Treatment of Urinary Tract Infections During Pregnancy
First-line treatment for urinary tract infections during pregnancy should be nitrofurantoin, fosfomycin trometamol, or cephalosporins with a treatment duration of 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 third trimester due to risk of hemolytic anemia in the newborn 1
- Fosfomycin trometamol (3g single dose) offers convenient administration that improves compliance and is equally effective as multi-day regimens 1
- Cephalosporins such as cefixime are appropriate options, particularly when resistance to other agents is suspected 1, 2
- Amoxicillin-clavulanate can be used for UTIs caused by beta-lactamase-producing isolates of E. coli and other susceptible organisms 3
Important Diagnostic Considerations
- A urine culture should always be performed in pregnant women with UTI symptoms to confirm diagnosis and guide treatment 1, 4
- Screening for asymptomatic bacteriuria is recommended at least once in early pregnancy, typically during the first trimester 4
- Pregnant women with asymptomatic bacteriuria should receive treatment, as it's associated with a higher risk of developing pyelonephritis 4, 1
Treatment Duration and Follow-up
- Treatment duration should be 5-7 days for symptomatic UTIs in pregnancy, as shorter courses are generally not recommended 1
- A follow-up urine culture should be performed 7 days after completing therapy to ensure cure 5
- For women whose symptoms do not resolve by the end of treatment, or recur within 2 weeks, a urine culture with antimicrobial susceptibility testing should be performed 4
Medications to Avoid During Pregnancy
- Trimethoprim-sulfamethoxazole should be avoided in the first trimester (potential teratogenic effects) and third trimester (risk of neonatal hyperbilirubinemia) 4, 1
- Fluoroquinolones are contraindicated during pregnancy 1
- Use of sulfonamides and nitrofurantoin during the first trimester should be limited due to potential risk for birth defects 6
Management of Recurrent UTIs in Pregnancy
- For pregnant women with a history of recurrent UTIs, postcoital prophylaxis with a single dose of cephalexin (250 mg) or nitrofurantoin macrocrystals (50 mg) can significantly reduce the risk of recurrence 7
- This prophylactic approach has been shown to be highly effective, with only a single UTI occurring during pregnancy after prophylaxis implementation in one study 7
Potential Complications of Untreated UTIs in Pregnancy
- Untreated UTIs can lead to serious complications including pyelonephritis, preterm labor, low birth weight, and sepsis 6
- Treatment of asymptomatic bacteriuria in pregnant women has been shown to decrease rates of pyelonephritis from 1.8-2.1% to 0.5-0.6% 4
Common Pitfalls to Avoid
- Using fluoroquinolones, which are contraindicated in pregnancy 1
- Prescribing nitrofurantoin in the third trimester due to risk of hemolytic anemia in the newborn 1
- Using unnecessarily long antibiotic courses, which can promote resistance 1
- Failing to obtain a urine culture before initiating treatment 4, 1
- Neglecting to screen for and treat asymptomatic bacteriuria during pregnancy 4