Treatment of Recurrent UTIs in Pregnancy
For pregnant women with recurrent UTIs, first-line prophylaxis should be cephalexin 250-500mg or nitrofurantoin 100mg (contraindicated after 37 weeks) as continuous or post-coital prophylaxis. 1
Diagnosis and Initial Management
- Asymptomatic bacteriuria screening should be performed at least twice during pregnancy (early pregnancy and third trimester)
- Any significant bacteriuria (≥10^5 CFU/mL in midstream sample) requires treatment during pregnancy
- Urine cultures should always be collected in pregnant women with suspected UTI before starting antibiotics
Treatment Options for Active UTIs in Pregnancy
First-line options:
Second-line options:
- Nitrofurantoin 100mg every 6 hours for 5 days (contraindicated after 37 weeks of pregnancy due to risk of hemolytic anemia in the newborn) 1
Important: Trimethoprim-sulfamethoxazole should be avoided in the first trimester and near term due to potential risks including birth defects (anencephaly, heart defects, and orofacial clefts) 4, 5
Prophylaxis for Recurrent UTIs in Pregnancy
Prophylaxis is strongly recommended for any pregnant woman with a history of recurrent UTIs to prevent complications such as pyelonephritis, preterm labor, and low birth weight 3.
Antimicrobial Prophylaxis Options:
- Cephalexin (250-500mg) as continuous or post-coital prophylaxis 1, 3
- Nitrofurantoin (100mg) as continuous or post-coital prophylaxis (contraindicated after 37 weeks) 1, 3
Post-coital prophylaxis has been shown to be highly effective, with studies demonstrating significant reduction in UTI recurrence during pregnancy 3.
Non-antimicrobial Preventive Measures:
- Increased fluid intake (at least 2L daily) 4
- Urge-initiated and post-coital voiding 4
- Avoidance of spermicidal-containing contraceptives 4
Follow-up and Monitoring
- Repeat urine culture 7 days after treatment to confirm cure 1, 6
- Regular surveillance with urine cultures throughout pregnancy for women with history of recurrent UTIs 7
- Clinical improvement should be evaluated within 48-72 hours of starting treatment 4
Clinical Considerations and Cautions
- Untreated UTIs in pregnancy can lead to serious complications including pyelonephritis, preterm labor, low birth weight, and sepsis 5
- The quality of evidence for optimal prophylaxis regimens is limited, but post-coital or continuous prophylaxis has shown significant benefit 3, 7
- Local resistance patterns should guide empiric therapy choices 4
- Cranberry products have weak evidence supporting their use in pregnancy 1
Treatment Algorithm
- Confirm diagnosis with urine culture
- Treat active infection with amoxicillin-clavulanate or cephalexin
- Verify cure with follow-up urine culture 7 days after treatment
- Initiate prophylaxis with either:
- Cephalexin 250-500mg (continuous or post-coital)
- Nitrofurantoin 100mg (continuous or post-coital, but avoid after 37 weeks)
- Monitor with regular urine cultures throughout pregnancy
This approach has been shown to significantly reduce recurrent UTIs during pregnancy, with one study showing only a single UTI occurring during pregnancy among women receiving prophylaxis, compared to 130 UTIs before prophylaxis 3.