ANTIBIOTIC USE What should be the strategy ?

Dr. Seetha .P.M. Asst. Professor S A T Hospital Trivandrum.

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Two Factors should be considered

Physiologic changes in pregnancy Effects on feotus

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Physiologic changes affect the pharmacokinetics of the drug

Examples : 1. Weight gain in pregnancy 2. GIT mobility 3. E C F volume 4. Albumin So free drug 5. Renal blood flow - so fast elimination 6. Hepatic enzymes more active
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EFFECT ON FOETUS

Depends on rate & extent of placental transfer which depends on molecular size & lipid solubility of the drug Structural functional & Behavioural Changes in off springs of which the latter two difficult to asses. After fertilization before missing period All or none effect First trimester more risky
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Maximum teratogenicity between 42-72 days. Sulfa drugs dangerous in both early and later months Generally safe in second trimester In general penicillins, macrolides and cephalosporins are safe in pregnancy

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Categorisation of drugs as per safety

a) Very Safe through out preg. Controlled studies done Eg: B. Complex b) Safe through out pregnancy Eg: Penicillin c) Toxic but can be given if benefit outweigh the risk. Eg: Ciprofloxacin, Norfloxacin d)Can be given only in life threatening situations - +ve foetal risk demonstrated. x Contra indicated. Eg: Chloramphenicol, 7 Tetra cyclines www.similima.com

Common indications of Antibiotic use in pregnancy

Urinary tract infections Respiratory tract infections

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Ideally a culture & sensitivity report should be obtained

Infection Urinary tract a. A Symptomatic bacteri uria b. A cute cystitis c. Acute pyelonephritis Antibiotics

- Amoxyllin & sulfa

-Amoxyllin clavulanate

IV 3rd generation cephalosporin x 72 hrs. & then oral cephalosporin

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A symptomatic bacteriuria
4 10%, 25% - acute pyelo nephritis Screen twice. 80% - E. coli Culture & Colony counting done Treat till culture is ve Amoxyllin 500mg 8th hrly x 7 days Sulfa safe only in second trimester, 1st trimester Anti folate action CVS defect, last trimester exaggerated jaundice.

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Acute - cystitis
Amoxyllin clavulanate (250+125) 8thhrly x 7 days to 14 days SEVERE CASES Parenteral 1 gm + 0.2 gm IV 8th hrly x 3 days & then oral Acute pyelonephritis Cefotaxime 1-2 gm IV 6-8 hrly x 72 Hrs Then oral Cephalosporin for 7-14 days

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Other Urinary antibiotics like

Norfloxacin Ciprofloxacin Cartilage defect Gentamicin - Nephro & Ototoxicity Furadantin - Haemolytic anaemia Ampicillin very safe but drug resistance

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CEPHALOSPORINS
Ist generation (Gm +ve) Cephalexin (500mg 6th hrly) Cephadroxyl (500mg bd) Cephradine Cefazolin (1gm 8th or 12 th hrly) Cephaloridine Cephalothin Second (Gm ve) Cefaclor (125-250mg bd) Cefuroxime Axetil (250mg bd) Cefuroxime (1.5 gm 8thhrly) Cefoxitin Third (both + Pseudomona) Cefixime (200-400 mg bd) Fourth (More potent)

ORAL

PARENTERAL

Cefotaxim
(1-2 gm 8th or 12th hrly)

Ceftriaxone (1 gm daily) Ceftazidine 0.5 - 2 gm 8th hrly

Cefiprime Cefpirome

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Respiratory Infections
Macrolide group & penicillin group Erythromycin 250 to 500 mg 8th hrly x 5-7 days Estolate - enterohepatic circulation Jaundice exacerbation Azithromycin 500mg daily x 3 days Roxithromycin & Clarithromycin

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Intrapartum Uses
Normal labour no need PROM & Prolonged labour Parenteral - Amoxycillin clavulanate / cephalosporin (1.2 gm 8th hrly) Ampi + Genta + Metronidazole

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Caesarean Section

a. b. c.

Clean case per operative & Maximum 24 hrs (Start hr before surgery) Cefazolin 1 gm IV 8th hrly Cefuroxime 1.5 gm IV 8th hrly Amoxyllin clavulanate 1.2 gm IV 8th hrly

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SURGICAL PROPHYLAXIS only for 24 hrs & per operative cover, Why ? Wound infection is directly related to No. of bacteria in the wound at the time of closure Extent of devascularisation Presence of dead issue, prosthesis & haematomas Contn. Beyond 24 hrs increased chance of infection with resistant strains
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INTRA PARTUM SEPSIS

Full course of antibiotic after culture and sensitivity Severe infections monobactems like Aztreonam 2 gm IV 12 hrly

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Failure of Antibiotics
Improper drug, dose, route, duration of Rx Starting too late Failure of Adjuvant measures Poor host defence Focus of infection remaing Relapse Fever due to virus, malignancy/collagen disease

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