From the Guidelines
The patient should be treated for a urinary tract infection (UTI) with an antibiotic that is safe in pregnancy, such as nitrofurantoin (Macrobid) 100 mg orally twice daily for 7 days, as recommended by the Infectious Diseases Society of America guidelines 1.
Treatment Plan
- The urinalysis findings of elevated WBCs, RBCs, bacteria, cloudy appearance, protein, and leukocyte esterase strongly suggest a UTI, which is common in pregnancy due to physiological changes in the urinary tract.
- For her pregnancy-related nausea, I recommend pyridoxine (vitamin B6) 25 mg orally three times daily, with the addition of doxylamine 12.5 mg at night if needed.
- She should increase fluid intake to 2-3 liters daily to help with both the UTI and pregnancy symptoms.
- The low CO2 on her CMP may reflect a mild metabolic acidosis from dehydration related to her diarrhea and vomiting.
- Her urinary frequency could be due to both early pregnancy and the UTI.
- Follow-up urinalysis after completing antibiotics is recommended to ensure resolution of the infection, as untreated UTIs in pregnancy can lead to pyelonephritis and increase risks of preterm labor and low birth weight, as noted in the guidelines for recurrent lower urinary tract infections in females 1 and the treatment and prevention of recurrent lower urinary tract infections in women 1.
Key Considerations
- The patient's symptoms and urinalysis results indicate a UTI, which requires prompt treatment to prevent complications.
- The choice of antibiotic should be guided by the patient's allergy history, side effects, and cost, as well as local antibiogram patterns 1.
- Self-start antibiotic therapy can be considered in reliable patients who are willing to obtain urine specimens before starting therapy and communicate effectively with their provider 1.
- Asymptomatic bacteriuria should not be treated in women with recurrent UTIs, as this can foster antimicrobial resistance and increase the number of recurrent UTI episodes 1.
From the Research
Patient Presentation
The patient is 5 weeks pregnant and presents with nausea for 5 weeks, diarrhea, and urinary frequency for the last 3 days. Laboratory results show:
- CBC is unremarkable
- CMP shows CO2 18
- Urinalysis:
- WBC urine 6-10
- RBC urine 3-5
- Bacteria moderate
- Clarity urine cloudy
- Protein urine 30mg/dl
- Leukocyte trace
Treatment Plan
Based on the patient's symptoms and laboratory results, a urinary tract infection (UTI) is suspected. The treatment plan should consider the patient's pregnancy status and the potential for antibiotic resistance.
- First-line treatment options for UTI in pregnancy include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 2
- Nitrofurantoin is a widely used antibiotic for UTI treatment and has been shown to be effective in preventing UTI recurrence 3
- A dose of 50 mg nitrofurantoin daily may be recommended for prophylaxis, as it has been associated with a lower risk of adverse effects compared to 100 mg daily 4
- It is essential to consider local susceptibility patterns and the patient's medical history when selecting an antibiotic regimen 5
- Urine culture is the gold standard for detecting UTI, and treatment should be guided by culture results whenever possible 2
Considerations
- The patient's pregnancy status requires careful consideration when selecting an antibiotic regimen
- The potential for antibiotic resistance should be taken into account when choosing a treatment option 5, 2
- The patient's symptoms and laboratory results should be monitored closely to ensure the treatment plan is effective and to adjust the plan as needed 2, 6