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

Treatment of UTIs in Pregnancy

For urinary tract infections in pregnancy, nitrofurantoin (100mg twice daily for 5-7 days) is the first-line treatment for uncomplicated lower UTIs, while cephalexin (500mg four times daily for 7-14 days) is recommended for complicated UTIs or pyelonephritis. 1

First-Line Treatment Options

Uncomplicated Lower UTI

• First choice: Nitrofurantoin 100mg twice daily for 5-7 days 1
  • Safe during second trimester of pregnancy
  • Achieves high bactericidal concentrations in the urinary tract
  • Minimal development of resistance in bacterial flora 2
  • Should not be used for pyelonephritis 1

Complicated UTI or Pyelonephritis

• First choice: Cephalexin 500mg four times daily for 14 days 1
  • Safe throughout pregnancy
  • For severe symptoms, consider initial parenteral therapy 1
  • Cefepime is also safe during pregnancy with no established risk of major birth defects 3

Alternative Treatment Options

• Fosfomycin trometamol: 3g single dose 4

  • European Association of Urology recommends as an alternative treatment 4
  • Comparable efficacy to nitrofurantoin for uncomplicated UTIs 5

• Amoxicillin-clavulanate: 500mg three times daily for 14 days for complicated UTIs 1

  • Alternative when first-line options cannot be used

Screening and Diagnosis

1. Screen for asymptomatic bacteriuria in pregnant women 4

   • Recommended in the first trimester with a single urine culture 6
   • Treatment of asymptomatic bacteriuria may reduce the incidence of low birth weight and preterm birth 6

2. For symptomatic UTIs:

   • Obtain urine culture before starting antibiotics 1
   • Document positive cultures to establish diagnosis 1
   • Repeat urine studies if initial specimen is suspected of contamination 1

Prevention of Recurrent UTIs in Pregnancy

For pregnant women with history of recurrent UTIs:

• Post-coital prophylaxis: Single dose of either:

  • Cephalexin 250mg 2
  • Nitrofurantoin macrocrystals 50mg 2
  • Take within 2 hours after intercourse 1

• Self-care measures:

  • Adequate hydration (2-3L daily)
  • Urge-initiated voiding
  • Post-coital voiding 1

Important Considerations and Cautions

• Avoid during pregnancy if possible:

  • Fluoroquinolones (potential fetal cartilage damage) 1
  • TMP-SMX (especially in first and third trimesters) 1

• Nitrofurantoin contraindications:

  • Not for use in pyelonephritis 1
  • Avoid in patients with G6PD deficiency 1
  • Use caution in the first trimester

• Duration of therapy:

  • Uncomplicated lower UTI: 5-7 days
  • Pyelonephritis: 14 days 1

Common Pitfalls to Avoid

1. Treating without obtaining a urine culture first
2. Using fluoroquinolones as first-line therapy
3. Using nitrofurantoin for pyelonephritis
4. Failing to adjust treatment based on local resistance patterns
5. Not providing adequate follow-up to ensure resolution

UTIs during pregnancy require prompt and appropriate treatment to prevent complications such as pyelonephritis, preterm delivery, and low birth weight. The choice of antimicrobial therapy should be guided by safety in pregnancy, efficacy, and local resistance patterns.