Treatment of Urinary Tract Infections in Pregnancy
Nitrofurantoin, fosfomycin trometamol, or cephalosporins are the recommended first-line treatments for urinary tract infections (UTIs) in pregnancy, with treatment duration typically 5-7 days depending on the specific medication. 1
First-Line Treatment Options
- Nitrofurantoin (100 mg twice daily for 5 days) is safe and effective in pregnancy but should be avoided in the last trimester due to risk of hemolytic anemia in the newborn 1, 2
- Fosfomycin trometamol (3g single dose) offers convenient administration that improves compliance and is equally effective as multi-day regimens 1, 2
- Cephalosporins (such as cefixime) are appropriate options, particularly when resistance to other agents is suspected 1, 3
Important Considerations
- A urine culture should always be performed in pregnant women with UTI symptoms to confirm diagnosis and guide treatment 1
- Treatment duration should be 5-7 days for symptomatic UTIs in pregnancy, as shorter courses (1-3 days) are generally not recommended 1
- Avoid trimethoprim-sulfamethoxazole in the first trimester (potential teratogenic effects) and third trimester (risk of neonatal hyperbilirubinemia) 1, 2
- Fluoroquinolones are contraindicated during pregnancy 1, 2
- Beta-lactam antibiotics are not considered first-line therapy for uncomplicated UTI due to collateral damage effects and their propensity to promote more rapid recurrence 2
Treatment Algorithm
- Confirm diagnosis with urine culture in all pregnant women with suspected UTI 1
- Select antibiotic based on:
- First-line options: Nitrofurantoin (except in third trimester), fosfomycin trometamol, or cephalosporins 1, 2
- Pregnancy trimester: Avoid nitrofurantoin in third trimester; avoid trimethoprim-sulfamethoxazole in first and third trimesters 1
- Local resistance patterns: Consider local E. coli resistance patterns when selecting empiric therapy 3
- Treatment duration: 5-7 days for symptomatic UTIs 1
- Follow-up: Obtain repeat urine culture 7 days after completing therapy to confirm cure 4
Special Situations
Asymptomatic Bacteriuria
- All pregnant women with asymptomatic bacteriuria should receive treatment, as it's a marker for heavy genital tract colonization 2, 5
- Treatment follows the same antibiotic recommendations as symptomatic UTI 1
Recurrent UTIs in Pregnancy
- For women with history of recurrent UTIs, post-coital prophylaxis with a single dose of cephalexin (250 mg) or nitrofurantoin (50 mg) can be highly effective 6
- Daily low-dose antibiotic prophylaxis can be considered in select cases with frequent recurrences 1
Common Pitfalls to Avoid
- Failing to treat asymptomatic bacteriuria in pregnancy (unlike in non-pregnant patients) 1, 5
- Using antibiotics with inadequate urinary concentrations 1
- Using fluoroquinolones, which are contraindicated in pregnancy 1, 2
- Prescribing nitrofurantoin in the third trimester 1
- Using unnecessarily long antibiotic courses, which can promote resistance 2
UTIs affect 5-10% of pregnant women and can lead to serious maternal and fetal complications if not properly treated 3, 5. Timely diagnosis and appropriate antibiotic selection are essential to prevent adverse outcomes for both mother and baby 7.