Pyelonephritis

Acute pyelonephritis is one of the leading causes for hospital admission during pregnancy. Although intravenous antibiotics are the mainstays of therapy, recent studies have indicated that outpatient management using intramuscular antibiotics followed by oral antibiotic therapy may be just as safe and effective. If this outpatient management is comparable in clinical outcomes to traditional hospitalization, it offers patients many advantages and could lead to significant savings in health care costs. Wing and colleagues compared the safety and efficacy of outpatient management of acute pyelonephritis with inpatient therapy in women beyond 24 weeks' gestation.

Emergency department personnel recruited patients for the study. Inclusion criteria included more than 24 weeks' gestation and one or more clinical symptoms of acute pyelonephritis. Exclusion criteria included serious medical conditions, obstetric complications, signs of premature labor or contraindications to the study medications. The 92 participants were all admitted to the hospital for assessments and an initial treatment. The initial treatment consisted of two intramuscular doses of 1 g each of ceftriaxone given 24 hours apart, plus analgesia and measures to reduce fever as necessary. After 24 hours, patients randomized to outpatient therapy were discharged if they were clinically stable. Inpatients were discharged if stable after 48 hours. All patients were treated with oral cephalexin in a dosage of 500 mg four times daily for 10 days and provided with information on the management of symptoms and signs of deterioration. Patients were reassessed five to 14 days after therapy. In addition to a history and physical examination, the follow-up visit included urinalysis and pill counts. All patients were given nitrofurantoin in a dosage of 100 mg daily for the remainder of the pregnancy and for six weeks postpartum. The clinical outcome for the women and their babies was monitored.

The two groups of women were similar in all important variables. Escherichia coli was the most common pathogen. Six outpatients and one inpatient required changes in therapy because of bacteremia or deterioration in symptoms. Thirteen (28 percent) of the outpatients required hospitalization longer than 24 hours. Within two weeks of treatment, two outpatients and one inpatient had positive urine cultures. In patients who completed treatment and follow-up, no differences were observed in maternal or fetal outcomes.

The authors conclude that outpatient management of acute pyelonephritis in pregnancy is possible but only in carefully selected and monitored patients. Most patients in the third trimester were not suitable candidates for outpatient management. Overall, one third of patients were not able to comply with outpatient management. The authors stress the need for hospitalization for assessment and initial therapy as well as the careful selection and monitoring of patients for attempted outpatient management of acute pyelonephritis during pregnancy.

ANNE D. WALLING, M.D.

Wing DA, et al. Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks. Obstet Gynecol November 1999;94:683-8.

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