Professional Documents
Culture Documents
OBJECTIVE: Over ten million women are either pregnant icol, ciprofloxacin, doxycycline, levofloxacin, and
or lactating in the United States at any time. The risks of rifampin) to undetermined (clindamycin, gentamicin,
medication use for these women are unique. In addition and vancomycin). Assessments were based on good
to normal physiologic changes that alter the pharmaco- data (penicillin G and VK), fair data (amoxicillin, chlor-
kinetics of drugs, there is the concern of possible terato- amphenicol, ciprofloxacin, doxycycline, levofloxacin, and
genic and toxic effects on the developing fetus and rifampin), limited data (clindamycin and gentamicin),
newborn. This article reviews the risks and pharmacoki- and very limited data (vancomycin). Significant phar-
netic considerations for 11 broad-spectrum antibiotics macokinetic changes occurred during pregnancy for the
that can be used to treat routine and life-threatening penicillins, fluoroquinolones and gentamicin, indicating
infections during pregnancy and lactation. that dosage adjustments for these drugs may be neces-
sary. With the exception of chloramphenicol, all of these
DATA SOURCES: Information from the U.S. Food and
antibiotics are considered compatible with breastfeed-
Drug Administration (FDA) product labels, the Teratogen
ing.
Information Service, REPROTOX, Shepards Catalog of
Teratogenic Agents, Clinical Pharmacology, and the peer- CONCLUSION: Health care professionals should con-
reviewed medical literature was reviewed concerning the sider the teratogenic and toxic risk profiles of antibiotics
use of 11 antibiotics in pregnant and lactating women. to assist in making prescribing decisions for pregnant and
The PubMed search engine was used with the search lactating women. These may become especially impor-
terms [antibiotic name] and pregnancy, [antibiotic tant if anti-infective countermeasures are required to
name] and lactation, and [antibiotic name] and breast- protect the health, safety, and survival of individuals
feeding from January 1940 to November 2005, as well as exposed to pathogenic bacteriologic agents that may
standard reference tracing. occur from bioterrorist acts.
(Obstet Gynecol 2006;107:112038)
METHODS OF STUDY SELECTION: One hundred twen-
ty-four references had sufficient information concerning
numbers of subjects, methods, and findings to be in-
cluded.
TABULATION, INTEGRATION, AND RESULTS: The ter-
A ntibiotics are among the most commonly pre-
scribed prescription medications for pregnant
and lactating women.1 More than 10 million women
atogenic potential in humans ranged from none (pen- are either pregnant or lactating in the United States at
icillin G and VK) to unlikely (amoxicillin, chloramphen- any one time, and they are administered antibiotics
for many reasons.2 Because of the special consider-
From the Department of Obstetrics and Gynecology, Uniformed Services Uni- ations associated with fetal and newborn develop-
versity of the Health Sciences, Bethesda, Maryland; Office of Womens Health, ment, these women constitute a uniquely vulnerable
U.S. Food and Drug Administration, Rockville, Maryland; FDA Center for
Drug Evaluation and Research, Silver Spring, Maryland.
population for which the risks of medication use must
Presented in part at the FDA Science Forum in Washington, DC, April 2728,
be separately assessed.
2005. In addition to the pharmacokinetic and pharma-
The views, opinions, interpretations, and conclusions expressed in this article are codynamic changes that may occur during pregnancy
those of the authors only and do not reflect either the policies or positions of the and lactation that can alter the effectiveness of drugs,3
Center for Drug Evaluation and Research, the U.S. Food and Drug Adminis- there is the added concern of the possible teratogenic
tration, or the U.S. Department of Health and Human Services.
and toxic effects that medications may have on the
Corresponding author: Gerard G. Nahum, MD, FACOG, FACS, Box 2184,
Rockville, MD 20847; e-mail: GNahum2003@yahoo.com.
developing fetus and newborn. In general, there is a
2006 by The American College of Obstetricians and Gynecologists. Published
dearth of pharmacokinetic and pharmacodynamic
by Lippincott Williams & Wilkins. information regarding the use and proper dosing of
ISSN: 0029-7844/06 Food and Drug Administration (FDA)approved
VOL. 107, NO. 5, MAY 2006 Nahum et al Antibiotic Use in Pregnancy 1121
Table 1. Description of the Eleven Broad-Spectrum Antibiotics Investigated
Year of Initial FDA
Antibiotic Description Approval
Amoxicillin Semi-synthetic beta-lactam antibiotic. Inhibits the final stage of 1974
bacterial cell wall synthesis, leading to cell lysis.
