Pregnancy and Antibiotic Use

Introduction to Risks

The American Academy of Dermatology recommends avoiding Bactrim (trimethoprim/sulfamethoxazole) during pregnancy due to increased risks of preterm birth, low birthweight, neural tube defects, cardiovascular malformations, and kernicterus in the newborn (Conditional recommendation, Low quality evidence) 1, 2, 3
Bactrim use during pregnancy is associated with increased risks of preterm birth and low birthweight 1

The North American clinical practice guidelines recommend cephalexin and azithromycin as first-line options for pregnant patients requiring antibiotics (Conditional recommendation, Moderate evidence) 1
Clindamycin is recommended as a second-line option for pregnant patients requiring antibiotics (Conditional recommendation, Moderate evidence) 1
Penicillins (e.g., amoxicillin) and cephalosporins (e.g., cephalexin) are recommended as safer alternatives to TMP-SMX for pregnant patients requiring antibiotics, according to the American Academy of Dermatology and European Respiratory Journal 2, 1

If Bactrim must be used during pregnancy, it is essential to consider the risks vs. benefits, add folic acid supplementation (at least 400 μg daily), and use the shortest course possible to reduce the risk of neural tube defects and kernicterus (hyperbilirubinemia) in the newborn 1, 3, 4
For hidradenitis suppurativa, cephalexin or azithromycin are recommended as first-line treatments during pregnancy, according to the American Academy of Dermatology 1
For skin and soft tissue infections where MRSA is suspected, clindamycin is preferred over TMP-SMX during pregnancy, as recommended by the Clinical Infectious Diseases journal 5
TMP-SMX is contraindicated in pregnant women in the third trimester due to the risk of kernicterus, as stated by MMWR Recommendations and Reports 4