What is the recommended management for recurrent Urinary Tract Infections (UTIs) in pregnancy and breastfeeding?

Management of Recurrent UTI in Pregnancy and Breastfeeding

For pregnant women with recurrent UTIs, implement non-antimicrobial preventive measures first, followed by antibiotic prophylaxis with nitrofurantoin (50-100 mg daily) or cephalexin (250-500 mg daily) if non-pharmacological approaches fail, while ensuring urine culture confirmation before each acute treatment episode. 1, 2

Diagnostic Approach

Confirm Each Episode with Culture

• Obtain urine culture and sensitivity testing before initiating treatment for every symptomatic acute episode to guide appropriate therapy and document true recurrence versus treatment failure 1, 2
• Recurrent UTI is defined as ≥3 culture-positive episodes within 12 months or ≥2 episodes within 6 months 1, 2
• Confirm eradication of previous UTI with negative urine culture 1-2 weeks after treatment before starting prophylaxis 2

Screening Considerations in Pregnancy

• Routine screening for asymptomatic bacteriuria in pregnancy is not universally recommended by recent guidelines, as most women with ASB do not develop complications and contamination is common 3
• However, if ASB is detected (≥10⁵ CFU/mL), treatment is indicated due to risk of ascending infection and adverse pregnancy outcomes 4, 5

Treatment of Acute Episodes

First-Line Antibiotics for Acute Cystitis in Pregnancy

• Nitrofurantoin macrocrystals: 100 mg twice daily for 5-7 days (avoid after 37 weeks gestation) 1, 4, 5
• Fosfomycin trometamol: 3 g single dose 4, 5
• Cephalexin or other first-generation cephalosporins: 500 mg twice daily for 3-7 days 1, 4
• Cefixime (third-generation cephalosporin): appropriate dosing for 7 days when first-line agents are unsuitable 5

Important Pregnancy-Specific Restrictions

• Avoid trimethoprim in first trimester (folate antagonist) 1
• Avoid trimethoprim-sulfamethoxazole in third trimester (kernicterus risk) 1
• Avoid nitrofurantoin after 37 weeks (hemolytic anemia risk in newborn) 4
• Treat for shortest effective duration, generally no longer than 7 days 1

Prevention Strategies: Stepwise Approach

Step 1: Non-Antimicrobial Measures (First-Line)

Implement these behavioral and non-pharmacological interventions before considering antibiotic prophylaxis: 1, 2

• Increase fluid intake to promote frequent urination 1, 2
• Void after intercourse (postcoital voiding) 1, 2
• Avoid prolonged urinary retention (urge-initiated voiding) 1
• Discontinue spermicide-containing contraceptives if applicable 1, 2
• Cranberry products (minimum 36 mg/day proanthocyanidin A) may reduce recurrence, though evidence quality is low 1, 2
• Vaginal probiotics (Lactobacillus rhamnosus GR-1 or Lactobacillus reuteri RC-14) once or twice weekly 2, 4

Step 2: Antibiotic Prophylaxis (When Non-Antimicrobial Measures Fail)

For Pregnant Women:

• Nitrofurantoin: 50-100 mg once daily at bedtime (contraindicated after 37 weeks) 6, 4
• Cephalexin: 250-500 mg once daily at bedtime 6, 4
• Postcoital prophylaxis alternative: Single dose of cephalexin 250 mg or nitrofurantoin 50 mg after intercourse 6
• Duration: Continue throughout pregnancy if effective 6, 4

Evidence Supporting Pregnancy Prophylaxis: A study of 33 pregnant women with recurrent UTI history showed that postcoital prophylaxis with either cephalexin 250 mg or nitrofurantoin 50 mg reduced UTI incidence from 130 infections during 7 months pre-prophylaxis to only 1 infection during pregnancy—a highly significant reduction 6

For Breastfeeding Women:

• Nitrofurantoin: 100 mg daily (continuous or postcoital) 4
• Fosfomycin trometamol: 3 g every 10 days 4
• Cephalexin: 250-500 mg daily (continuous or postcoital) 4
• Duration: 6-12 months with periodic reassessment 1, 2

Step 3: Alternative Prophylactic Options

• Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1, 7
• Immunoactive prophylaxis to reduce recurrence (strong recommendation) 1, 7

Critical Pitfalls to Avoid

Antibiotic Selection Errors

• Do not use fluoroquinolones during pregnancy (cartilage development concerns) 1
• Do not use nitrofurantoin after 37 weeks gestation due to hemolytic anemia risk in newborn 4
• Avoid empiric broad-spectrum antibiotics without culture confirmation—this drives resistance 1, 7

Diagnostic Errors

• Do not treat asymptomatic bacteriuria in non-pregnant women—this increases resistance without benefit 1, 3
• Do not skip urine cultures in pregnant women with UTI symptoms—always confirm diagnosis and guide therapy 1, 4, 5
• Do not assume recurrence without culture documentation—lack of correlation between symptoms and microbiology should prompt consideration of alternative diagnoses 1

Management Errors

• Do not perform routine imaging (cystoscopy, ultrasound) in women <40 years with uncomplicated recurrent UTI and no risk factors—yield is extremely low 1
• Do not continue prophylaxis indefinitely without reassessment—evidence supports 6-12 month courses with periodic evaluation 1, 2

When to Escalate or Investigate Further

Consider Complicated UTI if:

• Rapid recurrence within 2 weeks of treatment completion 1
• Bacterial persistence without symptom resolution 1
• Repeated pyelonephritis (suggests complicated etiology requiring imaging) 1
• Risk factors present: diabetes, immunosuppression, structural abnormalities, indwelling catheter, urinary obstruction 1

Imaging Indications

• Obtain renal ultrasound if history of urolithiasis, renal dysfunction, or high urine pH 1
• Consider CT with contrast if patient remains febrile after 72 hours of appropriate treatment or clinical deterioration occurs 1

Special Considerations for Breastfeeding

• Most antibiotics used for UTI prophylaxis are compatible with breastfeeding, including nitrofurantoin, cephalosporins, and fosfomycin 4
• Avoid sulfonamides in first month postpartum if breastfeeding due to kernicterus risk in newborns 1
• Non-antimicrobial measures remain first-line and are safe during breastfeeding 2, 4