Treatment of UTIs in Pregnancy
First-line antibiotics for UTI treatment in pregnancy include nitrofurantoin, fosfomycin, and cephalexin, which provide effective treatment while maintaining safety for both mother and fetus. 1
Diagnosis and Screening
- Screen all pregnant women for asymptomatic bacteriuria by urine culture at least once in early pregnancy 1
- Obtain urine culture before starting antibiotics to confirm the causative pathogen and determine susceptibility 1
- Unlike in non-pregnant women, asymptomatic bacteriuria in pregnancy requires treatment to prevent complications 2, 1
First-Line Treatment Options
For Uncomplicated UTIs in Pregnancy:
| Antibiotic | Dosing | Duration | Notes |
|---|---|---|---|
| Nitrofurantoin | 100 mg twice daily | 5-7 days | Avoid after 36 weeks due to risk of neonatal hemolytic anemia [1] |
| Fosfomycin trometamol | 3 g single dose | One-time dose | Convenient dosing with good safety profile [2,1] |
| Cephalexin | 500 mg four times daily | 5-7 days | High safety profile with low resistance rates [1] |
For Symptomatic UTI:
- 5-7 days of therapy is generally recommended, as single-dose therapy (except for fosfomycin) and 3-day regimens may be insufficient for complete resolution 1
Alternative Option:
- Amoxicillin-clavulanic acid: 500/125 mg three times daily for 5-7 days (recommended by WHO when first-line agents are contraindicated) 1
Important Precautions
- Avoid trimethoprim-sulfamethoxazole (TMP-SMX) in the first trimester due to potential teratogenic effects and in the third trimester due to risk of neonatal hyperbilirubinemia 1
- Adjust therapy based on culture results to ensure effective treatment and minimize resistance development 1
- Consider local resistance patterns when selecting empiric therapy 1
Follow-up and Prevention
- Repeat urine culture 1 week after completing therapy to confirm cure 1
- For recurrent UTIs, consider prophylaxis with:
- Nitrofurantoin 50-100 mg daily (avoid near term)
- Cephalexin 250 mg post-coital dose 1
Management of Different UTI Types
Asymptomatic Bacteriuria
- Must be treated in pregnancy (unlike non-pregnant women) 2, 1
- Increases risk of pyelonephritis, preterm birth, and low birth weight if untreated 1, 3
- Use standard treatment regimens as for symptomatic UTI 1
Pyelonephritis
- Requires hospitalization and intravenous antibiotics 4
- Preferred options include amoxicillin with an aminoglycoside, third-generation cephalosporins, or carbapenems 3
Behavioral Modifications
- Recommend adequate hydration
- Voiding after intercourse
- Avoiding prolonged urine retention 1
UTIs affect up to 10% of pregnant women and are the second most common ailment of pregnancy after anemia 5. Proper treatment is essential as all forms of UTI during pregnancy can lead to serious maternal and fetal complications, making this a critical condition requiring prompt and appropriate management.