Beginning January 2000, all pregnant women with acute pyelonephritis admitted to Parkland Hospital, Dallas, Texas, were enrolled in a specialized prenatal clinic for women with infectious diseases. A change in management because of bacteremia alone occurred in only 1% of cases. Klebsiella, Enterococcus, and Proteus spp. “Pyelonephritis in pregnancy: a prospective randomized trial to prevent recurrent disease evaluating suppressive therapy with nitrofurantoin and close surveillance”. If renal insufficiency is suspected, close observation with 24-hour urine protein/creatinine or spot urine protein/creatinine ratios may be followed sequentially throughout gestation and following delivery. With higher frequencies of the associated complications of pyelonephritis in pregnancy, such as preterm labor and delivery and acute respiratory compromise, occurring in the third trimester compared to earlier gestational ages, inpatient management is considered the standard of care in the third trimester. Chen, Y, Nitzan, O, Saliba, W. “Are blood cultures necessary in the management of women with complicated pyelonephritis”. Copyright © 2017, 2013 Decision Support in Medicine, LLC. Another potentially fatal complication of the disease is respiratory insufficiency. More contemporary research, however, has questioned this paradigm. Therapy traditionally consists of inpatient administration of intravenous antibiotics, but recent studies have shown that intramuscular ceftriaxone can be an effective outpatient regimen in selected patients. Archabald, KL, Friedman, A, Raker, CA, Anderson, BL. Recurrent pyelonephritis occurs in approximately 8-20% of women before delivery.

Monitoring serum lactate dehydrogenase levels is a common practice and is used to evaluate for hemolysis attributed to endotoxin mediated hemolysis.

In addition to urinalysis and urine culture, laboratory evaluation should include a complete blood cell count with differential to evaluate for leukocytosis and anemia, and serum chemistry evaluation. “Acute pyelonephritis in pregnancy”. Of 368 women delivered at Parkland Hospital with a history of pyelonephritis during the pregnancy, 19/368 (5%) delivered at less than 37 weeks, and only 4/368 (1%) delivered preterm during their admission for acute pyelonephritis. Amino- and carboxy-penicillin derivatives, ureidopenicillins and cephalosporins have good safety profiles in pregnancy (most are U.S. Food and Drug Administration Category B) and have good urinary penetration. Intravenous pyelography is also a radiologic modality that has been historically used to aid in the diagnosis of urinary tract anatomic or functional deficits; computed tomography of the urinary tract with minimal number of exposures obtained so as to minimize fetal exposure to ionizing radiation has replaced IVP. The pathogenesis of urosepsis is mediated by endotoxin present in the cell wall of Gram negative bacteria.

)(This important comparative investigation outlines the importance of antibiotic suppression for the duration of pregnancy following treatment for acute pyelonephritis in pregnancy, with a nearly 30% reduction in the frequency of positive urine cultures in women treated with prophylaxis versus those without. The uropathogen most commonly found was Urine cultures were obtained from 149 of the patients two weeks after initial treatment. )(This is a description of the frequency of acute pyelonephritis in pregnancy and its associated complications from a large inner-city facility in Dallas, Texas.
There is insufficient data to recommend one antibacterial regimen at the current time, although consideration should be given to the antimicrobial-resistance patterns at a given hospital. If after initiation of IV fluid hydration, parenteral antibiotics and monitoring fluid status, the patient is afebrile for more than 48 hours and has symptomatic improvement, she is discharged home with outpatient completion of oral antibiotics for a total of 2 weeks. Widmer, M, Lopez, I, Gülmezoglu, AM, Mignini, L, Roganti, A. Graham, JM, Oshiro, BT, Blanco, JD, Magee, KP.

Significant savings could result from the selective use of ceftriaxone, as it can be administered on an outpatient basis. “Duration of treatment for asymptomatic bacteriuria during pregnancy”. In addition, mechanical compression of the bladder and relaxation in detrusor muscle tone, lending to post-void residual urine volume, contribute to higher propensities toward UTI in pregnancy. Cefazolin has now replaced ampicillin as the initial broad-spectrum antibiotic of choice, and has the added benefit of being cost-effective. Lenke, RR, VanDorsten, JP, Schifrin, BS.

Amoxicillin or amoxicillin combined with clavulanic acid may then be used. The average birth weight was 3,274 g (7 lb, 3 oz), and 11 (6.9 percent) births were premature.The authors conclude that the three treatment regimens were equally safe and effective in treating pyelonephritis in pregnancy before 24 weeks' gestation.
(This report characterizes of frequencies with which associated morbidities of acute pyelonephritis in pregnancy are encountered.