What is the treatment for Urinary Tract Infection (UTI) during the second trimester of pregnancy?

From the Guidelines

The most appropriate treatment for urinary tract infections (UTIs) during the second trimester of pregnancy is nitrofurantoin 100 mg orally twice daily for 5 days, as recommended by the European Association of Urology guidelines 1. This guideline prioritizes the safety and efficacy of antimicrobial therapy during pregnancy, emphasizing the importance of avoiding certain antibiotics that may pose risks to the fetus. The European Association of Urology guidelines 1 suggest the following first-line treatment options for uncomplicated cystitis in women, which can be applied to pregnant women in their second trimester:

• Nitrofurantoin macrocrystals 50–100 mg four times a day for 5 days
• Nitrofurantoin monohydrate or macrocrystals 100 mg twice a day for 5 days
• Nitrofurantoin macrocrystals prolonged release 100 mg twice a day for 5 days It is essential to note that trimethoprim-sulfamethoxazole should be avoided during the first trimester of pregnancy 1, and fluoroquinolones should be avoided altogether during pregnancy due to potential fetal risks. In contrast, the 2011 guidelines from the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 1 provide recommendations for non-pregnant women, which may not be directly applicable to pregnant women. However, these guidelines do suggest nitrofurantoin as a viable option for treating uncomplicated cystitis, which aligns with the more recent European Association of Urology guidelines 1. Ultimately, the choice of antibiotic should be individualized based on patient-specific factors, such as allergy history and local resistance patterns, while prioritizing the safety of the developing fetus. Key considerations in treating UTIs during pregnancy include:
• Prompt antibiotic therapy to prevent complications
• Avoiding certain antibiotics that may pose fetal risks
• Obtaining urine cultures to guide therapy and ensure cure
• Encouraging increased fluid intake, frequent urination, and proper hygiene practices to support treatment.

From the FDA Drug Label

URINARY TRACT INFECTIONS (complicated and uncomplicated) Caused by Escherichia coli, Proteus mirabilis, Proteus vulgaris, Morganella morganii or Klebsiella pneumoniae The FDA drug label for ceftriaxone 2 indicates that it is used to treat urinary tract infections caused by susceptible organisms. Key points:

• Ceftriaxone is indicated for the treatment of urinary tract infections.
• The drug label does not specifically address the treatment of UTI in the second trimester of pregnancy.
• However, since ceftriaxone is used to treat UTIs in general, it may be considered for use in pregnant women, but the decision should be made with caution and under the guidance of a healthcare provider.
• Amoxicillin/clavulanate 3 is also an option for treating UTIs, but its use during pregnancy should be carefully considered due to the lack of adequate and well-controlled studies in pregnant women.

From the Research

Treatment Options for UTI in Pregnancy

• The recommended treatment for urinary tract infection (UTI) in pregnancy involves separating pregnant subjects with UTI into two groups: those with asymptomatic bacteriuria and those with symptomatic UTI 4.
• For asymptomatic bacteriuria, a single dose of an antimicrobial to which the organism is susceptible can be used, while for symptomatic UTI, amoxicillin 500 mg tid for three days is recommended 4.
• Other treatment options include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole, which have minimal collateral damage and resistance 5.
• Nitrofurantoin is considered a effective drug in the treatment of acute urinary infection, but its long-term side effects, especially in elderly patients, need to be considered 6.

Considerations for Nitrofurantoin Use

• Nitrofurantoin 50 mg daily prophylaxis is recommended over 100 mg daily prophylaxis for recurrent UTI, as it has a better safety profile and equivalent efficacy 7.
• The clinical cure rates of nitrofurantoin for uncomplicated UTI range from 51 to 94%, and bacteriological cure rates range from 61 to 92% 8.
• Patients taking nitrofurantoin report fewer side effects than other drugs, with the most commonly reported side effects being gastrointestinal and central nervous system symptoms 8.

Diagnosis and Testing

• Urine culture is the gold standard for detection of UTI, and asymptomatic bacteriuria should not be treated with antibiotics 5.
• Dipstick urinalysis can be used as a screening test, but its results must be interpreted in the context of the patient's pretest probability based on symptoms and characteristics 5.
• Bacteriuria is more specific and sensitive than pyuria for detecting UTI, even in older women and during pregnancy 5.