What is the first line treatment for dysuria (painful urination) in a 7-month pregnant woman?

Treatment of Burning Micturition (Dysuria) in a 7-Month Pregnant Woman

First-line treatment for dysuria in a 7-month pregnant woman should be an appropriate oral antibiotic, with nitrofurantoin, fosfomycin trometamol, or cefixime being the preferred options after obtaining a urine culture. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Obtain urine culture and sensitivity testing:

   • Collect urine sample before starting antibiotics 2
   • Urinalysis to check for pyuria, bacteriuria, and hematuria
   • Culture results will guide definitive therapy

2. Clinical assessment for UTI symptoms:

   • Dysuria (burning micturition)
   • Frequency
   • Urgency
   • Suprapubic discomfort
   • Presence/absence of fever (to rule out pyelonephritis)

Treatment Algorithm

Step 1: Empiric Antibiotic Therapy

While awaiting culture results, initiate empiric therapy with one of these first-line options:

• Nitrofurantoin 100mg orally twice daily for 5-7 days 1, 3
• Fosfomycin trometamol 3g single oral dose 1
• Cefixime 400mg orally daily for 5-7 days 1

Step 2: Adjust Treatment Based on Culture Results

• Modify antibiotic if resistance is detected
• Complete a 5-7 day course for uncomplicated cystitis 2

Step 3: Follow-up

• Repeat urine culture 7 days after completing treatment to confirm cure 4
• Monitor for symptom resolution

Special Considerations

Safety in Pregnancy

• Avoid fluoroquinolones and tetracyclines due to potential fetal harm
• Avoid trimethoprim in first trimester due to folate antagonism
• Beta-lactams (including cephalosporins) are generally considered safe in pregnancy 3

Risk of Complications

• Untreated UTIs in pregnancy can progress to pyelonephritis in up to 25% of cases 5
• Pyelonephritis increases risk of preterm labor, low birth weight, and maternal sepsis 3, 5

Antimicrobial Resistance Concerns

• Rising prevalence of ESBL-producing E. coli and methicillin-resistant Staphylococci in pregnancy 6
• If local resistance patterns show high resistance to first-line agents, consider cefoperazone-sulbactam as an alternative 6

Prevention of Recurrence

• Adequate hydration
• Urinate before and after sexual activity
• Proper perineal hygiene
• Consider prophylactic antibiotics if recurrent UTIs occur 3

Common Pitfalls to Avoid

1. Delaying treatment: Prompt treatment prevents ascending infection
2. Failing to obtain culture: Essential for confirming diagnosis and guiding therapy
3. Inadequate follow-up: Repeat cultures are necessary to confirm cure
4. Misdiagnosing asymptomatic bacteriuria: Requires treatment in pregnancy to prevent complications 2
5. Using inappropriate imaging: Ultrasound is the preferred imaging modality if needed; avoid radiation exposure 2

Remember that even asymptomatic bacteriuria requires treatment during pregnancy to prevent complications, and a 4-7 day course of antibiotics is recommended rather than single-dose therapy for symptomatic infections 2.