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

Treatment of Urinary Tract Infections in Pregnancy

For pregnant women with UTIs, first-line treatment should include nitrofurantoin, fosfomycin trometamol, or amoxicillin-clavulanate based on local antibiogram patterns, as these medications are both effective and safe during pregnancy. 1, 2, 3

Diagnostic Approach

• Obtain urine culture before initiating treatment to confirm diagnosis and guide therapy 1
• Do not screen for or treat asymptomatic bacteriuria in most populations, but pregnant women are an exception 1
• Screen for and treat asymptomatic bacteriuria in pregnant women with standard short-course treatment 1

First-Line Treatment Options for UTI in Pregnancy

1. Nitrofurantoin

   • Dosing: 100 mg twice daily for 5 days
   • Advantages: High urinary concentration, low resistance rates
   • Caution: Avoid in G6PD deficiency and near term (>36 weeks)

2. Fosfomycin trometamol

   • Dosing: 3 g single dose
   • Advantages: Convenient single-dose regimen, high compliance
   • Particularly effective for uncomplicated cystitis

3. Amoxicillin-clavulanate

   • Dosing: 875/125 mg twice daily for 5-7 days
   • Effective against beta-lactamase-producing E. coli and other common uropathogens
   • Useful when resistance to first-line agents is suspected 2

4. Cephalosporins (e.g., cefixime)

   • Alternative when first-line agents cannot be used
   • Particularly useful when local resistance patterns indicate better coverage 3

Treatment Duration

• Asymptomatic bacteriuria: Single-dose fosfomycin or short course (3-5 days) of antibiotics
• Symptomatic lower UTI (cystitis): 5-7 days of antibiotics
• Pyelonephritis: 7-14 days of antibiotics, often starting with parenteral therapy 1

Special Considerations

Pyelonephritis in Pregnancy

• Requires hospitalization and initial parenteral antibiotics
• Options include:
  • Ceftriaxone 1-2 g daily
  • Amoxicillin-clavulanate with an aminoglycoside
  • Switch to oral therapy when clinically improved 4

Recurrent UTIs in Pregnancy

• Post-coital prophylaxis with cephalexin (250 mg) or nitrofurantoin (50 mg) is highly effective 5
• For women with history of recurrent UTIs, prophylactic antibiotics significantly reduce recurrence risk during pregnancy 5

Follow-up

• Obtain follow-up urine culture 1-2 weeks after completing treatment to confirm cure
• Persistent bacteriuria requires retreatment with a different antibiotic based on susceptibility testing

Common Pitfalls to Avoid

1. Failing to treat asymptomatic bacteriuria in pregnant women, which can lead to pyelonephritis and adverse pregnancy outcomes
2. Using trimethoprim-sulfamethoxazole in the first or third trimester (contraindicated)
3. Not obtaining pre-treatment cultures which are essential for confirming diagnosis and guiding therapy
4. Inadequate follow-up after treatment, which may miss persistent infection
5. Using fluoroquinolones which should be avoided during pregnancy due to potential fetal risks

By following this evidence-based approach to UTI management in pregnancy, clinicians can effectively treat infections while minimizing risks to both mother and fetus.