4.2 Bacterial infections

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

In addition to antimicrobial therapy, administer paracetamol PO (1 g 3 times daily) in case of axillary temperature ≥ 38.5 °C.

4.2.1 Syphilis

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

– For the mother:
benzathine benzylpenicillin IM1 : 2.4 MIU per injection (half-dose in each buttock)
Early syphilis (primary, secondary, or latent infection of less than 12 months duration): single dose
Late latent syphilis (infection of more than 12 months duration or of unknown duration): one injection weekly 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, use erythromycin PO: 500 mg 4 times daily for 14 days (early syphilis) or 30 days (late latent syphilis). 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 neonate, see Chapter 10, Section 10.4.1.

4.2.2 Gonorrhoea

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

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

– For the neonate, see Chapter 10, Section 10.4.2.

4.2.3 Urinary tract infections (including asymptomatic bacteriuria)

Asymptomatic bacteriuria and cystitis, if left untreated, can lead to pyelonephritis and preterm labour.

Asymptomatic bacteriuria

Asymptomatic bacteriuria is defined as the presence of leukocytes and nitrites in urine, with no urinary symptoms. 
If only leukocytes are detected in urine, repeat the dipstick test after vulval toilet with soap and water. If, on repeat, leukocytes without nitrites are again detected, diagnose asymptomatic bacteriuria and treat as acute cystitis.

Acute cystitis

Cystitis is defined as urinary symptoms and the presence of leukocytes and/or nitrites in urine. 
Antibiotherapy for acute cystitis:
fosfomycin-tromethamine PO: 3 g single dose or cefixime PO: 200 mg 2 times daily for 5 days
Inform the patient that cystitis symptoms should disappear within 2 to 3 days. If not, she should consult again.
Advise the patient to drink 1.5 litres of water daily.

Acute pyelonephritis

Acute pyelonephritis can progress to maternal sepsis and preterm labour. Early treatment is important in preventing these complications. 

– Look for signs of serious illness (sepsis or septic shock, dehydration) or complications (urinary tract obstruction, renal abscess) or risk of complications (functional or structural abnormality of the urinary tract (lithiasis, malformation, etc.) or severe immunodepression.
– Admit to inpatient department; bed rest.

– Increase fluid intake: 1.5 litres of water daily.
– Antibiotherapy:
Uncomplicated pyelonephritis:
Start with ceftriaxone IM or slow IV injection (over 3 minutes)
2 : 1 g once daily then change to oral route after 24 to 48 hours of apyrexia with:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 10 to 14 days of treatment 
Ratio 8:1: 2000 mg daily (= 2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (= 1 tablet of 875/125 mg 2 times daily)

cefixime PO: 200 mg 2 times daily to complete 10 to 14 days of treatment
Severe or complicated pyelonephritis or absence of clinical improvement after 24 hours of treatment:
ceftriaxone slow IV injection (over 3 minutes) or infusion (over 30 minutes)2 : 1 g once daily then amoxicillin/clavulanic acid PO or cefixime PO as above
+ gentamicin IM or slow IV (over 3 minutes): 5 mg/kg once daily for the first 3 days of treatment
– In the event of threatened preterm delivery: see Section 4.10.

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