Chloramphenicol Broad-spectrum antibiotic isolated from Streptomyces venezuela in 1950
1947, now synthetically available. Binds to the 50S subunit of
bacterial ribosomes, inhibiting peptide bond formation and
protein synthesis.
Ciprofloxacin Fluoroquinolone antibiotic. Exerts its bactericidal effect by 1987
disrupting DNA replication, transcription, recombination, and
repair by inhibiting bacterial DNA gyrase.
Clindamycin Antibiotic derived from lincomycin that has wide-ranging 1970
antimicrobial activity. Binds to the 50S ribosomal subunit,
thereby inhibiting bacterial protein synthesis.
Doxycycline Broad-spectrum antibiotic that binds to the 30S bacterial ribosomal 1967
subunit. Blocks the binding of transfer-RNA to messenger-RNA,
thereby disrupting protein synthesis.
Gentamicin Aminoglycoside antibiotic with broad-spectrum activity. Binds 1966
irreversibly to 30S bacterial ribosomal subunit, thereby inhibiting
protein synthesis.
Levofloxacin Fluoroquinolone antibiotic. L-isomer of ofloxacin, which provides 1996
its principal antibiotic effect. Inhibits bacterial DNA replication,
transcription, recombination, and repair by inhibiting bacterial
type II topoisomerases.
Penicillin G Beta-lactam antibiotic that is primarily bactericidal. Inhibits the 1943
final stage of bacterial cell wall synthesis, leading to cell lysis.
Penicillin V Naturally derived beta-lactam antibiotic. Inhibits the final stage of 1956
(phenoxymethyl bacterial cell wall synthesis, leading to cell lysis. Considered
penicillin) preferable to penicillin G for oral administration because of its
superior gastric acid stability.
Rifampin Rifamycin B derivative that inhibits bacterial and mycobacterial 1971
DNA-dependent RNA polymerase activity. Used primarily for
the treatment of tuberculosis, with additional utility for the
treatment of both leprosy and meningococcal carriers.
Vancomycin Glycopolypeptide antibiotic. Binds to the precursor units of 1964
bacterial cell walls, inhibiting their synthesis and altering cell wall
permeability while also inhibiting RNA synthesis. Because of its
dual mechanism of action, bacterial resistance is rare.
FDA, U.S. Food and Drug Administration.
11 drugsincluding idiosyncratic and dose-related lin G, and penicillin VK), lower circulating drug
bone marrow suppression with chloramphenicol, ar- concentrations were measured in pregnant women
thropathies and bone and cartilage damage with than nonpregnant, suggesting that a shorter dosing
ciprofloxacin and levofloxacin, dental staining and interval or increased maternal dose or both may be
hepatic necrosis with doxycycline, and ototoxicity necessary to obtain similar circulating drug concen-
and nephrotoxicity with gentamicin and vancomy- trations as for women in the nonpregnant state. In the
cinnone of these toxicities has been documented case of ciprofloxacin and levofloxacin, circulating
in human mothers or offspring either during preg- concentrations were generally reduced in pregnant
nancy or breastfeeding with these antibiotics (Table women, also suggesting that an increased maternal
3). dose or a shorter dosing interval or both may be
Very limited information was available pertain- necessary. In 3 cases (chloramphenicol, gentamicin,
ing to maternal pharmacokinetics in pregnancy for 8 and vancomycin), therapeutic drug monitoring of
