Uncomplicated, otherwise health'
Macrolidesb: clarithromycin or azithromycin
Respiratory fluoroquinolones: moxifloxacin, gemifloxacin, or levofloxacin 3-lactams: amoxicillin/clavulanate, ceftriaxone, cefotaxime, or cefuroxime plus a macrolide aUse as inpatient or outpatient regimen. bDoxycyciine may be given instead if postpartum. (See Table 51-3 for criteria.
otherwise healthy pregnant women. It is, however, recommended for women who are immunocompromised, including those with HIV infection; significant smoking history; diabetes; cardiac, pulmonary, or renal disease; and asplenia, such as with sicklecell disease (Table 9-7, p. 173). Protection against pneumococcal infection in women with chronic diseases may be less eicacious than in healthy patients (Moberley, 2013).
Each year, 10 percent of pregnant women develop influenza (Cantu, 2013). Influenza A and B are RNA viruses that cause respiratory infection, including pneumonitis, that is epidemic in the winter months. The virus is spread by aerosolized droplets and quickly infects ciliated columnar epithelium, alveolar cells, mucus gland cells, and macrophages. Disease onset is 1 to 4 days following exposure. Common symptoms include fever, cough, myalgia, and chills (Sokolow, 2015). In most healthy adults, infection is self-limited.
Pneumonia is the most frequent complication of inluenza and mimics bacterial pneumonia. According to the CDC (201 Oa), infected pregnant women are more likely to be hospitalized and admitted to an ICU. Others have corroborated these observations (Mertz, 2017). At Parkland Hospital during the 2003 to 2004 inluenza season, pneumonia developed in 12 percent of gravidas with influenza (Rogers, 2010).
he 2009 to 2010 pandemic with the influenza (NHINI) pdm09 strain was particularly severe (Rasmussen, 2014). In an MFMU Network study, 10 percent of pregnant or postpartum women admitted with HINI inluenza were cared for in an ICU, and 11 percent of these patients died (Varner, 201I). Risk factors included late pregnancy, smoking, and chronic hypertension. Overall, inluenza accounted for 12 percent of pregnancy-related deaths during the 2009 to 2010 pandemic (Callaghan, 2015). During the 2013 to 2014 inluenza season, a fourth of pregnant women admitted to California ICUs died (Louie, 2015). Of865 pregnant women with influenza, Oboho and coworkers (2016) noted that 7 percent of their cohort had severe disease, and four women died. If inluenza causes ARDS, extracorporeal membrane oxygenation (ECMO) may be lifesaving (Anselmi, 2015; Saad, 2016).
Primary influenza pneumonitis is characterized by sparse sputum production and radiographic interstitial infiltrates (Cohen, 2015). More commonly, either secondary or mixed pneumonia develop from bacterial superinfection by streptococci or staphylococci after 2 to 3 days of initial clinical improvement. he CDC (2007) reported several cases in which CA-MRSA caused influenza-associated pneumonitis with a case-fatality rate of 25 percent. Other possible adverse efects of inluenza A and B on pregnancy outcome are discussed in Chapter 64 (p. 1213).