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

Treatment of Urinary Tract Infections in Pregnancy

For pregnant women with urinary tract infections (UTIs), the recommended first-line treatments are nitrofurantoin, fosfomycin trometamol, or cephalosporins, with treatment duration typically 5-7 days depending on the specific medication. 1, 2

Diagnosis and Screening

• All pregnant women should have urine cultures performed at their first prenatal visit to screen for asymptomatic bacteriuria 2
• A urine culture is specifically recommended in pregnant women with UTI symptoms to confirm diagnosis and guide treatment 1
• Untreated bacteriuria in pregnancy carries significant risks, including progression to pyelonephritis in 20-40% of cases 3

First-Line Treatment Options for UTIs in Pregnancy

Oral Antibiotics:

• Nitrofurantoin: 100 mg twice daily for 5 days 1, 2

  • Safe and effective in pregnancy except in the last trimester
  • Should not be used near term due to risk of hemolytic anemia in the newborn 1

• Fosfomycin trometamol: 3 g single dose 1, 2, 4

  • Convenient single-dose administration improves compliance
  • Equally effective as multi-day regimens for uncomplicated cystitis in pregnancy 3
  • Studies show 95.2% therapeutic success rate in pregnant women 3

• Cephalosporins: 1, 2

  • Cefixime: 400 mg daily for 3-5 days
  • Other oral cephalosporins (cephalexin, cefpodoxime) are also appropriate options
  • Particularly useful when resistance to other agents is suspected

For Parenteral Treatment (if needed for complicated UTIs):

• Ceftriaxone, cefotaxime, or ceftazidime are appropriate options 1

Duration of Treatment

• For symptomatic UTIs in pregnancy: 5-7 days of treatment is generally recommended 1
• Single-dose therapy with fosfomycin is an exception and has shown comparable efficacy to 3-day regimens 3
• Shorter courses (1-3 days) are generally not recommended for pregnant women 1

Special Considerations

• Trimethoprim-sulfamethoxazole should be avoided in the first trimester due to potential teratogenic effects and in the third trimester due to risk of neonatal hyperbilirubinemia 1
• Fluoroquinolones are contraindicated during pregnancy 1
• For women with recurrent UTIs during pregnancy, postcoital prophylaxis with nitrofurantoin 50 mg or cephalexin 250 mg has been shown to be highly effective 5

Follow-up

• Urine cultures should be repeated 7 days after completing therapy to confirm cure 6
• Persistent or recurrent infections require further evaluation and possibly longer treatment courses 1

Prevention of Recurrent UTIs in Pregnancy

• For pregnant women with history of recurrent UTIs, prophylactic antibiotics significantly reduce the risk of infection 5
• Options for prophylaxis include:
  • Postcoital single dose of nitrofurantoin 50 mg or cephalexin 250 mg 5
  • Daily low-dose antibiotics in select cases with frequent recurrences 1

Common Pitfalls to Avoid

• Failing to screen for asymptomatic bacteriuria in pregnancy, which requires treatment unlike in non-pregnant women 1, 2
• Using antibiotics that don't achieve adequate urinary concentrations (e.g., certain macrolides) 1
• Inadequate follow-up after treatment, which can miss persistent or recurrent infections 6
• Treating asymptomatic bacteriuria outside of pregnancy, which is not recommended in most populations 1