What is the recommended treatment for a urinary tract infection (UTI) in pregnancy?

From the Guidelines

The recommended treatment for a urinary tract infection (UTI) during pregnancy is typically a course of antibiotics that are safe for both mother and fetus, with nitrofurantoin macrocrystals (100 mg twice daily for 5 days) being a first-line treatment option, as suggested by the European Association of Urology guidelines 1. When considering treatment options, it's essential to prioritize the safety of both the mother and the fetus.

• First-line treatment usually involves nitrofurantoin macrocrystals (100 mg twice daily for 5 days) or nitrofurantoin monohydrate (100 mg twice daily for 5 days), as these are considered safe for use during pregnancy, except in the first trimester and at term (36 weeks and beyond) due to potential risks 1.
• Alternative options include pivmecillinam (400 mg three times daily for 3-5 days) or cephalosporins (e.g., cefadroxil, 500 mg twice daily for 3 days), but the choice of antibiotic should be guided by local resistance patterns and the specific circumstances of the patient 1.
• Trimethoprim-sulfamethoxazole is contraindicated during the first trimester and near term due to potential birth defects and neonatal jaundice risks, while fluoroquinolones and tetracyclines should be completely avoided during pregnancy.
• It's crucial to complete the full course of antibiotics even if symptoms improve quickly, and increased fluid intake, particularly water, can help flush bacteria from the urinary system.
• Untreated UTIs during pregnancy can lead to serious complications, including pyelonephritis, preterm labor, and low birth weight, making prompt treatment essential, as highlighted by the Infectious Diseases Society of America's clinical practice guideline for the management of asymptomatic bacteriuria 1.
• After treatment, a follow-up urine culture is recommended to confirm the infection has cleared completely.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination

The recommended treatment for a urinary tract infection (UTI) in pregnancy is not explicitly stated in the provided drug labels. However, trimethoprim-sulfamethoxazole is indicated for the treatment of urinary tract infections due to susceptible strains of certain organisms.

• The drug label for trimethoprim-sulfamethoxazole 2 provides information on its use for urinary tract infections, but it does not specifically address its use in pregnancy.
• The drug label for amoxicillin-clavulanate 3 discusses its use for complicated urinary tract infections, but it also does not provide information on its use in pregnancy. Given the lack of direct information on the use of these medications in pregnancy, a conservative clinical decision would be to consult additional resources or guidelines for the recommended treatment of UTIs in pregnant women.

From the Research

Treatment of Urinary Tract Infections (UTIs) in Pregnancy

• The recommended treatment for UTIs in pregnancy varies depending on the type of infection and the trimester of pregnancy 4, 5, 6.
• For asymptomatic bacteriuria, a single dose of an antimicrobial to which the organism is susceptible is recommended 4.
• For symptomatic UTI, amoxicillin 500 mg tid for three days is recommended, with urine cultures repeated seven days following therapy to assess cure or failure 4.
• Other antibiotics such as trimethoprim/sulfamethoxazole, cephalosporins, and nitrofurantoin may also be effective, but their use should be guided by susceptibility testing and clinical judgment 4, 7, 6.

Prevention of Recurrent UTIs in Pregnancy

• Postcoital prophylaxis with a single oral dose of either cephalexin or nitrofurantoin macrocrystals may be effective in preventing recurrent UTIs in pregnancy 7.
• Antibiotic prophylaxis should be considered for pregnant women with a history of recurrent UTIs 7, 5.

Management of UTIs in Pregnancy

• All types of UTIs, including asymptomatic bacteriuria, require treatment during pregnancy to prevent maternal and fetal complications 5, 6.
• A short course of β-lactams, nitrofurantoin, or fosfomycin is recommended for the treatment of asymptomatic bacteriuria and cystitis 6.
• For acute pyelonephritis, preferred antimicrobials include amoxicillin combined with an aminoglycoside, third-generation cephalosporins, or carbapenems 6.
• International guidelines agree on several key points regarding antibiotic use for UTIs in pregnancy, but there are areas of discordance, such as antenatal screening for bacteriuria and the use of fluoroquinolones 8.