How to manage a pregnant patient with suspected infection?

Management of Pregnant Patients with Suspected Infection

Pregnant women with suspected infection should be promptly evaluated and treated with appropriate antibiotics that are safe during pregnancy, with careful consideration of the specific pathogen and potential impact on both maternal and fetal outcomes.

Initial Assessment

• Evaluate the type and severity of infection, as this will determine the appropriate antibiotic choice and need for hospitalization 1
• Consider common pregnancy-specific infections including urinary tract infections, chorioamnionitis, and toxoplasmosis 2
• Assess for signs of systemic involvement including fever, tachycardia, hypotension, or altered mental status 3

Antibiotic Selection Principles

• Choose antibiotics with established safety profiles in pregnancy 2
• Avoid tetracyclines (including doxycycline) during pregnancy due to risk of dental staining and potential effects on fetal bone growth 2
• Consider that pharmacokinetics of antibiotics may be altered during pregnancy, potentially requiring dose adjustments 4
• For severe infections, do not delay appropriate antibiotic therapy solely due to pregnancy concerns 2

Management by Infection Type

Group B Streptococcus (GBS) Colonization

• For GBS-positive pregnant women, administer intravenous penicillin G (5 million units initial dose, then 2.5-3.0 million units every 4 hours until delivery) 1
• For penicillin-allergic women not at high risk for anaphylaxis, use cefazolin (2g IV initial dose, then 1g IV every 8 hours) 1
• For penicillin-allergic women at high risk for anaphylaxis, use clindamycin if the GBS isolate is susceptible, otherwise use vancomycin 1

Suspected Toxoplasmosis

• For pregnant women with negative amniotic fluid PCR and negative fetal ultrasound findings, administer spiramycin (1g PO TID) until delivery 2
• For women ≥18 weeks pregnant with confirmed fetal infection, use pyrimethamine plus sulfadiazine plus folinic acid 2
• Spiramycin is available in the US only through the FDA's Investigational New Drug process 2

Chlamydia Infection

• Treat with azithromycin 1g orally in a single dose 2
• Alternative regimen: erythromycin base 500mg orally four times daily for 7 days 2
• Avoid doxycycline during pregnancy 2

Lyme Disease

• Pregnant patients may be treated identically to non-pregnant patients with the same disease manifestation, except doxycycline should be avoided 2
• For early Lyme disease, use amoxicillin or cefuroxime axetil 2
• For neurologic involvement, use ceftriaxone or penicillin G administered intravenously 2

Special Considerations

Aminoglycoside Use

• If aminoglycosides (e.g., gentamicin) must be used, monitor drug levels carefully due to risk of fetal ototoxicity 2, 5
• Consider alternative antibiotics when possible 5

Hospitalization Criteria

• Hospitalize pregnant patients with signs of sepsis, inability to tolerate oral medications, or evidence of systemic infection 3
• For hospitalized pregnant women with IBD or other conditions requiring admission, provide anticoagulant thromboprophylaxis due to increased risk of thromboembolism 2

HIV Co-infection

• Pregnant women with HIV should be treated for HIV regardless of immunologic or virologic status to prevent fetal infection 2
• Treat any concurrent infections promptly to minimize risks to both mother and fetus 2

Follow-up

• Monitor clinical response to therapy within 24-48 hours of initiating treatment 3
• Adjust antibiotics based on culture results when available 2
• For severe infections, consider consultation with infectious disease specialists and maternal-fetal medicine 2

Pitfalls to Avoid

• Do not delay medically necessary antibiotic treatment due to pregnancy concerns 2
• Avoid oral antibiotics for GBS colonization during pregnancy as this is ineffective in preventing neonatal disease 1
• Do not use fluoroquinolones as first-line therapy due to potential concerns about cartilage development, unless benefits clearly outweigh risks 6
• Remember that some infections (e.g., listeriosis) may present atypically during pregnancy and require a high index of suspicion 3