Commonly Used Antibiotics in Pregnancy

by Marjorie Greenfield, M.D.

Women in the childbearing years are commonly treated with antibiotics and other anti-microbial
medications. In pregnancy, the issue of which medication to use comes up frequently, whether for
a bladder infection, yeast vaginitis, sinus infection, herpes, or other conditions. Obstetricians
frequently get calls from women who were prescribed something by another physician, calls from
dentists, and calls from other doctors checking to be sure that a particular antibiotic is OK to use
during pregnancy. In this article, I will review commonly used anti-microbial medications. I will not
include medications that are given by vein or are used only in rare instances. For information on
those sorts of medications, and for information about your individual risks and benefits for any
medication, you should speak to your practitioner.
In general, every medication is assigned to a category (B, C, D, or X) based on how safe or risky
it is to use during pregnancy. To learn more about general principles of medication use in
pregnancy, see Medications in Pregnancy.
Category A
Only a few medications fall into category A, which means that human studies have shown no
evidence of fetal harm in the first trimester or later in the pregnancy.
Nystatin vaginal (Mycostatin)
Category B
Most antibiotics are Category B, which means that there is no known association with birth
defects or other pregnancy-related complication and the drug is probably safe. These include:
Amoxicillin
Ampicillin
Augmentin (amoxicillin-clavulanate)
Dicloxicillin
Macrobid (nitrofurantoin)
Flagyl (metronidazole) (although there is some controversy about taking it by mouth in the first
trimester)
Cephalosporins including: Keflex (cephalexin), Ceclor (cefaclor), Duricef (cefadroxil)
Cleocin (clindamycin)

Erythromycin (all forms)

Zithromax (azithromycin)
 Sulfa drugs (until near term)
Famvir (famciclovir)
Zovirax (acyclovir)
Valtrex (valacyclovir)
Clotrimazole-vaginal (Mycelex, Lotrimin)
Category C
Others are Category C, meaning that either there isn't enough information or there are some
concerns arising from animal studies, but no confirmation of problems like birth defects in
humans. These include:
Bactrim
Trimethoprim
Biaxin (clarithromycin)
Cipro (ciprofloxacin)
Diflucan (fluconazole)
Monistat (miconazole)
Terazol (terconazole)
Isoniazid
Rifampin
Vermox (mebendazole)
Tetanus booster (tetanus toxoid)
Vaccines: hepatitis A, hepatitis B, influenza, meningococcus, pneumonia (pneumococcus), polio
Vaccines: Measles, Mumps, Rubella (in this category because there is no proof that the MMR
vaccine causes birth defects, but it is never purposefully used during pregnancy because there is
some fear that the rubella component could adversely affect an unborn child)
Category D
Category D medications have clear-cut problems in pregnancy and should not be used unless
there are no better alternatives. Category D includes:
Tetracycline derivatives, which can cause discoloration of teeth: tetracycline, doxycycline
(Vibramycin), Minocin (minocycline)
Sulfa drugs - if near delivery (because they can increase the chance of serious newborn jaundice)
 CDC Study Links 2 Antibiotics to Birth Defects
MONDAY, Nov. 2 (HealthDay News) -- Taking antibiotics during pregnancy does not raise the risk for most
birth defects, though there are some exceptions, new research has found.

Penicillin, which is the most commonly used antibiotic during pregnancy, as well as erythromycin,
cephalosporins and quinolones, other widely prescribed antibiotics, were not associated with increased risk
for about 30 different birth defects.

However, the study found that two types of antibiotics were linked with a higher risk for several birth defects:
nitrofurantoins and sulfonamides, sometimes called "sulfa drugs," which are prescribed for urinary tract and
other infections.

Women whose children had anencephaly, a fatal malformation of the skull and brain, were three times more
likely to have taken sulfonamides, the study found. Sulfonamides were also tied to an increased risk for such
heart defects as hypoplastic left heart syndrome and coarctation of the aorta, choanal atresia (a blockage of
the nasal passage), transverse limb deficiency and diaphragmatic hernia, an abnormal opening in the
diaphragm that results in severe breathing difficulties.