antibiotics (amoxicillin, ciprofloxacin, clindamycin, serum peak and trough levels is recommended to
gentamicin, levofloxacin, penicillin G, penicillin VK, assess circulating drug levels. In 1 case (clindamycin),
and vancomycin), and none was available for 3 the standard pharmacokinetic parameters did not
(chloramphenicol, doxycycline, and rifampin) (Table change appreciably during the first, second, or third
2). For 4 antibiotics (amoxicillin, gentamicin, penicil- trimester of pregnancy (Table 2). Very little pharma-
Nahum et al
2001). Considered usually compatible with pregnant than in
9
In 20 women at 1925 weeks of gestation who breastfeeding. nonpregnant women, but
received two 200-mg IV doses q 12 hours, the In 10 women given 750 mg q12 hours PO, serum no specific
mean amniotic fluid level 24 hours after and milk concentrations were obtained 2, 4, 6, pharmacokinetic data is
dosing was 0.12 0.06 g/mL (n 7; 9, 12, and 24 hours after the 3rd dose. available regarding
amniotic fluid: maternal serum concentration Concentrations were 3.79 1.26, 2.26 0.75, ciprofloxacin in pregnant
[AF:MS ratio] 0.57), 0.13 0.07 g/mL at 0.86 0.27, 0.51 0.18, 0.20 0.05, and women.19 It is unknown
68 hours (n 7; AF:MS ratio 1.44), and 0.02 0.006 g/mL at these times and the whether dose adjustments
0.10 0.04 g/mL at 1012 hours (n 6; AF: ratios of breast milk: serum concentration were during pregnancy are
17
MS ratio 10.00). 1.84, 2.14, 1.60, 1.70, 1.67, and 0.85, necessary.
17
respectively. For breastfeeding infants Approximately 5070% of
consuming 150 mL/kg per day, the estimated a dose is excreted in the
maximum dose is 0.569 mg/kg per day or urine and, if renal function
2.8% the approved dose for infants of is impaired, the serum half-
18
20 mg/kg per day. life is slightly prolonged
1123
Table 2. Current Information for Eleven Broad-Spectrum Antibiotics That May Be Used in Pregnant and Lactating Women (continued)
1124
Possible Pregnancy
Dosage/ Schedule
Adjustments, Metabolism,
Microbiologic Excretion, and
Spectrum of Recommendations for
Antibiotic Activity* Placental Transmission Transmission Into Breast Milk Monitoring
Nahum et al
Clindamycin Gram-positive Crosses the human placenta readily.44,2023 Excreted in human breast milk (Product Pharmacokinetic parameters do
anaerobes, gram- In 54 women undergoing cesarean delivery who information Clindamycin, 1970). not change during pregnancy
negative anaerobes, received 600 mg IV 30 minutes before surgery, Considered usually compatible with in women studied during the
aerobic gram-positive umbilical cord blood concentrations were 46% of breastfeeding.9 1st, 2nd, and 3rd trimesters of
cocci, streptococci, maternal serum levels.20 At maternal doses of 150 mg orally to 600 mg gestation.20,24 There are no
Clostridia strains After multiple oral doses prior to therapeutic IV, breast milk concentrations range from 0.7 studies to indicate that dosing
abortion, fetal blood concentrations were 25% and to 3.8 g/mL (Product information should be modified during
amniotic fluid levels were 30% of maternal blood Clindamycin, 1970). pregnancy.
levels.21 Cmax and Tmax (after a single
standard dose) and Css (after
multiple doses) do not change
appreciably at any time
during pregnancy.
