asb-study screening and treating as ymptomatic b acteriuria in pregnancy
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ASB-study Screening and treating as ymptomatic b acteriuria in pregnancy. Symposium 3 handen op 1 buik 13/12/11. Brenda Kazemier (AMC) Suzanne Geerlings (AMC) Prof. Christianne de Groot (VU) Prof. Ben Willem Mol (AMC). Bacteria Urine. Pregnancy. - PowerPoint PPT PresentationTRANSCRIPT
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ASB-studyASB-study
Screening and treating Screening and treating asasymptomatic ymptomatic bbacteriuria in pregnancyacteriuria in pregnancy
Brenda Kazemier (AMC)Suzanne Geerlings (AMC)Prof. Christianne de Groot (VU)Prof. Ben Willem Mol (AMC)
Symposium 3 handen op 1 buik 13/12/11Symposium 3 handen op 1 buik 13/12/11
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BacteriaBacteria UrineUrine
http://4.bp.blogspot.com/_bAIZPjDtT_Q/TNsTfObFrXI/AAAAAAAAGes/yzeidwY2CC8/s1600/pee.jpgwww.bacteriapictures.nethttp://4.bp.blogspot.com/-IHm3oSut4-U/TbfJk77WWgI/AAAAAAAAA2o/fyQP8qo3OKs/s1600/ultrasounds.jpg
PregnancyPregnancy
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Urinary tract and Urinary tract and pregnancypregnancy
http://health.nytimes.com/health/guides/disease/urinary-tract-infection/background.htmlhttp://www.nvscc.com/images/normal_female_anatomy.jpg
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What is ASB?What is ASB?Urine is normally sterile (contains no
bacteria)
2-10% have bacteria in urine without complaints
ASB = ASymptomatic Bacteriuria
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What is ASB?What is ASB?
Outside pregnancy no problems with ASB
In pregnancy untreated ASB can lead to pyelonephritis (up to 30%)
Also increased risk of preterm delivery and delivering a low birthweight baby
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Screening and treating Screening and treating ASBASBOther countries routinely screen and treat
ASB
Dutch obstetric guideline: not enough evidence for routine screen and treat program
Usefulness of screening depends on incidence in population
In Netherlands different antenatal care system
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Evidence Evidence Author
Year
ASB diagnosis
Intervention N Endpoint
Kass 1960 <32 wks GA Sulfamethopyridazine vs placebo 214 pyelonephritis
Kincaid 1965 <26 wks GA Sulphamethodiazine vs placebo 145 pyelonephritis
Gold 1966 Any GA Sulfadiazide vs placebo 65 pyelonephritis
Little 1966 First visit Different types of antibiotics vs placeo 265 pyelonephritis
Elder 1966 Not stated Sulfasymazine 0.5g until delivery vs placebo 106 Bacterial clearance
Pathak 1969 <24 wk GA Nitrofurantoin vs placebo 178 Bacterial clearance
Elder 1971 First visit Tetracycline 6wks vs placebo 281 pyelonephritis
Brumfitt 1975 First visit Single dose sulphonamide vs placebo 425 Low bw, pyelonephritis
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EvidenceEvidence Author Year ASB
diagnosisIntervention Endpoint
Robertson 1968 Not stated Cycloserine 250mg vs sulphadimine 500mg
Symptomatic infection
Bint 1979 Not stated Pivmecillinam 400mg vs ampicillin 500mg Bacterial eradication
Campbell-Brown
1987 First visit Cephalexin vs pivmecillinam/pivampicillin Symptomatic infection
Bayrak 2007 2nd trimester
Single dose fosfomycin trometamol vs 5 day cefuroxim
Bacterial eradication
Estebanez 2009 First visit (18 wks GA)
Single dose vs 7-day course amoxicillin-clavulanate
Bacterial eradication
Lumbiganon 2009 12-32 wks AD
1 day vs 7 day nitrofurantoin Bacterial eradication
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Research questionsResearch questionsWhat is the incidence of ASB in the
Dutch population?Is a screening strategy with a dipslide
useful and costeffective?Does treatment with nitrofurantoin
decrease the incidence of pyelonephritis and preterm delivery?
What are the riskfactors for developing ASB ?
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Study designStudy designAlongside the Triple P
◦ Screeningpart (4400 women)◦ Treatpart (230 women)
Population: singletons
Use logistic network of
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ASB screeningASB screeningGold standard is urinary culture
Dutch primary antenatal care no direct access to microbiology lab urinary culture not feasible
Alternative: dipslide◦ Sensitivity: 98 *◦ Specificity: 99.6 *
* Mignini 2009 obstetrics and gynaecology
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ASB screeningASB screeningScreening between 16-22 weeks
Easy to implement in Triple P screening◦ Need of emptying bladder for cervical
length measurement
Exclusion criteria:◦ Previous spontaneous preterm delivery
<34wks◦ Diabetes Mellitus◦ Allergy to nitrofurantoin
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ASB treatASB treat
Randomized controlled trial
230 women
Intervention: 2x100mg nitrofurantoin for 5 days or placebo
One week after finishing studymedication again urine dipslide
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EndpointsEndpointsPrimary endpoint:
◦ Pyelonephritis and/or preterm delivery <34 weken
Secondary endpoints:◦ Neonatal and maternal morbidity/mortality◦ Costeffectiveness
Screening for ASB Screening for cervical-length Screening for both
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Current situationCurrent situation105 women participated in ASB
screening
51 also had a cervical length measurement
12 positive dipslide
2 randomisations◦ 2 thinking about participation◦ 4 excluded◦ 3 refusers◦ 1 got symptomatic before randomisation
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Why research in primary Why research in primary care?care?Effect of screening study needs to be
investigated in whole population
Improve risk selection and care in primary setting◦ Treat patients accordingly within their own
setting
4 hands on one belly
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4 hands on one pregnant 4 hands on one pregnant belly:belly:
http://static.zoom.nl/78783E7FA227DD69B691F42FB910B2EC-4-handen-op-1-buik.jpg
Primary carePrimary care
Secondary care
Secondary care
Pregnant womanPregnant woman
Tertiary care
Tertiary care
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Participating centres:Participating centres:Primary care:
◦ Espérance, Arnhem◦ MaMa, Velserbroek◦ EVA, Varsseveld◦ FARA, Ede
Secondary care:◦ Flevoziekenhuis, Almere◦ Diakonessenhuis, Utrecht◦ Atrium Medisch Centrum, Heerlen
Tertiary care:◦ AMC, Amsterdam◦ Vu, Amsterdam◦ MMC, Veldhoven
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Distribution care Distribution care NetherlandsNetherlands
◦20 weeks ultrasound screening referral
from midwivery practice to:
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My dreams for 2012My dreams for 2012Follow in Triple P’s great footstepsFinish ASB study in 12 monthsPublish in high impact journal
Increase the participating centres Increase the participating centres of the ASB study to at least 20 of the ASB study to at least 20 ultrasoundcentresultrasoundcentres
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Thank you for your Thank you for your attention!attention!
Want to participate?Email or call Brenda:
◦[email protected]◦Tel: 0630471389 ◦Website: www.studies-obsgyn.nl/asb◦Approach me after symposium