APT Vignette Discussion Session and Master Cards

1. APT VignetteDiscussion Session and Master Cards Management of UTI in pregnancy

2. Descriptive Information

3. Title: Management of UTI in pregnancy • Student level: 4th Year • Learning objectives for this Vignette (focus): • Identify the risks of asymptomatic bacteruria to the foetus. • Make the correct choice of antibiotic for asymptomatic bacteruria in pregnancy. • Recognise the potential hazards of antibiotics in pregnancy. • Appreciate the cost-effectiveness of ante-natal screening for urinary tract infection.

4. Which of the 12 Outcomes this Vignette Can Cover (1) This Vignette is primarily designed to help the student achieve outcomes 1- 12. 1. Clinical Skills - Elicit key symptoms and signs of commonest sites of bacterial infection. - Recognise and interpret common symptoms and signs of inflammatory response. - Interpret symptoms and signs; distinguish between bacterial infection, viral infection and other causes of inflammatory response. - Formulate a management plan. - Record findings. 2. Practical Procedures - Measures of inflammatory response (pulse, temperature, respiratory rate). - Measures of severe pneumonia (blood pressure, respiratory rate, pulse, oximetry). - Relevant near patient testing techniques. - Technique for obtaining microbiology samples from commonest sites of bacterial infection. - Correct methods for storage and transport of microbiology specimens. Core Resources

5. Which of the 12 outcomes this Vignette can Cover (2) 3. Patient Investigation - General principles of patient investigation. - Appropriate choice and use informed by local protocols. - Laboratory based investigations. - Radiology. 4. Patient Management - Management strategies for common clinical syndromes, including alternatives to antibiotics. - Deciding on duration of treatment, measures of response to treatment and of successful outcome. - Recognition of complications, persisting or recurrent symptoms and management plan for dealing with them. • Health Promotion and Disease Prevention - Principles of control of infection in the hospital and in the community. 6 . Communication - Communication of therapeutic objective, and management plan. - Accessing advice and sharing responsibility with infection control practitioners and obstretrician. Core Resources

6. Which of the 12 outcomes this Vignette can Cover (3) 7. Appropriate Information Handling Skills • Minimum dataset to be recorded in order to support a decision to prescribe antibiotics. • Local antibiotic policy. • Local guidelines. • National guidelines. • Keeping up to date with resistance. • Personal record keeping for professional development: building a portfolio of achievement of learning outcomes. 8. Understanding of Social, Basic and Clinical Sciences and Underlying Principles • Host defences, immunological and non-immunological. • Pathology of inflammation and sepsis. • Mechanisms and spread of antibiotic resistance. • Classes of antibiotics used and shared allergies. • Pharmacokinetics in relation to drug selection for common infections in pregnant women. • Infection control. • Epidemiology of resistance. 9. Appropriate Attitudes, Ethical Understanding and Legal Responsibilities • Principles of prudent antimicrobial prescribing. • Shared decision making. Core Resources

7. Which of the 12 outcomes the Vignette can Cover (4) 10. Appropriate Decision Making Skills, Clinical Reasoning and Judgement - Coping with uncertainty. - What is an acceptable risk to withholding any antibiotics, when you are uncertain of your diagnosis? - What is an acceptable prevalence of resistance to first line drugs in antibiotic policies? 11. Role of the Doctor within the Health Service - Role of other members of the multi-professional team in prudent antibiotic prescribing. 12. Personal Development - Assessment of own competence as an antibiotic prescriber; evaluating own capabilities and personal effectiveness. Assessment of need for support in decision making about antibiotics. - Searching for appropriate learning resources for antibiotic prescribing and resistance. - Recognising limits of current understanding and identifying areas that need to be refreshed or extended. - Setting realistic but challenging learning goals as a basis for personal growth. Core Resources

8. B. Case Details

9. History A 24-year old woman attends her first antenatal clinic appointment (10 weeks pregnant). Her routine urinalysis is abnormal. She denies dysuria, frequency, nocturia or fever, and she feels very well, although a little tired.

10. Investigations • Investigations: • Mid-stream specimen of urine (MSSU): • Leucocytes >100/mm3 • Red cells = 0 • Epithelial cells = 0 • Culture: Group B beta-haemolytic Streptococcus >105 cfu/mm3. • Sensitive to penicillin, erythromycin, cephradine, trimethoprim, • co-amoxiclav

11. C. Question Categories

12. Consider a Working Diagnosis 1.1 What is the diagnosis? 1.2 Why was a urinalysis and MSSU taken?

13. Assess Severity 2.1 What are the different clinical presentations of bacteruria in pregnancy? 2.2 What signs and symptoms help to differentiate them?

14. Consider Investigations 3.1 What investigations are indicated at follow up in relation to this positive urine culture, and how soon should they be performed?

15. Consider Public Health Issues 4.1 What is the frequency of asymptomatic bacteruria in the antenatal population? 4.2 What are the risks to mother and foetus? 4.3 What are the pros and cons of offering antenatal screening for bacteruria?

16. Appropriate Prescribing 5.1 Is antibiotic therapy indicated: if so what? 5.2 What antibiotics are contra-indicated in first and second trimesters of pregnancy? 5.3 Give other reasons why you might choose penicillin in preference to other agents in this particular situation?