Nitrofurantoins were also associated with multiple birth defects, including anophthalmia and microphthalmos
(eye defects) and several congenital heart defects. Mothers whose children were born with a cleft lip or cleft
palate were twice as likely to have taken nitrofurantoins, the study found.

But pregnant women should not be overly worried if they need an antibiotic to treat an infection during
pregnancy, stressed the study's lead author, Krista Crider, a geneticist with the National Center on Birth
Defects and Developmental Disabilities, part of the U.S. Centers for Disease Control and Prevention.

"The most important message is that most commonly used antibiotics do not seem to be associated with the
birth defects we studied," Crider said.

The findings are published in the November issue of Archives of Pediatrics & Adolescent Medicine.

Crider and her colleagues analyzed data on more than 13,000 women whose babies had one of more than
30 birth defects, including cleft palate, heart or limb defects and anencephaly. They compared the women's
rates of antibiotic usage, from the month leading up to pregnancy through the end of the first trimester, with
that of almost 5,000 women whose children did not have a birth defect. The data was culled from the
National Birth Defects Prevention Study, which began in 1997 and includes about 30,000 women from 10
states.

Information on the impact of many prescription drugs on developing fetuses is sorely lacking, Crider pointed
out. Much of that stems from the fact that ethical considerations preclude conducting drugs trials in pregnant
women, she said.

Though many antibiotics have been used safely for decades, resistant strains of bacteria are forcing doctors
to use a wider array of antibiotics. For some, little data exist.

The researchers found that about 30% of women took an antibiotic between the three months prior to
conception and the end of the pregnancy.

Even antibiotics that generally were safe were found to be associated with a few specific birth defects.
Women whose babies were born with a certain type of limb malformation were three times more likely to
have taken penicillin. Erythromycin, cephalosporins and quinolones were also associated with an increased
risk for one or two specific birth defects.

However, the researchers said they did not know if the birth defects were caused by the antibiotics or the
underlying infection.
 One expert said women need to remember the good antibiotics can do mom and baby, as well. Though
many pregnant women want to avoid taking any drugs during pregnancy, infections pose a risk to mother
and baby and often need to be treated, said Dr. Jennifer Wu, an obstetrician-gynecologist at Lenox Hill
Hospital in New York City.

"Untreated infections during pregnancy can lead to severe consequences, such as maternal sepsis [blood
infection] and preterm labor," Wu said. "Yet many patients are afraid to take medications such as antibiotics
during pregnancy."

The study "supports the evidence that antibiotics are safe for pregnant women," she said. "It is reassuring
for doctors and patients to have more data on necessary drugs for pregnancy."

Crider also stressed that the chances of having a baby with a birth defect remain small, even if an antibiotic
has been linked to an elevated risk. For example, the risk of having a child with hypoplastic left heart
syndrome is about one in 4,200. Sulfonamides were associated with a three-fold increase, making the
likelihood about one in 1,400, she said.

Brand names for nitrofurantoins include Furadantin, Macrobid and Macrodantin. Bactrim and Septra are
among the brand names of sulfonamides.

Given the data, Crider said, women should be cautious about taking either of those types of drugs during
pregnancy and should discuss other options with their physicians,.

According to the study, the overall risk for having a child with a birth defect is about three percent.

The study did not look at chromosomal defects, including Down syndrome.
Antibiotics linked to birth defects
Ties in common drugs for urinary infections

CARLA K. JOHNSON,AP Medical Writer

CHICAGO (AP) - Researchers studying antibiotics in pregnancy have found a surprising link between
common drugs used to treat urinary infections and birth defects. Reassuringly, the most-used antibiotics in
early pregnancy penicillins appear to be the safest.

Bacterial infections themselves can cause problems for the fetus if left unchecked, experts said, so pregnant
women shouldn't avoid antibiotics entirely. Instead, women should discuss antibiotics choices with their
doctors.

The new study is the first large analysis of antibiotic use in pregnancy. It found that mothers of babies with
birth defects were more likely than mothers with healthy babies to report taking two types of antibiotics
during pregnancy: sulfa drugs (brand names include Thiosulfil Forte and Bactrim) and urinary germicides
called nitrofurantoins (brand names include Furadantin and Macrobid).

