Use of antibiotics in pregnancy
Refer to the BNF and UK Teratology Information Service http://www.uktis.org or phone 0344 8920909.
A Canadian case-control study has found new evidence of increased risk of spontaneous abortion associated with use of antibiotics in pregnancy (Flory TM et al. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ. 2017; 1(189):625-33: http://www.cmaj.ca/content/189/17/E625).
Further analysis from this Canadian study suggests increased risk of major congenital malformations associated with certain antibiotics. The antibiotics in this study which increased the risk included erythromycin, doxycycline, phenoxymethylpenicillin, ofloxacin, clindamycin, moxifloxacin. The authors highlight that the results should be interpreted with caution as only a small number of cases were exposed to antibiotics. The absolute increased risk remains small, but the authors suggest clinicians use other antibiotics for pregnant women.
Public Health England (PHE) now states:
in pregnancy, take specimens to inform treatment, use this guidance or seek specialist advice. Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin and high dose metronidazole 2g stat unless the benefit outweighs the risk. Short term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist.
Heads-up from the European Medicines Agency (EMA) regarding new restrictions on use of fluoroquinolone antibiotics follow review of disabling and potentially long-lasting side effects.
The EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) reported that very rarely, patients treated with fluoroquinolone antibiotics have suffered long-lasting and disabling side effects, mainly involving muscles, tendons and bones and the nervous system. New recommendations and cautions will be added to prescribing information of individual antibiotics now that the EMA’s Committee for Medicinal Products for Human Use (CHMP) has endorsed PRAC’s recommendations.
Restrictions on fluoroquinolones include:
- avoid in patients who have previously had serious adverse effects with a fluoroquinolone or quinolone antibiotic.
- discontinue fluoroquinolone treatment at the first sign of tendon pain or inflammation and patients should be advised to stop treatment with a fluoroquinolone and speak with the doctor in case of symptoms of neuropathy such as pain, burning, tingling, numbness or weakness so as to prevent development of potentially irreversible condition.
- use with special caution in the elderly, patients with renal impairment and those who have had an organ transplantation as these patients are at increased risk of tendon injury.
- avoid concomitant treatment with a fluoroquinolone and a corticosteroid.
In addition, systemic and inhaled fluoroquinolones may be associated with a small increased risk of aortic aneurysm and dissection, particularly in older patients. Further details from the MHRA.
Primary Care Antimicrobial Guidelines
This guideline is currently being up-dated following publication of new joint NICE/PHE Guidance. New sections are also being worked on. These include diabetic foot; absent or dysfunctional spleen; surgical site infections; acute infection of Meibomian Cysts; cholecystitis; treatment of adults with otitis media.
If you have any questions on this please email SWYAPC@greaterhuddersfieldccg.nhs.uk
These guidelines should be used in conjunction with professional judgement and involving patients in management decisions.
|Antibiotic Prophylaxis||Urinary Tract Infections|
|Genital Tract Infections|
|Lower Respiratory Tract Infection|
|Upper Respiratory Tract Infection|
|Skin and Soft Tissue|
Leaflets and forms
A range of leaflets for patients are available from the Royal College of General Practitioners TARGET Antibiotics Toolkit page.
One can be used during consultations with women who are experiencing non-complicated urinary tract infections, when the clinician feels that the patient does not require an antibiotic prescription:
The leaflet is available in different languages from the TARGET website.
FOR CARE HOME STAFF: Form to complete and fax to GP if an older resident has a suspected urinary tract infection:
For hospital patients and visitors
Public Health England has produced a patient information leaflet about an uncommon fungus called Candida auris.
CCGs are continuing to work with healthcare professionals, patients and the public to reduce inappropriate prescribing of antibiotics. In addition, from 1 April 2017 we will be working to reduce gram negative blood stream infections (BSI) across the whole health economy and reduce inappropriate antibiotic prescribing for urinary tract infections (UTI) in primary care.
Hospitals are working on reducing the impact of serious infections. This includes timely identification and treatment of sepsis and a reduction of clinically inappropriate antibiotic prescription and consumption. Further details are here.