4.2 Bacterial infections

For clinical signs and diagnosis, refer to the MSF handbook Clinical guidelines.

Fever above 38.5°C, no matter what its cause, should be treated with paracetamol PO: 3 g/day in 3 divided doses.

4.2.1 Meningitis

– Admit to inpatient department; perform lumbar puncture if possible.

– Start antibiotic therapy while waiting for the results:
ceftriaxone IM: 2 g once daily
or, if not available:
ampicillin IV: 12 g/day divided in 3 doses administered 8 hours apart, then amoxicillin PO: 6 g/day in 2 or 3 divided doses
Duration of therapy depends on the causative organism (10 to 14 days for S. pneumoniae; 7 to 10 days for H. influenzae; 5 to 7 days for N. meningitidis; 10 days if the pathogen is unknown).

– Simultaneously start a short-course of corticosteroids:
dexamethasone IV: 10 mg every 6 hours for 2 days

– In a context of meningococcal meningitis epidemic:
ceftriaxone IM: 2 g once daily for 5 days

4.2.2 Typhoid fever

Typhoid fever can cause major complications both for the mother (gastrointestinal perforation, peritonitis, septicaemia) and the foetus (spontaneous abortion, preterm birth, intrauterine death).

– Admit to inpatient department.

– In the absence of drug resistance, amoxicillin PO: 3 g/day in 3 divided doses for 14 days

– In cases of drug resistance or severe infection, ceftriaxone IM or IV1 : 2 to 4 g once daily for 10 to 14 days

Fever persists 4 to 5 days after starting treatment, even when treatment is effective. It is essential to treat the fever and to monitor for maternal and foetal complications.

4.2.3 Shigellosis

Admit to inpatient department; ceftriaxone IM: 1 g once daily for 3 to 5 days

4.2.4 Syphilis

Syphilis can cause spontaneous abortion, intrauterine death, foetal growth retardation, preterm birth, polyhydramnios, and congenital syphilis.

– For the mother:
benzathine benzylpenicillin IM2 : 2.4 MIU/injection (half-dose in each buttock)
In early syphilis (less than 2 years): single dose.
In late syphilis (more than 2 years) or if the duration of infection is unknown: one injection per week for 3 weeks2.
Administer the same treatment to the sexual partner(s).

Note: a Jarisch-Herxheimer reaction may occur after the first dose of penicillin, especially in patients with early syphilis. The patient presents with some of the following symptoms: abrupt onset of fever, chills, muscle pain, tachycardia, flushing, exacerbated skin rash or mild hypotension, usually within 2 to 5 hours. The treatment is symptomatic (paracetamol PO, 1 g every 6 hours). The reaction is most often moderate, however severe reactions may occur3.

For penicillin-allergic patients only, erythromycin PO: 2 g/day in 4 divided doses for 14 days. The effectiveness of erythromycin in all stages of syphilis and its ability to prevent the stigmata of congenital syphilis are both highly questionable, and many failures have been reported.

– For the treatment of the newborn, see Chapter 10, Section 10.4.1.

4.2.5 Gonorrhoea

Gonorrhoea can cause premature rupture of membranes, preterm delivery, and severe neonatal conjunctivitis.
Gonorrhoea is often associated with chlamydial infection.

– For the mother:
Treat simultaneously for gonorrhoea and chlamydia4:
ceftriaxone IM: 250 mg as a single dose
(or, if not available, cefixime PO: 400 mg as a single dose)
azithromycin PO: 1 g as a single dose
Give the same treatment to the sexual partner(s).

– For the treatment of the newborn, see Chapter 10, Section 10.4.2.

4.2.6 Cystitis and asymptomatic bacteriuria

Cystitis is defined by functional urinary symptoms (frequent, painful urination) and leukocytes and/or nitrites in urine on dipstick.

Asymptomatic bacteriuria is defined by leukocytes and nitrites in urine on dipstick.
If only leukocytes are detected in urine, repeat the test after vulval toilet with soap and water.
If still leukocytes only are detected, treat an asymptomatic bacteriuria.

– Increase fluid intake: at least 1.5 litres per day.

– Antibiotic therapy for cystitis or asymptomatic bacteriuria:
fosfomycin-tromethamine PO: 3 g as a single dose
cefixime PO: 400 mg/day in 2 divided doses for 5 days
nitrofurantoin PO (except during the last month of pregnancy): 300 mg/day in 3 divided doses for 5 to 7 days

Inform the patient that cystitis symptoms should disappear within 2 to 3 days. If not, she should consult again.

4.2.7 Pyelonephritis

– Admit to inpatient department; bed rest (risk of preterm delivery).

– Increase fluid intake: at least 1.5 litres per day.

– Antibiotic therapy:

• In uncomplicated pyelonephritis:
ceftriaxone IM: 1 g once daily for at least 3 days, then cefixime PO: 400 mg/day in 2 divided doses to complete 14 days of treatment

• In complicated pyelonephritis (e.g. patient in an advanced stage of infection, with sepsis or in poor clinical condition, vomiting) or treatment failure after 48 hours:
ceftriaxone1  IM or slow IV injection (over 3 minutes) or infusion (over 30 minutes): 1 g once daily then cefixime PO as above
+ gentamicin IM or slow IV (over 3 minutes) or infusion: 3 to 5 mg/kg once daily for the first 3 days of treatment

– In the event of uterine contractions before 37 weeks LMP:
nifedipine or, if not available, salbutamol for 48 hours (Section 4.10)

Ref Notes

The diluent used to prepare ceftriaxone for IM injection contains lidocaine. Do not administer ceftriaxone reconstituted with this diluent intravenously. For IV administration, use water for injection only.

[ a b ]
2 Only the intramuscular route may be used. To reduce the pain during the injection, the powder can be reconstituted with 8 ml of 1% lidocaine (without epinephrine).