It was the first time an association had been seen between urinary tract treatments and birth defects, said
lead author Krista Crider, a geneticist with the Centers for Disease Control and Prevention, which funded the
research. "Additional studies are going to need to be done to confirm these findings."

Used for many decades, the antibiotics in question predate the Food and Drug Administration and its
requirements for rigorous safety testing. The FDA now grades all drugs for safety to the fetus based on
available research, but rigorous studies are so lacking in many cases, that no antibiotics get the highest
grade of "A."

Sulfa drugs are the oldest antibiotics and some animal studies have found harm during pregnancy.
Nitrofurantoins previously have been viewed by doctors as safe to treat urinary tract infections during
pregnancy.

The study, appearing in November's Archives of Pediatrics and Adolescent Medicine, may cause doctors to
change the drugs they choose to treat pregnant women with infections. The findings were released Monday.

Dr. Susan Mehnert-Kay, a family practice doctor in Tulsa, Okla., who has written about diagnosing and
managing urinary tract infections, said the research is "very interesting" and would cause her to reconsider
antibiotic choices in early pregnancy.

The study is important because it looked at drugs that have been used for decades without large studies of
their safety in pregnant women, said Dr. Michael Katz of the March of Dimes.

"Some physicians are not as attuned to this as they ought to be, so patients have the right to ask questions,"
Katz said.

The researchers analyzed data from more than 13,000 mothers whose infants had birth defects and nearly
5,000 women who lived in the same regions with healthy babies.

The women were interviewed by phone from six weeks to two years after their pregnancies. Those who
remembered taking antibiotics during the month before conception through the first three months of
pregnancy were identified as exposed to antibiotics.

The women's memories could have been faulty, a substantial weakness of the study, which the authors
acknowledged. About one-third of the women who took antibiotics couldn't remember the specific type of
drug they took.
It's also unclear whether the birth defects were caused by the drugs or by the underlying infections being
treated, Crider said.

Birth defects linked to sulfa drugs included rare brain and heart problems, and shortened limbs. Those linked
to nitrofurantoins (ny-troh-fyoor-AN'-toyns) included heart problems and cleft palate. The drugs seemed to
double or triple the risk, depending on the defect.

"These defects are rare. Even with a threefold increase in risk, the risk for the individual is still quite low,"
Crider said.

Katz of the March of Dimes said anencephaly, a fatal brain problem linked to sulfas, affects about 1 in
10,000 births in the United States. Cleft palate occurs about 20 per 10,000 births.

Crider said the findings give doctors another opportunity to caution against overuse of antibiotics. Viral
illnesses like colds and flus shouldn't be treated with antibiotics, she said.

Women in 10 states, including California, Texas and New York, were interviewed as part of the National Birth
Defects Prevention Study.

The FDA recommends that pregnant women discuss medications with their doctors, said FDA
spokeswoman Sandy Walsh. The agency has proposed changes to prescription drug labeling that would
require more complete information for women of childbearing age, pregnant women and those who
breastfeed, Walsh said.
Antibiotic Use During Pregnancy And Birth Defects: Study
Examines Associations
ScienceDaily (Nov. 3, 2009) Penicillin and several other antibacterial
medications commonly taken by pregnant women do not appear to be
associated with many birth defects, according to a report in the
November issue of Archives of Pediatrics & Adolescent Medicine, one of
the JAMA/Archives journals. However, other antibiotics, such as
sulfonamides and nitrofurantoins, may be associated with several
severe birth defects and require additional scrutiny.
Treating infections is critical to the health of a mother and her baby, according to background information in
the article. Therefore, bacteria-fighting medications are among the most commonly used drugs during
pregnancy. Although some classes of antibiotics appear to have been used safely during pregnancy, no
large-scale studies have examined safety or risks involved with many classes of antibacterial medications.

