What is the recommended treatment for a urinary tract infection (UTI) in a woman at 4 weeks gestation experiencing urinary symptoms?

Treatment of Urinary Tract Infection at 4 Weeks Gestation

For pregnant women at 4 weeks gestation with urinary tract infection symptoms, a urine culture should be obtained prior to initiating treatment, followed by standard short-course antibiotic therapy or single-dose fosfomycin trometamol. 1

Diagnosis

• Obtain a urine culture before starting antibiotics, as this is specifically recommended for pregnant women with urinary symptoms 1
• Pregnant women should be screened for asymptomatic bacteriuria, as untreated bacteriuria can lead to pyelonephritis in up to 30% of cases 1, 2
• Common symptoms include dysuria, frequency, and urgency without vaginal discharge 1

Treatment Options

First-line antibiotics:

• Fosfomycin trometamol: 3g single dose 1
  • Advantages: Convenient single-dose treatment with good safety profile in pregnancy
• Nitrofurantoin: 100mg twice daily for 5 days 1
  • Note: Avoid in G6PD deficiency and near term (>36 weeks)

Alternative options:

• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3-5 days) 1
• Trimethoprim (200mg twice daily for 5 days) - but avoid in first trimester 1
• Trimethoprim-sulfamethoxazole (160/800mg twice daily for 3 days) - but avoid in last trimester 1

Clinical Considerations

• Untreated UTIs in pregnancy significantly increase risks of:

  • Preterm delivery 2, 3
  • Maternal pyelonephritis 2, 4
  • Intrauterine growth restriction 2, 3
  • Maternal hypertension and pre-eclampsia 2
  • Maternal anemia 2

• Choice of antibiotic should consider:

  • Local resistance patterns 1
  • Patient allergies 1
  • Trimester of pregnancy (avoid trimethoprim in first trimester, avoid TMP-SMX in third trimester) 1

Follow-up

• Test-of-cure urine culture is recommended 1-2 weeks after treatment 1
• Women with recurrent UTIs in pregnancy require prophylactic antibiotic treatment 2
• No routine post-treatment urinalysis is needed if symptoms resolve 1

Prevention Strategies

• Adequate hydration 1
• Urge-initiated and post-coital voiding 1
• Avoiding spermicide-containing contraceptives 1
• Consider vaginal estrogen with lactobacillus probiotics for postmenopausal women 1

Special Considerations

• Any presence of GBS bacteriuria during pregnancy requires treatment at diagnosis and intrapartum prophylaxis during delivery 1
• Pyelonephritis requires more aggressive treatment, often with parenteral antibiotics 1
• Pregnant women with UTI symptoms should be treated promptly to prevent ascending infection and complications 4, 3