What is the recommended treatment for recurrent Urinary Tract Infections (UTIs) in pregnancy?

Treatment of Recurrent UTIs in Pregnancy

For pregnant women with recurrent urinary tract infections (UTIs), first-line treatment should include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, with antibiotic selection guided by local antibiogram patterns and pregnancy-specific considerations. 1, 2

Diagnostic Criteria for Recurrent UTIs

• Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 2
• Confirmation requires documented positive urine cultures during symptomatic episodes 1
• Avoid surveillance urine testing in asymptomatic patients 1

Acute Treatment of UTI During Pregnancy

• First-line antibiotics for symptomatic UTIs in pregnancy:
  • Nitrofurantoin 50-100 mg daily (avoid in third trimester) 1, 2, 3
  • Fosfomycin 3g single dose 2, 3
  • TMP-SMX 160/800 mg (avoid in first and third trimesters) 1, 2
  • Oral cephalosporins (cefixime preferred due to high E. coli sensitivity) 3
• Treatment duration should be as short as reasonable, generally 3-7 days 1, 4
• For complicated UTIs requiring hospitalization, parenteral antibiotics may be necessary 3

Prevention of Recurrent UTIs in Pregnancy

• Post-coital prophylaxis is highly effective for preventing recurrent UTIs during pregnancy 5
  • Single oral dose of cephalexin (250 mg) or nitrofurantoin macrocrystals (50 mg) after intercourse 5
• Continuous daily prophylaxis options:
  • Nitrofurantoin 50-100 mg daily 2, 6
  • TMP-SMX 40/200 mg daily (avoid in first and third trimesters) 2
  • Cephalexin 250 mg daily 2, 5

Special Considerations for Pregnancy

• Asymptomatic bacteriuria should be treated in pregnant women, unlike non-pregnant populations 1
• Avoid TMP-SMX in first trimester (risk of neural tube defects) and third trimester (risk of neonatal hyperbilirubinemia) 2
• Avoid nitrofurantoin in late third trimester due to risk of hemolytic anemia in G6PD-deficient neonates 2, 3
• Amoxicillin/clavulanate is pregnancy category B but may be associated with necrotizing enterocolitis in neonates with premature rupture of membranes 7

Monitoring and Follow-up

• Obtain follow-up urine culture 7 days after completing treatment to confirm cure 4
• Weekly urine cultures may be beneficial for high-risk pregnant women on prophylaxis 6
• Do not perform routine post-treatment cultures in asymptomatic patients 2

Non-antibiotic Approaches

• Increased fluid intake (weak recommendation but minimal risk) 2
• Consider cranberry products as adjunctive therapy (weak recommendation) 2
• Behavioral modifications: voiding after intercourse, adequate hydration, avoiding prolonged holding of urine 1

Common Pitfalls

• Treating asymptomatic bacteriuria in non-pregnant women increases antibiotic resistance without benefit, but treatment is indicated in pregnancy 1
• Single-dose antibiotic therapy has higher bacteriological persistence rates compared to 3-7 day courses 1
• Failure to obtain follow-up cultures may miss persistent or recurrent infection 4
• Continuous antibiotic prophylaxis shows higher cure rates (88%) compared to short-term therapy (65%) but increases risk of resistance 6