What are the treatment options for uncomplicated urinary tract infections (UTIs) in pregnancy?

Treatment Options for Uncomplicated UTIs in Pregnancy

For uncomplicated urinary tract infections in pregnancy, first-line treatment options include nitrofurantoin, fosfomycin trometamol, and cephalosporins, with the choice guided by local resistance patterns and patient-specific factors. 1, 2

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days is recommended due to minimal resistance and low propensity for collateral damage 1
• Fosfomycin trometamol 3 g single dose offers a convenient regimen for pregnant women with uncomplicated UTIs 3, 1
• Cephalosporins (particularly cefixime) are rational choices due to high sensitivity of E. coli, safety in pregnancy, and good compliance 2

Diagnostic Approach

• Urine culture is specifically recommended for pregnant women with suspected UTI 1
• While systematic screening for asymptomatic bacteriuria (ASB) in pregnancy is not universally recommended, the European Association of Urology advises screening for and treating ASB in pregnant women 3, 4
• When ASB is detected in pregnancy, treatment with standard short-course therapy or single-dose fosfomycin trometamol is recommended 3

Treatment Duration and Follow-up

• Shortest possible course of antibiotic treatment should be used to minimize adverse effects while ensuring complete eradication 4
• Follow-up urine culture should be performed 7 days after completing therapy to confirm cure 5
• Routine post-treatment urinalysis is not indicated if the patient becomes asymptomatic 1

Special Considerations for Recurrent UTIs in Pregnancy

• For pregnant women with history of recurrent UTIs, postcoital prophylaxis with a single dose of either cephalexin (250 mg) or nitrofurantoin macrocrystals (50 mg) has shown significant effectiveness in preventing recurrence 6
• This prophylactic approach is particularly important during pregnancy to prevent progression to acute pyelonephritis 6

Important Caveats and Pitfalls

• Fluoroquinolones should be avoided during pregnancy due to potential risks to fetal development 1, 7
• Trimethoprim is not recommended in the first trimester of pregnancy due to potential teratogenic effects 1
• Even asymptomatic bacteriuria in pregnancy requires treatment, unlike in non-pregnant women, due to increased risk of ascending infection and complications 2, 4
• Local resistance patterns should guide empiric antibiotic selection, particularly important in pregnancy where treatment failure can have serious consequences 1, 7

Treatment Algorithm

1. Confirm diagnosis with urine culture in pregnant women with UTI symptoms 1
2. Select antibiotic based on:
   • Local resistance patterns
   • Patient's allergy history
   • Stage of pregnancy (avoid trimethoprim in first trimester)
   • Previous antibiotic exposure 1, 4
3. First-line options:
   • Nitrofurantoin 100 mg twice daily for 5 days (contraindicated near term)
   • Fosfomycin trometamol 3 g single dose
   • Cephalosporins (e.g., cefixime) 1, 2
4. Perform follow-up urine culture 7 days after treatment completion 5
5. For recurrent UTIs, consider postcoital prophylaxis 6

By following these evidence-based recommendations, clinicians can effectively treat uncomplicated UTIs in pregnancy while minimizing risks to both mother and fetus.