Krista S. Crider, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues analyzed
data from 13,155 women whose pregnancies were affected by one of more than 30 birth defects (cases).
The information was collected by surveillance programs in 10 states as part of the National Birth Defects
Prevention Study. The researchers compared antibacterial use before and during pregnancy between these
women and 4,941 randomly selected control women who lived in the same geographical regions but whose
babies did not have birth defects.

Antibacterial use among all women increased during pregnancy, peaking during the third month. A total of
3,863 mothers of children with birth defects (29.4 percent) and 1,467 control mothers (29.7 percent) used
antibacterials sometime between three months before pregnancy and the end of pregnancy.

"Reassuringly, penicillins, erythromycins and cephalosporins, although used commonly by pregnant women,
were not associated with many birth defects," the authors write. Two defects were associated with
erythromycins (used by 1.5 percent of the mothers whose children had birth defects and 1.6 percent of
controls), one with penicillins (used by 5.5 percent of case mothers and 5.9 percent of controls), one with
cephalosporins (used by 1 percent of both cases and controls) and one with quinolones (used by 0.3
percent of both cases and controls).

Two medications -- sulfonamides and nitrofurantoins (each used by 1.1 percent of cases and 0.9 percent of
controls) -- were associated with several birth defects, suggesting that additional study is needed before
they can be safely prescribed to pregnant women.

"Determining the causes of birth defects is problematic," the authors write. "A single defect can have multiple
causes, or multiple seemingly unrelated defects may have a common cause. This study could not determine
the safety of drugs during pregnancy, but the lack of widespread increased risk associated with many
classes of antibacterials used during pregnancy should be reassuring."

The National Birth Defects Prevention Study is funded by a cooperative agreement from the Centers for
Disease Control and Prevention.
Antibiotic Use During Pregnancy And Birth Defects: Study Examines
Associations

ScienceDaily (Nov. 3, 2009) Penicillin and several other antibacterial

medications commonly taken by pregnant women do not appear to be associated
with many birth defects, according to a report in the November issue of Archives
of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.
However, other antibiotics, such as sulfonamides and nitrofurantoins, may be
associated with several severe birth defects and require additional scrutiny.

Treating infections is critical to the health of a mother and her baby, according to background
information in the article. Therefore, bacteria-fighting medications are among the most commonly
used drugs during pregnancy. Although some classes of antibiotics appear to have been used
safely during pregnancy, no large-scale studies have examined safety or risks involved with many
classes of antibacterial medications.

Krista S. Crider, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and
colleagues analyzed data from 13,155 women whose pregnancies were affected by one of more
than 30 birth defects (cases). The information was collected by surveillance programs in 10 states
as part of the National Birth Defects Prevention Study. The researchers compared antibacterial
use before and during pregnancy between these women and 4,941 randomly selected control
women who lived in the same geographical regions but whose babies did not have birth defects.

Antibacterial use among all women increased during pregnancy, peaking during the third month.
A total of 3,863 mothers of children with birth defects (29.4 percent) and 1,467 control mothers
(29.7 percent) used antibacterials sometime between three months before pregnancy and the
end of pregnancy.

"Reassuringly, penicillins, erythromycins and cephalosporins, although used commonly by

pregnant women, were not associated with many birth defects," the authors write. Two defects
were associated with erythromycins (used by 1.5 percent of the mothers whose children had birth
defects and 1.6 percent of controls), one with penicillins (used by 5.5 percent of case mothers
and 5.9 percent of controls), one with cephalosporins (used by 1 percent of both cases and
controls) and one with quinolones (used by 0.3 percent of both cases and controls).

Two medications -- sulfonamides and nitrofurantoins (each used by 1.1 percent of cases and 0.9
percent of controls) -- were associated with several birth defects, suggesting that additional study
is needed before they can be safely prescribed to pregnant women.

"Determining the causes of birth defects is problematic," the authors write. "A single defect can
have multiple causes, or multiple seemingly unrelated defects may have a common cause. This
study could not determine the safety of drugs during pregnancy, but the lack of widespread
increased risk associated with many classes of antibacterials used during pregnancy should be
reassuring."The National Birth Defects Prevention Study is funded by a cooperative agreement
from the Centers for Disease Control and Prevention.