Welcome to NP Certification Q&A presented by Fitzgerald Health  Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.   

 A 28-year-old woman G2P1LC1AB0. Currently 22 weeks pregnant presents with a three-day history of urinary frequency and dysuria. She's in no acute distress, without fever or vaginal discharge, and reports the baby is moving around a lot and also denies GI symptoms. Fundal height is consistent with gestational age and fetal heart tones are at 140 beats per minute and regular. UA dip in the office is positive for leukocyte esterase and nitrites, yielding a working diagnosis of lower UTI. Which of the following antimicrobials is preferred for the treatment of UTI during pregnancy? Is it: 

 A. Doxycycline 

B. Levofloxacin 

C. Cephalexin

D. Azithromycin 

 The correct answer here is C, cephalexin. Where do you start?  

 First, determine what kind of question this is, given we're told the working diagnosis and directed to treat. This is a plan question. Let's take a look at the background information. And remember, background information is going to help you with your knowledge building and the knowledge will direct you to the correct answer on the NP boards. About 8% of all women will develop a symptomatic UTI during pregnancy. 

Particularly if recurrent, UTI is a risk factor for low-birth-weight infants and preterm labor. Why so many UTIs? While not a disease, the body undergoes many changes during pregnancy. Some of these changes, including the urine becoming less acid, that's a physiologic change allowing for increased possibility of bacterial growth, pregnancy related changes in the urinary tract, such as pressure on the bladder from the enlarging uterus, an increase in the size of the ureters contributing to urinary reflux, are all contributors to UTI development. In addition, asymptomatic bacteria where a pathogen is grown out of the urine but the patient is without symptoms in other words, does not appear clinically to have a UTI, is found in about 9% of all women during pregnancy and is a potent risk factor for the development of cystitis or pyelonephritis.  

 As with all UTIs across the lifespan, the most common causative organism will be E.coli, a gram negative rod. Women with symptomatic UTI during pregnancy, which clearly this woman has, should be treated for seven days. In addition, there are periodic screening recommendations for urine cultures to be done during the duration of the pregnancy. Let's take a look at the question and the answer options.  

 A 28-year-old woman who is G2P1LC1AB0, currently 22 weeks pregnant, presents with a three day history of urinary frequency and dysuria. She's in no acute distress without fever or vaginal discharge and reports the baby is moving, reports the baby is really moving around a lot and denies GI symptoms. Fundal height is consistent with gestational age and fetal heart tones are 140 beats per minute. UA dip in the office is positive for leukocyte esterase in nitrites yielding a working diagnosis of lower UTI. Which of the following antimicrobials is preferred for the treatment of UTI during pregnancy?  

 So, before I get into going through the answers here, I want to make a couple of comments about questions about pregnancy on the NP boards. If you talk to somebody who took the NP boards many, many years ago and this would be specific to the family NP boards, not the adult-gero primary care, only family. But if you talk to somebody who boards ten, 20 years ago, they'll tell you about a significant section on the boards that look at caring during pregnancy that has really shrunk back to literally a handful of questions these days. I recommend that you go in, take a look at the outline of the exam you plan to take so that you can be reassured that you're not going to get a big percentage of the questions on the boards about pregnancy care, rendering prenatal care. At the same time, what you want to do when you're approaching boards is not say, well, there are going to be not that many prenatal questions, so I'm not going to bother studying it. No, you want to focus in on the more common issues that will tend to come up during pregnancy and therefore they are the ones that are most likely to land on boards. UTI is one of them. And choice of treatment is critically important because what you have to do in this scenario is choose an antimicrobial that's going to eradicate the UTI plus be acceptable to use during pregnancy. And given that we're told she has leukocyte esterase, which tells us there are white blood cells in the urine and nitrites that lean towards the nitrites in the urine telling us there's a gram negative UTI going on. We're going to go with this working diagnosis of lower UTI. But equally important, read what we've got here. The baby's moving around a lot. The baby is growing well because the fundal height is consistent with gestational age. The fetal heart tones are about 140-- spot on, and we're told she's in no acute distress. So, this is not a woman who's terribly ill, but she has a condition we need to treat. Please keep that in mind when approaching this question. So back to the options here. A, doxycycline. First of all, doxycycline is typically not used to treat UTI regardless of birth, gender assignment, regardless of presence of pregnancy, not pregnancy or presence of pregnancy. That is because it's not an antimicrobial that concentrates terrifically well within the urine. So other options are preferred. In addition, this drug is a known teratogen with the propensity to cause permanent teeth staining in the offspring if mom takes it during pregnancy. So, option A is out and this has been known about Doxy for many, many years. And if this was a respiratory tract infection question and they asked about treating some kind of respiratory tract infection that's thought to be bacterial during pregnancy, you would also avoid choosing Doxy as an option because of the potential teratogenic effect. 

 B. Levofloxacin. Levofloxacin is a member of the fluoroquinolone antimicrobials all with the -floxacin suffix. Levofloxacin, moxifloxacin, and ciprofloxacin are all in the same category. That drug class used during pregnancy is not recommended due to the risk, which I have to say is more theoretical than actual, of fetal arthropathy. In addition, the fluoroquinolones are not recommended as first line UTI therapy, one more time, regardless of age, regardless of birth gender assignment due to the concern about antimicrobial resistance. 

Option C: Cephalexin. This is the correct answer. Cephalexin is a cephalosporin, part of a larger group of the beta lactam antimicrobials. The beta lactams, which include the penicillins and the cephalosporins, have a long history of being used safely during pregnancy. In addition, cephalexin has a track record of successfully treating UTIs. And what you're going to find is with prescribing medications during pregnancy, a lot of times we go back to kind of the older meds, the meds that have been around for literally decades. Cephalexin has been on the market, it's probably 40, if not 50 years, and it's been used extensively during pregnancy. And if there was a problem with it being a teratogen, we would no doubt know by now.  

Option D, is it Azithromycin? This is also incorrect. While azithromycin does have a significant safety record for use during pregnancy and is quite frankly the first line recommended medication for the treatment of Chlamydia trachomatis during pregnancy, it is a member of the Macrolide antimicrobial class. That class of antimicrobials is ineffective in treating UTIs. So there is an example in option D where we've got a drug that's okay to use during pregnancy, but we don't use it to treat UTIs regardless of who the person is. Option C, our correct answer is a drug that’s acceptable to use during pregnancy, plus it treats UTIs. Option B levofloxacins, a med that is not recommended for the use during pregnancy, but can be used in certain scenarios to treat the UTI. And doxycycline, we had a med that was not acceptable to use during pregnancy and not used to treat UTI.  

Key takeaway: in treating any illness an important consideration is to choose a medication that's both effective, but also with a history of preferred use during pregnancy.  

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