Increased dose requirements of vancomycin in a pregnant patient with endocarditis

When one drug affects 2 patients: a review of medication for the management of nonlabor-related pain, sedation, infection, and hypertension in the hospitalized pregnant patient

One of the most difficult challenges health care providers encounter is drug selection for pregnant patients. Drug selection can be complex as efficacy and maternal side effects must be weighed against potential risk to the embryo or fetus. Verification of an individual drug's fetal safety is limited as most evidence is deduced from epidemiologic, prospective cohort, or case-control studies. Medication selection for the pregnant inpatient is a particularly complex task as the illnesses and conditions that require hospitalization mandate different medications, and the risk versus benefit ratio can vary significantly compared to the outpatient setting. Some degree of acute pain is not uncommon among inpatients. Acetaminophen is generally considered the drug of choice in pregnancy for mild to moderate acute pain, while most opioids are thought to be safe for short-term use to manage moderate to severe pain. Providing sedation is particularly challenging as the few options available for the general population are further limited by either known increased risk of congenital malformations or very limited human pregnancy data. Propofol is the only agent recommended for continuous sedation, which has a Food and Drug Administration classification as a pregnancy category B medication. Treatment of infections in hospitalized patients requires balancing the microbiology profile against the fetal risk. Older antimicrobials proven generally safe include beta-lactams, and those with proven fetal risks include tetracyclines. However, little to no information regarding gestational use is available on the newer antimicrobials that are frequently employed to treat resistant infections more commonly found in the inpatient setting. Management of maternal blood pressure is based on the severity of blood pressure elevations and not the hypertensive classification. Agents generally considered safe to use in hypertensive pregnant patients include methyldopa, labetolol, and hydralazine, while angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, hydrochlorothiazide, and atenolol should be avoided.

Bacterial endocarditis complicating pregnancy: case report and systematic review of the literature

INTRODUCTION

Infectious endocarditis is a rare life-threatening complication of pregnancy. We report a pregnancy complicated by a 3.5-cm infected vegetation of the tricuspid valve initially presenting as unilateral hip pain as well as systematic review of this entity.

SOURCES

A MEDLINE review of the English language literature from 1965 to present using the search terms 'endocarditis', 'pregnancy' and 'infection' as well as review of references was performed.

RESULTS

Sixty-eight cases of infectious endocarditis complicating pregnancy were identified. The calculated maternal and fetal mortality rates were 22.1% and 14.7% respectively.

CONCLUSIONS

With persistent symptomatic lesions, delivery should be considered without regard to measures of fetal lung maturity because of high fetal mortality rates.

Prevention and Management of Infective Endocarditis

Infective endocarditis is an infection of the endocardial surface of the heart and usually involves one or more heart valves but may occur on septal defects or the heart wall. Its incidence is approximately 1 per 1,000 adults and 0.5 per 1,000 pediatric hospital admissions. Factors predisposing to infective endocarditis include degenerative heart disease, survivable congenital cardiac defects, use of invasive procedures, chronic immunosuppression, and intravenous drug abuse. This article discusses the pathophysiology, diagnosis, therapy, and prevention of infective endocarditis.

Vancomycin during pregnancy: does it cause hearing loss or nephrotoxicity in the infant?

Vancomycin was administered intravenously to 10 pregnant women for the treatment of methicillin-resistant Staphylococcus aureus infections. Auditory brainstem response testing and renal function studies were performed on the 10 babies in the experimental group and 10 babies in each of two control groups to determine the safety of vancomycin use during pregnancy. Auditory brainstem responses were not normal at birth in six infants from the three different groups studied (N = 30) but were normal at 3 months in five. The sixth infant had conductive hearing loss unrelated to vancomycin use that spontaneously disappeared at 12 months of age. Renal function was normal in all infants. Vancomycin was detected in cord blood in two patients and in breast milk in one. Adequate serum levels were achieved with routine doses in eight mothers tested; no adverse reactions occurred. It appears that vancomycin use during the second and third trimesters of pregnancy does not produce sensorineural hearing loss or nephrotoxicity in the infant.