임신부 무증상 세균뇨, 방광염, 신우신염에서 사용하는 항생

임신부 무증상 세균뇨와 방광염에서 사용되는 항생제는 beta-lactams(amoxicillin-clavulanate, amoxicillin, cefpodoxime, cephalexin), nitrofurantoin, fosfomycin이며 선호되는 것은 amoxicillin-clavulanate, cefpodoxime, fosfomycin입니다. ESBL-producing Enterobacteriaceae가 의심되거나 배양된 경우에는 nitrofurantoin, fosfomycin이 in vitro에서 active하므로 선택이 됩니다. 치료 기간은 3-5일입니다. Nitrofurantoin, fosfomycin은 신장에서 치료 농도에 도달하지 못하므로 신우신염이 의심되는 경우에는 사용해서는 안됩니다.

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Antibiotic treatment of acute cystitis in pregnant women is often empiric, initiated at the time of complaints of dysuria, and then tailored to the susceptibility pattern of the isolated organism once urine cultures return. Potential options for empiric and directed therapy include beta-lactams, nitrofurantoin, and fosfomycin. The choice of an antimicrobial agent should also take into account any prior microbiological data and drug safety during pregnancy (including the particular stage of pregnancy).

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Antibiotic	Dose	Duration	Notes
Nitrofurantoin	100 mg orally every 12 hours	Five to seven days	Does not achieve therapeutic levels in the kidneys so should not be used if pyelonephritis is suspected. Avoid use during the first trimester and at term if other options are available.
Amoxicillin	500 mg orally every 8 hours or 875 mg orally every 12 hours	Five to seven days	Resistance may limit its utility among gram-negative pathogens.
Amoxicillin-clavulanate	500 mg orally every 8 hours or 875 mg orally every 12 hours	Five to seven days
Cephalexin	250 to 500 mg orally every 6 hours	Five to seven days
Cefpodoxime	100 mg orally every 12 hours	Five to seven days
Fosfomycin	3 g orally as single dose		Does not achieve therapeutic levels in the kidneys so should not be used if pyelonephritis is suspected.
Trimethoprim-sulfamethoxazole	800/160 mg (one double strength tablet) every 12 hours	Three days	Avoid during the first trimester and at term.

The durations listed in the table are based on data from studies conducted in both nonpregnant and pregnant women.

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For empiric therapy, we typically choose between cefpodoxime, amoxicillin-clavulanate, and fosfomycin, given their safety in pregnancy and the somewhat broader spectrum of activity compared with other agents (such as amoxicillin or cephalexin). Nitrofurantoin is another option during the second or third trimester or if the others cannot be used for some reason (eg, drug allergy). The choice between them should be individualized on the basis of several factors, including patient allergy history, local practice patterns, local community resistance prevalence, availability, and cost.

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Although there are limited data in pregnant women, a meta-analysis suggested that there are no large differences in outcomes between different antibiotic regimens in terms of cure rates, recurrent infection, incidence of preterm delivery, and the need for a change of antibiotics. All of the antibiotics studied were very effective and complications were rare. There was not enough evidence to recommend a particular treatment scheme.

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For women who are thought to be at risk for or have documented infection with extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, nitrofurantoin and fosfomycin are active in vitro against many such strains and are potential oral options.

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The optimal duration of treatment of acute cystitis during pregnancy is uncertain. As with asymptomatic bacteriuria, short courses of antibiotics are preferred, to minimize the antimicrobial exposure to the fetus. We treat acute cystitis with a three to seven day course of antibiotics as long as there are no symptoms suggestive of pyelonephritis (eg, flank pain, nausea/vomiting, fever [>38°C], and/or costovertebral angle tenderness). Based on data among nonpregnant individuals, there appear to be no differences between short antibiotic courses (three to seven days) and longer ones. Single-dose therapy is generally limited to fosfomycin.

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REF. UpToDate2020.03.12

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