Should a pregnant patient with a urinary tract infection (UTI) and costovertebral angle (CVA) tenderness be hospitalized for treatment, even if they appear clinically well?

Management of Pregnant Patient with UTI and CVA Tenderness

A pregnant patient with a urinary tract infection (UTI) and costovertebral angle (CVA) tenderness should be hospitalized for treatment, even if they appear clinically well, due to the high risk of maternal morbidity, fetal wastage, and preterm delivery. 1

Clinical Significance of UTI with CVA Tenderness in Pregnancy

The presence of CVA tenderness in a pregnant woman with UTI strongly suggests upper urinary tract involvement (pyelonephritis), which requires more aggressive management than uncomplicated lower UTIs. This is particularly important because:

• Pregnant women with suspected pyelonephritis should be hospitalized and treated with parenteral antibiotics due to the high risk of maternal morbidity, fetal wastage, and preterm delivery 1
• CVA tenderness, even without other systemic symptoms, is a clinical marker of potential upper urinary tract infection that can rapidly progress to urosepsis 1
• Approximately 20-21% of pregnant women with pyelonephritis demonstrate significant transient renal dysfunction 2

Diagnostic Considerations

The diagnosis of pyelonephritis in pregnancy is supported by:

• Fever (≥38°C) and/or chills
• Flank pain (typically unilateral)
• CVA tenderness
• Nausea/vomiting (common)
• Lower urinary tract symptoms (dysuria, frequency, urgency) may or may not be present 1, 3

Even if the patient appears clinically well, the presence of CVA tenderness indicates potential kidney involvement that warrants hospitalization in pregnancy.

Treatment Algorithm

1. Initial Management:

   • Hospitalize the pregnant patient with UTI and CVA tenderness
   • Obtain urine culture and antimicrobial susceptibility testing
   • Evaluate the upper urinary tract via ultrasound to rule out obstruction or stone disease 1

2. Antimicrobial Therapy:

   • Begin parenteral antibiotics immediately
   • Recommended regimens include:
     • Cefotaxime 2g three times daily
     • Ceftriaxone 1-2g daily
     • Cefepime 1-2g twice daily
     • Ampicillin plus aminoglycoside 1
   • Avoid fluoroquinolones in pregnancy

3. Monitoring and Follow-up:

   • Monitor for clinical improvement (resolution of fever, pain, and CVA tenderness)
   • Transition to oral antibiotics after clinical improvement for 14 days total therapy
   • Consider follow-up urine cultures after treatment completion

Risks of Outpatient Management

Outpatient management of pregnant women with UTI and CVA tenderness carries significant risks:

• 23% of pregnant women with antepartum pyelonephritis develop recurrent pyelonephritis 2
• Pyelonephritis in pregnancy is associated with increased risk of preterm labor and delivery
• Delayed treatment can lead to sepsis, which increases maternal and fetal morbidity and mortality
• Clinical appearance can be deceptively reassuring, with rapid deterioration possible

Pitfalls to Avoid

1. Do not rely solely on patient appearance: A "clinically well" appearance can be misleading in pregnant patients with pyelonephritis, as deterioration can occur rapidly.

2. Do not delay hospitalization: Even if symptoms seem mild, the presence of CVA tenderness in a pregnant woman with UTI warrants immediate hospitalization.

3. Do not use inadequate antibiotic regimens: Antibiotics effective for lower UTIs are frequently inadequate for pyelonephritis 3.

4. Do not discharge too early: Patients should demonstrate substantial clinical improvement before considering discharge.

The evidence clearly supports hospitalization for pregnant women with UTI and CVA tenderness, regardless of their apparent clinical well-being, to prevent serious maternal and fetal complications.