Doxycycline Gram-positives, gram- Crosses the placenta (Product information Excreted in human breast milk.25 Unknown whether dose
Nahum et al
trimesters.6,11
Penicillin VK Gram-positive aerobes Crosses the human placenta readily.5,7,10,33,34,35 Excreted in human breast milk in small amounts Shorter dosing interval and/or
including most Penicillins are transferred to the fetus and amniotic (Product information Penicillin V, 1997).15,36 increased dose have been
streptococci/ fluid reaching therapeutic levels.5 Considered usually compatible with suggested during pregnancy
enterococci, gram- breastfeeding.9 to attain similar plasma
positive anaerobes, In 18 women, penicillin V milk concentration concentrations as for
gram negatives depended on presence of mastitis, with peak nonpregnant women.6,11
levels 2.65.4 hours after a single PO 1,320-mg Penicillin V is excreted renally,
dose.35 Peak concentration was 3072 g/dL primarily via tubular
with mean concentration 26-37 g/dL. AUC secretion. Volume of
over 8 hours after dosing was 2.13.0 mg-h/L.35 distribution and renal
Estimated dose of penicillin V ingested per day clearance are increased
by breastfed infants is 4060 g/kg, or 0.09 during the 2nd and 3rd
0.14% of maternal dose per kg body weight.35 trimesters.6,11
1125
1126
Table 2. Current Information for Eleven Broad-Spectrum Antibiotics That May Be Used in Pregnant and Lactating Women (continued)
Nahum et al
Possible Pregnancy
Dosage/ Schedule
Adjustments, Metabolism,
Microbiologic Excretion, and
Spectrum of Recommendations for
Antibiotic Activity* Placental Transmission Transmission Into Breast Milk Monitoring
Rifampin Mycobacteria, Neisseria Crosses the human placenta (Product information Excreted in human breast milk (Product Unknown whether dosing
meningitidis, S aureus, Rifampin, 1971).3739 information Rifampin, 1971).15,40,41 adjustments during pregnancy
Haemophilus influenzae, Umbilical cord concentrations between 12% and Considered usually compatible with are necessary.
Legionella pneumophila, 33% of maternal blood levels, with peak levels breastfeeding.9 Pharmacokinetics during
Chlamydia occurring concurrently after drug administration.3739 After a single oral dose of 600 mg, a nursing pregnancy has not been
infant would ingest approximately 0.05% of the specifically studied.
maternal dose per day, or approximately 0.3 Hepatically deacetylated to
Nahum et al
the 3rd trimester was observed in a randomized controlled
trial including 4,826 pregnant patients.52,53
Chloramphenicol OR for major congenital anomalies 1.7 (95% CI 1.22.6) for No increased congenital Increased risk of teratogenicity is C
oral administration at any time during pregnancy in a case- anomalies in monkeys.60 unlikely, based on fair data.
control study of 22,865 malformed infants (risk marginally No teratogenicity in mice or Therapeutic doses of chloramphenicol
increased).57 rabbits at 1040 times the are unlikely to pose a substantial
RR for congenital malformations 1.19 (95% CI 0.522.31) in recommended human dose.61 teratogenic risk.
348 offspring born to women who took chloramphenicol at No teratogenicity in rats at 24
any time during pregnancy (no statistically increased risk).58 times the usual human dose,62
Potential for both dose-related and idiosyncratic bone marrow but various fetal anomalies at
toxicity. Caution should be used near term, during labor, 1040 times the human
and while breastfeeding due to the possibility of inducing dose.61,63
1127
(continued)
Table 3. Teratogenic and Toxic Potential of Eleven Broad-Spectrum Antibiotics Based on Available Human and Animal Data (continued)
1128
Magnitude of Human FDA
Animal Data: Teratogenic Teratogenic Fetal Risk Pregnancy
Antibiotic Human Data: Teratogenic and Toxic Effects and Toxic Fetal Effects (Based on TERIS Assessment)44 Category*
Ciprofloxacin Congenital malformation rate 4.0% and spontaneous No detectable adverse effects on Increased risk of teratogenicity is C
abortion rate 10.7% among liveborns to 56 women who embryonic or fetal unlikely, based on fair data.
Nahum et al
continued their pregnancies after exposure to ciprofloxacin development in monkeys.69 Therapeutic doses of ciprofloxacin
(ENTIS registry, 19861994). Rates of spontaneous No evidence of teratogenicity in during pregnancy are unlikely to pose
abortion/fetal death, post-natal disorders, prematurity and the offspring of mice, rats, and a substantial teratogenic risk, but the
intra-uterine growth retardation did not exceed background rabbits.70 data are insufficient to state that there
rates.64 is no [increased] risk.
