What is the recommended treatment for urinary tract infections (UTIs) in pregnancy?

From the Guidelines

The recommended treatment for urinary tract infections (UTIs) in pregnancy involves prompt antibiotic therapy with nitrofurantoin macrocrystals 50–100 mg four times a day for 5 days or nitrofurantoin monohydrate or macrocrystals 100 mg twice a day for 5 days, as first-line treatment options, to prevent complications for both mother and fetus. The choice of antibiotic should be based on the most recent and highest quality evidence, which in this case is the 2024 European Association of Urology guidelines on urological infections 1. According to these guidelines, other alternatives such as cephalosporins (e.g., cefadroxil) 500 mg twice a day for 3 days can be used, but trimethoprim and trimethoprim-sulfamethoxazole should be avoided in the first and last trimester of pregnancy, respectively. Pregnant women should increase fluid intake and urinate frequently during treatment. Follow-up urine cultures are important to confirm cure, and some providers recommend monthly urine screening throughout pregnancy after a UTI to detect recurrence. Prompt treatment is essential as untreated UTIs can lead to pyelonephritis, preterm labor, low birth weight, and other pregnancy complications. Some key points to consider when treating UTIs in pregnancy include:

• The optimal duration of antimicrobial therapy has not been well established, but a 5-day course is commonly recommended 1.
• Nitrofurantoin and β-lactam antimicrobials (usually ampicillin or cephalexin) are preferred due to their safety in pregnant women 1.
• Fosfomycin is effective for clearance of bacteria in the urine, but there is limited clinical evaluation of its use in pregnancy 1. It is essential to weigh the benefits and risks of different treatment options and consider the most recent evidence when making decisions about UTI treatment in pregnancy. In general, the treatment of UTIs in pregnancy should prioritize the use of safe and effective antibiotics, such as nitrofurantoin, to minimize the risk of complications for both mother and fetus. The European Association of Urology guidelines provide a comprehensive overview of the recommended treatment options for UTIs in pregnancy, and healthcare providers should consult these guidelines when making treatment decisions 1.

From the FDA Drug Label

1. 1 Lower Respiratory Tract and Complicated Urinary Tract Infections Data from 2 pivotal trials in 1,191 patients treated for either lower respiratory tract infections or complicated urinary tract infections compared a regimen of 875-mg tablets of amoxicillin and clavulanate potassium every 12 hours to 500-mg tablets of amoxicillin and clavulanate potassium dosed every 8 hours (584 and 607 patients, respectively). In one of these pivotal trials, patients with either pyelonephritis (n = 361) or a complicated urinary tract infection (i.e., patients with abnormalities of the urinary tract that predispose to relapse of bacteriuria following eradication, n = 268) were randomized (1:1) to receive either 875-mg tablets of amoxicillin and clavulanate potassium every 12 hours (n=308) or 500-mg tablets of amoxicillin and clavulanate potassium every 8 hours (n=321)

The recommended treatment for urinary tract infections (UTIs) in pregnancy is not directly stated in the provided drug label. However, amoxicillin/clavulanate is used to treat complicated urinary tract infections.

• The drug label does mention the treatment of complicated urinary tract infections and pyelonephritis with amoxicillin and clavulanate potassium, but it does not specifically address pregnancy.
• The label provides information on the efficacy and safety of amoxicillin and clavulanate potassium in treating urinary tract infections, but it does not provide guidance on its use during pregnancy 2.

From the Research

Treatment Options for UTIs in Pregnancy

• The recommended treatment for urinary tract infections (UTIs) in pregnancy is crucial to prevent complications and ensure the health of both the mother and the fetus 3, 4, 5, 6, 7.
• According to the studies, nitrofurantoin is a commonly used antibiotic for treating UTIs in pregnancy due to its safety record and lack of associated R-factor resistance 5, 6, 7.
• Fosfomycin is also considered a potentially useful and safe treatment option for uncomplicated UTIs in women, including those who are pregnant 4.
• Other treatment options for UTIs in pregnancy include amoxicillin, trimethoprim/sulfamethoxazole, and cephalosporins, although the effectiveness of these antibiotics may vary 3, 7.

Recommended Treatment Regimens

• For asymptomatic bacteriuria, a single dose of an antimicrobial to which the organism is susceptible may be recommended 7.
• For symptomatic UTIs, a three-day course of amoxicillin (500 mg tid) is suggested, with urine cultures repeated seven days after therapy to assess cure or failure 7.
• Postcoital prophylaxis with a single oral dose of either cephalexin (250 mg) or nitrofurantoin macrocrystals (50 mg) may be effective in preventing recurrent UTIs during pregnancy 6.

Considerations for Antibiotic Resistance

• The increasing prevalence of antibiotic-resistant bacteria is a concern in the treatment of UTIs, and the choice of antibiotic should be guided by local susceptibility patterns and the risk of resistance development 3.
• The use of new antimicrobials should be done wisely to avoid resistance development, and treatment options should be selected based on the specific characteristics of the infecting organism 3.