What is the best next step in managing a 35-year-old woman, gravida (number of times pregnant) 1, para (number of viable births) 0, at 35 weeks gestation, with persistent fever and chills, despite broad-spectrum intravenous antibiotics for acute pyelonephritis (infection of the kidney), and presenting with tachycardia (elevated heart rate), fever, and flank tenderness?

From the Guidelines

The best next step in management for this patient is to change her antibiotic regimen, as indicated by the persistence of fever and chills despite three days of broad-spectrum intravenous antibiotics for acute pyelonephritis, with consideration of obtaining blood and urine cultures to guide the selection of a new antibiotic regimen. This 35-year-old pregnant woman at 35 weeks gestation has continued symptoms, including fever of 38.3°C, tachycardia, and right flank tenderness, which indicate treatment failure with the current antibiotic regimen 1. The fetal tachycardia (heart rate 180/min) is likely a response to maternal fever. Before changing antibiotics, blood and urine cultures should be obtained to identify the causative organism and its antibiotic sensitivities. The new antibiotic regimen should provide broader coverage, potentially including agents like piperacillin-tazobactam, meropenem, or ertapenem, depending on local resistance patterns, as suggested by guidelines for the treatment of acute pyelonephritis 1.

Key considerations in managing this patient include:

• The patient's pregnancy status, which may affect the choice of antibiotics and the need for close monitoring of both the mother and the fetus
• The presence of fever and chills, which suggest ongoing infection and the need for effective antibiotic therapy
• The importance of obtaining cultures to guide antibiotic selection, as recommended by guidelines for the treatment of acute pyelonephritis 1
• The need for close maternal and fetal monitoring, with antipyretics to manage fever, as the fetus shows reassuring signs with moderate variability and accelerations on monitoring 1.

Delivery is not immediately indicated as the fetus shows reassuring signs, and management should focus on resolving the maternal infection first, prioritizing the patient's morbidity, mortality, and quality of life outcomes 1.

From the Research

Patient Evaluation

The patient is a 35-year-old woman, gravida 1 para 0, at 35 weeks gestation, presenting with fever and chills, and a history of acute pyelonephritis treated with broad-spectrum intravenous antibiotics. Key findings include:

• Temperature: 38.3 C (101 F)
• Blood pressure: 118/64 mm Hg
• Pulse: 112/min
• Fetal heart rate monitoring: 180/min with moderate variability, multiple accelerations, and no decelerations
• Tocometry: irregular contractions
• Cervix: 1 cm dilated and 25% effaced
• Amniotic membranes: intact
• Fetal presentation: vertex

Management Considerations

Given the patient's condition and the provided evidence, the following considerations are relevant:

• The patient has been on broad-spectrum intravenous antibiotics for acute pyelonephritis, but continues to have a fever and has developed chills 2, 3, 4.
• The presence of fever and chills despite antibiotic treatment may indicate a need to reassess the antibiotic regimen or consider other potential complications 5, 6.
• The patient's vital signs and fetal monitoring parameters are being closely watched, but there is no indication of severe sepsis or obstetric complications at this point.

Next Steps

Based on the evidence, the best next step in management would be to:

• Reassess the patient's antibiotic regimen and consider adjusting it based on culture results or clinical response 2, 3, 4, 5.
• Continue to closely monitor the patient's vital signs, fetal heart rate, and other parameters for any signs of deterioration or complications 6.
• Consider further diagnostic testing, such as urine cultures or imaging studies, to rule out other potential complications or underlying conditions 3, 6.