In a prospective registry of 116 pregnancies exposed to
ciprofloxacin, 91 resulted in live births and 69% of these
were exposed during the 1st trimester. Six liveborns were
malformed (congenital malformation rate 6.6%). There
was no pattern of minor or major malformations.64
OR for major congenital anomalies 0.85 (95% CI 0.21
3.49) in a controlled, prospective, observational study of
Nahum et al
All mothers reported that exposed infants were normal at 1 doses.87,88
year of age in a prospective study of 81 pregnancies treated No teratogenicity in rats or
with doxycycline for 10 days during the early 1st monkeys at more than 100
trimester.80 times the human dose.89
Tetracycline class antibiotics may induce hepatic necrosis in Delayed long bone skeletal
some pregnant women.8183 differentiation in albino rats
Some tetracyclines can cause cosmetic staining of primary given 8 mg/kg of doxycycline
dentition for exposures during the 2nd or 3rd trimester,84,85 intraperitoneally from
and there is some concern about possible enamel gestational day 8 to 19.90
hypoplasia and reversible depression of fetal bone growth.86 Delayed appearance of
No staining from doxycycline has been documented in primary ossification centers in
humans. the humerus, ulna, radius,
1129
(continued)
Table 3. Teratogenic and Toxic Potential of Eleven Broad-Spectrum Antibiotics Based on Available Human and Animal Data (continued)
1130
Magnitude of Human FDA
Animal Data: Teratogenic Teratogenic Fetal Risk Pregnancy
Antibiotic Human Data: Teratogenic and Toxic Effects and Toxic Fetal Effects (Based on TERIS Assessment)44 Category*
Gentamicin OR for major congenital anomalies 1.7 (95% CI 0.93.2), Mice given 112 times the Increased risk of teratogenicity is C
in a case-control study of 22,865 infants with congenital maximum human dose had a undetermined based on limited
Nahum et al
anomalies (no increased risk); included 19 critical slight statistically data.
exposures, with the majority occurring during the 2nd or nonsignificant increase in the A small [increased] risk cannot be
3rd month of pregnancy.91 rate of congenital anomalies at excluded, but there is no indication
A randomized trial of 3 parenteral antibiotic regimens showed lower doses, but not higher that the risk of malformations in
no congenital abnormalities among 57 infants whose ones.95 Fetal deaths were children of women treated with
mothers were treated with gentamicin during the 1st or 2nd increased.95 gentamicin during pregnancy is likely
trimesters.92 In mice treated with 1118 times to be great.
The frequency of newborn hearing screening failures was not the maximum human dose,
different between 46 infants whose mothers were treated dose-dependent ultrastructural
with gentamicin during pregnancy and 92 unexposed vestibular system damage was
control infants.93 demonstrated in offspring.96
Renal cystic dysplasia was reported in a child whose mother In rats treated systemically with
Nahum et al
among 7,171 infants whose mothers were treated with a day during pregnancy.104
penicillin derivative at any time during pregnancy (no No teratogenicity or impaired
increased risk).58 fertility in mice, rats and
The frequency of 1st-trimester penicillin use was no greater rabbits (Product information
than expected in a prospective study of 194 infants with Bicillin, 2001).
major malformations born in Sweden (19631965).100
OR for neural tube defects 0.90 (95% CI 0.372.17). Rate
of 1st-trimester penicillin use was no greater than expected
in a case-control study of 538 infants with neural tube
defects and 539 controls in California from 1989 to 1991
(no increased risk).101
No adverse effects noted in offspring despite widespread use
1131
Table 3. Teratogenic and Toxic Potential of Eleven Broad-Spectrum Antibiotics Based on Available Human and Animal Data (continued)
1132
Magnitude of Human FDA
Animal Data: Teratogenic Teratogenic Fetal Risk Pregnancy
Antibiotic Human Data: Teratogenic and Toxic Effects and Toxic Fetal Effects (Based on TERIS Assessment)44 Category*
Penicillin VK OR for congenital anomalies 1.25 (95% CI 0.841.86) (not No evidence of impaired fertility Increased risk of teratogenicity is none B
increased) among 654 users of penicillin VK with or without or harm to the fetus due to based on good data.
