Who takes precedence in management of asymptomatic bacteruria that was untreated since April 29, following prophylactic Erythromycin (Erythromycin) for Premature Rupture of Membranes (PROM)?

From the Guidelines

The priority in managing asymptomatic bacteriuria that was untreated since April 29th, with a background of prophylactic erythromycin for preterm premature rupture of membranes (PPROM), should be to initiate appropriate antibiotic therapy based on urine culture and sensitivity results, as untreated bacteriuria in pregnancy significantly increases the risk of pyelonephritis, preterm birth, and low birth weight 1. In this scenario, the patient's asymptomatic bacteriuria takes precedence in management due to the potential complications associated with untreated bacteriuria in pregnancy.

• The erythromycin being used for PPROM should be continued as prescribed, as it serves a different purpose (preventing ascending infection and prolonging latency in PPROM) and does not adequately treat urinary tract infections 1.
• Treatment with nitrofurantoin 100mg twice daily for 5-7 days is recommended as first-line therapy, unless contraindicated or resistance is identified, based on the guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults 1.
• Alternatives include amoxicillin-clavulanate or cephalexin, but the choice of antibiotic should be guided by urine culture and sensitivity results.
• Prompt treatment is crucial, as asymptomatic bacteriuria in pregnancy can lead to severe consequences, including pyelonephritis, preterm birth, and low birth weight 1.
• After completing the treatment course, a follow-up urine culture should be obtained to confirm clearance of the infection, and if bacteriuria persists or recurs, suppressive antibiotic therapy may be needed for the remainder of the pregnancy.

From the Research

Management of Asymptomatic Bacteriuria

In the context of asymptomatic bacteriuria, the management approach varies depending on the patient's condition and risk factors.

• The Infectious Disease Society of America (IDSA) updated its guidelines in 2019, emphasizing the risks and benefits of treating asymptomatic bacteriuria 2.
• According to the guidelines, pregnant women should be screened for asymptomatic bacteriuria in the first trimester and treated if positive 2, 3.
• Individuals undergoing endoscopic urologic procedures should also be screened and treated for asymptomatic bacteriuria 2, 3.
• However, treating asymptomatic bacteriuria in individuals with diabetes, neutropenia, spinal cord injuries, indwelling urinary catheters, and other conditions has not been found to improve clinical outcomes 2, 4, 3.

Use of Prophylactic Erythromycin for PRROM

Regarding the use of prophylactic erythromycin for preterm premature rupture of membranes (PRROM), there is evidence suggesting that erythromycin may be beneficial in reducing the risk of symptomatic urinary tract infections in patients with asymptomatic bacteriuria 5.

• A study published in 1989 found that erythromycin treatment for intercurrent infections in girls with untreated asymptomatic bacteriuria rarely led to changes in bacteriuria and did not result in symptomatic recurrences 5.
• However, the current evidence does not provide clear guidance on the use of prophylactic erythromycin specifically for PRROM in the context of asymptomatic bacteriuria.

Precedence in Management

In the management of asymptomatic bacteriuria, the precedence is given to:

• Pregnant women, who should be screened and treated if positive 2, 3.
• Individuals undergoing endoscopic urologic procedures, who should be screened and treated 2, 3.
• Patients with specific risk factors, such as those undergoing transurethral resection surgery, who may benefit from treatment 3.
• However, for most patients, including those with asymptomatic bacteriuria and no risk factors, treatment is not beneficial and may be harmful 2, 4, 3, 6.