Empirical therapy for sepsis without septic shock from a urinary tract source in pregnancy

The following regimens apply to pregnant adults with sepsis from a urinary tract source who do not have septic shock (see Definition of sepsis and septic shock in adults).

For pregnant adults with septic shock from a urinary tract source, see Empirical therapy for septic shock from a urinary tract source in adults.

See Approach to managing sepsis and septic shock from a urinary tract source in adults for a discussion of antibiotic choice.

It is widely accepted that gentamicin can be safely used to treat serious infections in pregnancy (eg sepsis or septic shock), despite its category D classification by the Australian Therapeutic Goods AdministrationChean, 2017 Glaser, 2015 The Royal Women's Hospital, 2023. There are fewer data on the use of tobramycin in pregnancy. For more information, see Aminoglycoside use in pregnant people.

For empirical therapy for pregnant adults with sepsis without septic shock from a urinary tract source, use:

1gentamicin intravenously; see Gentamicin initial dose calculator for adults for initial dose. See Principles of aminoglycoside use for prescribing considerations and subsequent dosing gentamicin gentamicin gentamicin

1tobramycin intravenously; see Tobramycin initial dose calculator for adults for initial dose. See Principles of aminoglycoside use for prescribing considerations and subsequent dosing tobramycin tobramycin tobramycin

PLUS with either of the above regimens

1amoxicillin 2 g intravenously 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin dosage adjustment amoxicillin amoxicillin amoxicillin

1ampicillin 2 g intravenously 6-hourly. For dosage adjustment in adults with kidney impairment, see ampicillin dosage adjustment ampicillin ampicillin ampicillin

OR as a single drug

2ceftriaxone 2 g intravenously, daily. ceftriaxone ceftriaxone ceftriaxone

For pregnant patients who have contraindications or precautions that preclude aminoglycoside use, use ceftriaxone (as above).

For pregnant patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use ceftriaxone (as above).

For pregnant patients who have had a severe (immediate or delayed)¹ hypersensitivity reaction to a penicillin, use gentamicin or tobramycin as a single drug and seek expert advice for additional antibiotic therapy with activity against Streptococcus agalactiae (group B streptococcus [GBS]).

For pregnant adults with sepsis without septic shock from a urinary tract source who are at risk of infection with multidrug-resistant gram-negative bacteria, while awaiting results of susceptibility testing and expert advice, replace the empirical regimens above with:

meropenem 1 g intravenously 8-hourly². For dosage adjustment in adults with kidney impairment, see meropenem dosage adjustment. meropenem meropenem meropenem

Empirical antibiotic regimens are intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg results of Gram stain, culture and susceptibility testing of urine or blood samples). Evaluate appropriateness of antibiotic therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.

Once the patient has clinically improved, for modification and duration of therapy, see Acute pyelonephritis in pregnancy.

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

² In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]), consider meropenem only in a critical situation when there are limited treatment options.Return