Nahum et al
other drug use during the 1st trimester (19911998). The rate penicillin in reproduction
of congenital anomalies (4.6%) was no greater than for 9,263 studies in mouse, rat, and
controls who did not redeem any prescription drug during rabbit (Product information
pregnancy (3.6%).105 Nine cardiovascular abnormalities Penicillin V, 1997).
occurred in the group exposed to penicillin VK (OR 1.74;
95% CI 0.833.65) (not statistically increased).105
OR for congenital anomalies 1.3 (95% CI 1.11.6) in a case-
control study (19801996) of 22,865 infants with congenital
anomalies (173 [0.8%] treated with penicillin V during
pregnancy). Adjusted OR for medically documented penicillin
V use during the 1st trimester showed no significant
association between maternal exposure and congenital
Nahum et al
fetus is considered low.42,44 No increase in congenital
malformation rate in rats or
rabbits treated with 15 or 13
times the human dose,
respectively.116,117
TERIS, Teratogen Information Service; OR, odds ratio; RR, relative risk; CI, confidence interval; ENTIS, European Network of Teratology Information Services; BSA, body surface area.
* A, B, C, D, X Pregnancy Category system, as defined under 21 CFR 201.57.
cokinetic data were available in lactating women for life-threatening illnesses, as is the case with many
any of the antibiotics (Table 2). agents of bioterrorism. These issues are particularly
relevant to emergency response professionals, as well
CONCLUSION as to primary health care providers who manage the
The safety of drug use in pregnancy is often an pregnancies of the nearly four million women who
enigma. Many drugs have a long usage history in deliver newborns each year in the United States.2
pregnancy without any controlled clinical trials ever The difficulty with the assessment of drug effects
having been conducted to ascertain their safety or
efficacy during human pregnancy. Although there is
Table 5. Eleven Broad-Spectrum Antibiotics That
little reason to believe that medications that have
May Be Used in Pregnant and Lactating
been demonstrated to be effective for particular con- Women in Cases of Exposure to Potential
ditions in nonpregnant subjects will not also prove Agent(s) of Bioterrorism4, 70,118-123
effective when delivered in proper doses to pregnant
Antibiotic Potentially Useful
women, the changes in basic physiology that occur in Against Bioterrorist
the maternal volume of distribution, renal clearance, Agent(s)*
and hepatic metabolismas well as the potential for
Amoxicillin Bacillus anthracis
pharmacokinetic effects related to the distribution and Chloramphenicol Bacillus anthracis
metabolism of the drug in the fetal compartment Yersinia pestis
make the issue of proper pregnancy-specific dosing Francisella tularensis
difficult to predict in the absence of empirical data. To Ciprofloxacin Bacillus anthracis
further complicate this issue, these physiologic Yersinia pestis
Francisella tularensis
changes of pregnancy vary greatly from the first to the Coxiella burnetii
third trimester. Clindamycin Bacillus anthracis
Often, because of inadequate data regarding the Doxycycline Bacillus anthracis
prevalence of use, timing, and duration of exposure of Yersinia pestis
sufficient numbers of pregnant women to drugs, there Francisella tularensis
Gentamicin Bacillus anthracis
is insufficient information to formulate conclusive Yersinia pestis
judgments about their safety and efficacy that are Francisella tularensis
different from that for nonpregnant patients. Con- Levofloxacin Bacillus anthracis
cerns regarding potential teratogenicity and fetal or Yersinia pestis
neonatal toxicity are often incompletely addressed by Francisella tularensis
Coxiella burnetii
the limited amount of pregnancy and lactation expo- Penicillin G Bacillus anthracis
sure data and adverse event reports that are available. Penicillin VK Bacillus anthracis
Because of this, conflicts can arise between the theo- Rifampin Bacillus anthracis
retical fear of adverse fetal or neonatal consequences Vancomycin Bacillus anthracis
and the general bias among most healthcare profes- * As cited by the Centers for Disease Control and Prevention based
sionals that the successful treatment of medical con- on in-vitro microbiologic susceptibility data from a limited set of
clinical isolates.
ditions in the mother is in the offsprings best interest.
Not currently a Food and Drug Administrationapproved indi-
This is especially true in the case of potentially cation.
VOL. 107, NO. 5, MAY 2006 Nahum et al Antibiotic Use in Pregnancy 1135
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