17. Patient Management 6.1 Give details of your management of the patient: • in the first week • b. at follow up

18. D. Best Practice Statement

19. Summary of Management Routine antenatal screening for UTI, a recommended practice, has shown asymptomatic bacteruria. This is not in doubt as the urine sample is good quality, as judged by the microscopy and culture results. Therefore treatment should be commenced with oral penicillin. This drug is concentrated in the urine and any problems with erratic absorption of oral penicillin will be negated by this fact. The other antibiotic options are unnecessarily broad-spectrum and some may be contra-indicated in pregnancy. Follow-up clinic examination along with MSSU should confirm successful treatment and exclude recurring infections. Repeat MSSU’s at subsequent clinic visits are indicated. Issues such as simple cystitis, pyelonephritis, catheter-associated bacteruria, recurring UTI and resistant organisms are considered in the other Vignettes. MCQ’S

20. E. Correct/Appropriate AnswersF. Potential Responses and FeedbackG. References and Resources Master Cards:

21. 1.1 What is the diagnosis? Correct Response and Reason: The diagnosis is asymptomatic bacteruria of pregnancy - the patient has no symptoms or signs (as revealed on subsequent examinations).

22. Asymptomatic bacteruria is a common finding in pregnancy but it does require action. Urinalysis and urine culture in pregnant women is a Good Practice Recommendation from NICE (National Institute for Clinical Excellence). 1.2 Why was a urinalysis and MSSU taken? Correct Response and Reason

23. 2.1 What are the different clinical presentations of bacteruria in pregnancy? • Correct Response and Reason: • Asymptomatic • Cystitis • Pyelonephritis • Sepsis / bacteraemia

24. 2.2 What signs and symptoms help to differentiate them? • Correct Response and Reason: • Dysuria • Urinary • Frequency • Offensive smelling urine • Nocturia • Loin pain • Fever • Chills • Rigors • Malaise • Confusion

25. 3.1 What investigations are indicated at follow up in relation to this positive urine culture, and how soon should they be performed? • Correct Response and Reason: • Blood pressure measurement • Repeat MSSU • Full blood count • C-reactive protein. • Ultrasound of urinary tract in case of recurrent UTI or • anatomical abnormality. • All tests should be performed as a matter of urgency. • Watch out for persistence of infection or relapse.

26. 4.1 What is the frequency of asymptomatic bacteruria in the antenatal population? Correct Response and Reason: Asymptomatic bacteruria is present in between 2 to 10% of the antenatal population.

27. 4.2 What are the risks to mother and foetus? Correct Response and Reason: Asymtomatic bacteruria can result in premature delivery, low birth weight, pyelonephritis, bacteraemia, hypertension or pre-eclampsia.

28. 4.3 What are the pros and cons of offering antenatal screening for bacteruria? Correct Response and Reason: It is the recommendation of NICE that all pregnant women should have a standard urine culture at their first antenatal appointment because of these risks to mother and foetus.There has, however, been much debate about the cost effectiveness of screening for asymptomatic bacteruria and how best to do it.

29. 5.1 Is antibiotic therapy indicated: if so what? Correct Response and Reason: Penicillin V (oral): it is narrow spectrum, concentrated in urine, active against the isolate, efficacious, inexpensive, non-toxic and safe in pregnancy. Not suitable if penicillin allergic.

30. 5.2 What antibiotics are contra-indicated in first and second trimesters of pregnancy? Correct Response and Reason: Trimethoprim and co-trimoxazole (trimethoprim/sulphamethoxazole), because of folate antagonism. This can result in teratogenesis. Ciprofloxacin and other quinolones, because of reports of arthropathy in animal studies.

31. 5.3 Give other reasons why you might choose penicillin in preference to other agents in this particular situation? Correct Response and Reason: Erythromycin would be unsuitable as it is not really concentrated in urine. Other agents may have an unnecessarily broad spectrum, leading to complications such as thrush (candidiasis), diarrhoea and antibiotic resistance. Some agents may have no licence for use in pregnancy.

32. 6.1 Give details of your management of the patient: a. in the first week Correct Response and Reason: Enquire about previous UTIs and look for laboratory evidence of past UTI or asymptomatic bacteruria. Treatment of this current asymptomatic bacteruria is indicated with Penicillin V, otherwise complications could occur.

33. 6.1 Give details of your management of the patient : b. at follow up Correct Response and Reason: Follow up to check urine remains sterile as relapse is common and associated with complications.

34. Core Resources • Urinary Tract Infection Self-learning Package. University of Aberdeen, Phase II, MB ChB • NICE Guideline CG6 Antenatal care - routine care for the healthy pregnant woman. • http://www.nice.org.uk/pdf/CG6_ANC_NICEguideline.pdf • http://www.nice.org.uk/pdf/ANC_FINAL_Algorithm.pdf

35. Multiple Choice Questions (1) • Question 1: • In urine microscopy, what indicates contamination of the specimen? • Bacteria • White blood cells • Epithelial (Squamous) cells • Red blood cells • Casts • Question 2: • 2. Which of the following is not a recognised complication of • asymptomatic bacteruria? • Pyelonephritis • Bacteraemia • Premature delivery • Low birth weight • Cleft palate ANSWERS

36. Multiple Choice Questions (2) • Question 3: • In urine culture, which bacterial count is taken as a threshold for asymptomatic bacteruria and pyelonephritis? • < 104/ml • > 105/ml • > 105/L • > 102/ml • 103/ml • Question 4: • Which 2 antibiotics are contra-indicated in pregnancy? • Trimethoprim • Penicillin • Ciprofloxacin • Amoxicillin • nitrofurantoin ANSWERS

37. Multiple Choice Questions (3) Question 5: Which one of the following is not a recognised side effect of co-amoxiclav? • Tiredness • Rash • Diarrhoea • Jaundice • Thrush Summary of Management ANSWERS

38. Multiple Choice Answers Summary of Management

39. Produced By Sandy, Hamish and Ian July 2004