days until resolution of costovertebral angle tenderness, or infecting organism. There were no statistically significant differences in birth outcomes between the three groups. The average (standard deviation) age at delivery was 38.8 +/- 3.6 weeks. The average birth weight was 3274 +/- 523 g. Eleven (6.9%) of 159 subjects delivered prematurely. Escherichia coli was the most common uropathogen isolated (137 of 179, 76.5%). Blood cultures were positive for organisms in 15 cases (8.4%). At follow-up examination within 2 weeks of initial therapy, eight (5.0%) of 159 subjects had urine cultures positive for organisms. Ten women (6.3%) had cultures positive for organisms later in their antepartum course, and 10 other participants (6.3%) developed recurrent pyelonephritis. CONCLUSION: 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.