How best to treat UTIs in women who breastfeed?

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Clinical Inquiries

How best to treat UTIs in women who breastfeed?

J Fam Pract. 2014 February;63(2):102-103

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References

1. Zalmanovici Trestioreanu A, Green H, Paul M, et al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database of Syst Rev. 2010;(10):CD007182.

2. Miller RD, Salter AJ. The passage of trimethoprim/sulfamethoxazole into breast milk and its significance. Proceedings of the 8th International Congress of Chemotherapy, Athens. Hellenic Soc Chemother. 1974;1:687-691.

3. Gerk PM, Kuhn RJ, Desai NS, et al. Active transport of nitrofurantoin into human milk. Pharmacotherapy. 2001;21:669-675.

4. Giamarellou H, Kolokythas E, Petrikkos G, et al. Pharmacokinetics of three newer quinolones in pregnant and lactating women. Am J Med. 1989;87:49S-51S.

5. Gardner DK, Gabbe SG, Harter C. Simultaneous concentrations of ciprofloxacin in breast milk and in serum in mother and breast-fed infant. Clin Pharm. 1992;11:352-354.

6. Bar-Oz B, Bulkowstein M, Benyamini L, et al. Use of antibiotic and analgesic drugs during lactation. Drug Safety. 2003;26:925-935.

7. Ito S, Blajchman A, Stephenson M, et al. Prospective followup of breast-fed infants exposed to maternal medication. Am J Obstet Gynecol.1993;168:1393-1399.

8. Harmon T, Burkhart G, Applebaum H. Perforated pseudomembranous colitis in the breast-fed infant. J Pediatr Surg. 1992;27:744-746.

9. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 8th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2008.

10. Gupta K, Hooton TM, Naber KG, et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International Clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103-e120.

11. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemical into human milk. Pediatrics. 2001;108:776-789.

Data from a case series and a case report suggest the amount of ciprofloxacin transferred to breastfed infants is low. In the case series, researchers gave 10 lactating women 3 oral doses of ciprofloxacin, 750 mg, at 12-hour intervals and then measured ciprofloxacin levels in breast milk.⁴ The highest levels occurred 2 hours after the third dose and averaged 3.79 μg/mL. Average levels fell gradually to 0.02 μg/mL 24 hours after the third dose. Assuming a milk intake of 150 mL/kg/d, a breastfed infant would consume approximately 0.3 mg/kg/d, much lower than the 10 to 40 mg/kg/d dose recommended for treating sick infants.

A case report of a woman who took oral ciprofloxacin 500 mg/d for 10 days noted a breast milk ciprofloxacin concentration of 0.98 mg/L at 10.7 hours after the last dose.⁵ Ofloxacin, norfloxacin, and levofloxacin have been associated with lower milk concentrations than ciprofloxacin.⁶

Adverse effects

In a cohort study of 838 women from a program for pregnant and lactating women exposed to drugs and other substances, 2 of 12 mothers taking TMP/SMX reported poor feeding in their infants.⁷

The same program received reports of infants with diarrhea from mothers taking amoxicillin (3 of 25 infants), nitrofurantoin (2 of 6 infants), and cephalexin (2 of 7 infants), but no reports of other adverse effects. Another study demonstrated that nitrofurantoin is actively transported into the mother’s milk, making hemolytic anemia a possibility in G6PD-deficient infants.³

Data from a case series and a case report suggest the amount of ciprofloxacin transferred to breastfed infants is low.Studies indicate that adverse effects of fluoroquinolones in children are similar to those in adults despite a contraindication in children because of reports of arthropathy in young animals. One case of pseudomembranous colitis in a breastfeeding infant and 2 cases of green teeth in neonates have been reported with ciprofloxacin use.^6,8,9

RECOMMENDATIONS

The Infectious Disease Society of America recommends nitrofurantoin, TMP/SMX, or fosfomycin for first-line treatment of uncomplicated UTIs in women, although fosfomycin appears to be inferior to other standard short-course antibiotics based on FDA data. Fluoroquinolones and β-lactams are recommended alternative treatments.¹⁰

The American Academy of Pediatrics’ Committee on Drugs says that TMP/SMX (unless G6PD deficiency is present), amoxicillin, nitrofurantoin, ciprofloxacin, and ofloxacin usually are compatible with breastfeeding.¹¹

Evidence-based answers from the Family Physicians Inquiries Network

How best to treat UTIs in women who breastfeed?

References

Adverse effects

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