From the Guidelines
For treating urinary tract infections (UTIs) in pregnant women, first-line therapy is typically nitrofurantoin 100mg twice daily for 5-7 days, except in the first trimester and near delivery. Alternatives include amoxicillin-clavulanate 500/125mg twice daily for 5-7 days or cephalexin 500mg four times daily for 5-7 days 1. Fosfomycin 3g as a single dose is also safe during pregnancy, but its effectiveness in preventing adverse outcomes such as pyelonephritis and preterm labor is not yet well studied 1. Trimethoprim-sulfamethoxazole should be avoided in the first trimester due to folate antagonism and near term due to risk of neonatal hyperbilirubinemia. Fluoroquinolones and tetracyclines are contraindicated throughout pregnancy.
Key Considerations
- Asymptomatic bacteriuria should also be treated in pregnancy as it increases the risk of pyelonephritis, preterm birth, and low birth weight 1.
- Urine culture should be obtained before treatment to guide antibiotic selection, and a test of cure should be performed 1-2 weeks after completing therapy.
- Increased fluid intake and urinating after intercourse may help prevent recurrence.
- UTIs in pregnancy require prompt treatment as they can ascend to the kidneys more easily due to pregnancy-related physiological changes including urinary stasis from progesterone effects and mechanical compression of the ureters.
Special Populations
- Diabetic women with asymptomatic bacteriuria do not benefit from screening or treatment, and may experience harm from antimicrobial therapy 1.
- The optimal duration of antimicrobial therapy for treatment of bacteriuria in pregnant women has not been determined, but current recommendations for a 4- to 7-day duration are reasonable 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for UTI in Pregnancy
- The recommended treatment for urinary tract infection (UTI) in pregnancy includes separating pregnant subjects with UTI into two groups: those with asymptomatic bacteriuria and those with symptomatic UTI 2.
- 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 2.
- Other treatment options include nitrofurantoin, trimethoprim/sulfamethoxazole, and cephalosporins, although the cure rates may vary 2.
International Guidelines for UTI Treatment in Pregnancy
- A literature review of international guidelines for UTI treatment in pregnancy found concordance between guidelines on several aspects, including the use of antibiotics and follow-up after treatment 3.
- However, there are areas of discordance, such as the use of fluoroquinolones in lower or upper UTI 3.
Current Prescribing Practices for UTI Treatment
- A study on current prescribing practices for uncomplicated UTI treatment in women found that guideline discordance continues, with the overuse of fluoroquinolones and underuse of first-line antibiotic agents 4.
- The study also found that obstetricians-gynecologists and urologists had a higher likelihood of concordant treatment than other specialties 4.
Nitrofurantoin as a Treatment Option
- Nitrofurantoin is a wide-spectrum antibiotic that is commonly used to treat UTIs and has been repositioned as first-line therapy for uncomplicated lower UTI 5.
- A narrative review found that nitrofurantoin can be considered the most effective drug in the treatment of acute urinary infection, but its long-term side effects, especially in elderly patients, need to be considered 5.