The antibiotic sensitivity testing revealed that most bacterial isolates were highly susceptible to Meropenem and had the least susceptibility to ceftriaxone. E.coli had
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variable sensitivities to the different antibiotics, the highest susceptibility was recorded with the use of meropenem (91.5%), while the least susceptibility was recorded with ceftriaxone (53.2%). Other organisms isolated had similar sensitivity pattern, however Proteus mirabilis and Proteus vulgaris demonstrated resistance to ceftazidime, co-amoxiclav, ciprofloxacin, nitrofurantoin and ceftriaxone. Streptococcus was resistant to ceftazidime, ceftriaxone and ciprofloxacin but had 100% susceptibility to TMP/SMX and meropenem. . The lower susceptibility to certain anti-microbials may be attributed to the inappropriate use and abuse of these drugs due to easy over the counter accessibility. It may also be related to the drug prescription by non-skilled practitioners or may be related to the unavailability and inaccessibility of guidelines for therapy when these drugs are used. Nearly all antibiotics cross the placenta and some of them exert teratogenic effects, however commonly accepted antibiotics include the penicillins and cephalosporins derived medications particularly those with low protein binding ability. Co-amoxiclav has been reported to be safe in pregnancy.109
Nitrofurantoin demonstrated sensitivity of 56% in this study. The use of this medication should be avoided in the first trimester due to the possible risk of foetal defects. In the second and third trimester, it is considered to be safe and well tolerated, in fact, it is considered as the first line of treatment up until the last week before delivery as it has been reported to increase the risk of neonatal jaundice which may predispose the neonates to kernicterus. Nitrofurantoin should be used with caution in pregnancy because theoretically it is said to be associated with the risk of foetal and neonatal haemolytic anaemia particularly if the mother has glucose-6-phosphate dehydrogenase deficiency, although this complication is yet to be reported.110
Trimethoprim a component of Septrin (TMP/SMX) is a folic acid antagonist and its use during the first trimester has been associated with structural defects such as neural tube
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and cardiovascular defects. TMP/SMX should be avoided because it increases the risk of neonatal jaundice.111
Ciprofloxacin, a fluoroquinolone which belongs to FDA pregnancy category-C is contra-indicated throughout the course of pregnancy due to the increased risk of foetal cartilage developmental disorders.112 It was included in the drug testing particularly due to the inclusion of non-pregnant controls. Though the sensitivity of ciprofloxacin was 74%, it is contra-indicated and not advised to be administered in pregnancy, although some authors are of the opinion that ciprofloxacin is safe and could be administered in pregnancy following the exploration of a number of studies.113-115
5.6 COST EFFECTIVENESS
The cost of treatment of acute pyelonephritis using meropenem which from this study is the antibiotic of choice will amount to N104,000 per patient without screening. When compared with the treatment of cystitis using urine dipstick and culture as the screening methods, it will cost N4700 and N6700 respectively which is significantly lower. This indicates that both screening strategies when applied are cost benefitial compared with treatment of pyelonephritis in the absence of screening.
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CHAPTER SIX
LIMITATION, CONCLUSION & RECOMMENDATION LIMITATION
1) Urine was cultured for 24 hours and as such fastidious organisms may have been missed
2) Sensitivity testing was done using a limited number of anti-biotic disc.
CONCLUSION
1) The prevalence of UTI among pregnant women at LUTH was high.
2) Asymptomatic bacteriuria was the pattern of UTI among the pregnant women at LUTH antenatal clinic.
3) UTI occurred twice as much in pregnant women than in the non-pregnant controls 4) The predominant causative organism of UTI in this environment was E.coli.
5) All bacterial isolates were highly sensitive to meropenem but had lower susceptibility to the frequently used anti-microbials.
6) Sexual intercourse, with-holding urine and wearing of under-pants the whole day were significant risk factors associated with UTI among the pregnant women with culture positive UTI.
7) There was an association of level of education with the occurrence of UTI, however there was no association of maternal age, trimester, parity and income on the frequency of UTI in pregnancy.
8) Screening for UTI with leucocyte esterase and nitrite containing urinalysis dipsticks was cost beneficial.
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1) All pregnant women should be screened for UTI at each ante-natal clinic visit since all the pregnant women with culture positive UTI were asymptomatic.
2) Screening of UTI should be with urine dipstick that test for urine nitrite and leucocyte esterase.
3) All pregnant women with positive urine dipstick should have urine culture done and should be placed on empiric treatment for UTI with oral co-amoxiclav pending the result of the urine culture.
4) Pregnant women should be switched to the appropriate and safe anti-biotics to reduce the risk of drug resistance.
5) All pregnant women should be counselled on the importance of post coital voiding and with-holding urine.
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