Treatment of Urinary Tract Infections in Pregnancy
The recommended first-line treatments for UTIs in pregnancy are nitrofurantoin, fosfomycin trometamol, or cephalosporins with a treatment duration of 5-7 days depending on the specific medication. 1
Diagnosis and Confirmation
- A urine culture should be performed in all pregnant women with UTI symptoms to confirm diagnosis and guide appropriate treatment 1
- UTIs occur in approximately 5-7% of pregnant women and require prompt treatment to prevent complications for both mother and fetus 2
First-Line Treatment Options
Nitrofurantoin
- Safe and effective during pregnancy except in the last trimester 1
- Should not be used near term due to risk of hemolytic anemia in the newborn 1
- Typical dosing is 100 mg for 5 days 3
Fosfomycin Trometamol
- Convenient single-dose (3g) administration that improves compliance 1, 4
- Equally effective as multi-day regimens for uncomplicated cystitis in pregnancy 1, 5
- Single-dose fosfomycin has shown 95.2% therapeutic success rate (clinical cure and bacteriological eradication) in pregnant women with acute cystitis 5
- FDA-approved for uncomplicated UTIs due to susceptible strains of E. coli and Enterococcus faecalis 4
Cephalosporins
- Appropriate options for treating UTIs in pregnancy, particularly when resistance to other agents is suspected 1
- Cefixime appears to be rational due to high sensitivity against common uropathogens (especially E. coli), efficacy, safety, and good compliance in pregnant women 2
- Ceftibuten (400 mg daily for 3 days) has shown 90% therapeutic success in pregnant women with acute cystitis 5
Treatment Duration
- 5-7 days of treatment is recommended for symptomatic UTIs in pregnancy 1
- Shorter courses (1-3 days) are generally not recommended for pregnant women, with the exception of single-dose fosfomycin 1, 5
Medications to Avoid in Pregnancy
- 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
Management of Recurrent UTIs
- For pregnant women with history of recurrent UTIs, postcoital prophylaxis may be considered 6
- Options include single oral doses of cephalexin (250 mg) or nitrofurantoin macrocrystals (50 mg) after intercourse 6
- Daily low-dose antibiotics can be used in select cases with frequent recurrences 1
Follow-up
- Urine cultures should be repeated 7 days following therapy to confirm cure or identify treatment failure 7
- Treatment should be continued for a minimum of 48-72 hours beyond symptom resolution 8
Common Pitfalls to Avoid
- Failing to distinguish between asymptomatic bacteriuria and symptomatic UTI in pregnancy (both require treatment in pregnancy) 1
- Using antibiotics that don't achieve adequate urinary concentrations (e.g., certain macrolides) 1
- Not following up with repeat urine cultures to confirm cure 7
- Using contraindicated medications like fluoroquinolones or trimethoprim-sulfamethoxazole in inappropriate trimesters 1