Treatment of Urinary Tract Infections in Pregnancy
First-line antibiotics for UTI in pregnancy are nitrofurantoin (100 mg twice daily for 5 days), fosfomycin trometamol (3g single dose), or cephalosporins (such as cefixime), with treatment duration of 5-7 days. 1
Recommended First-Line Agents
Nitrofurantoin (100 mg twice daily for 5 days) is safe and effective but must be avoided in the third trimester due to risk of hemolytic anemia in the newborn 1
Fosfomycin trometamol (3g single dose) offers convenient single-dose administration that improves compliance and demonstrates equal effectiveness to multi-day regimens 1
Cephalosporins (such as cefixime) are appropriate alternatives, particularly when resistance to other agents is suspected or in complicated cases 1, 2
Critical Diagnostic Requirements
Always obtain a urine culture in pregnant women with UTI symptoms before initiating treatment to confirm diagnosis and guide antibiotic selection 3, 1
Pregnancy is classified as a "complicated UTI" scenario, which mandates culture-based diagnosis rather than empiric treatment alone 3
Antibiotics to Avoid in Pregnancy
Fluoroquinolones (ciprofloxacin, levofloxacin) are absolutely contraindicated throughout pregnancy 1, 4
Trimethoprim-sulfamethoxazole should be avoided in the first trimester (teratogenic risk including neural tube defects) and third trimester (neonatal hyperbilirubinemia risk) 1, 5
Nitrofurantoin must not be used in the third trimester despite being first-line earlier in pregnancy 1
Treatment Duration
5-7 days is the recommended duration for symptomatic UTIs in pregnancy 1
Shorter courses (1-3 days) are not recommended in pregnant women, unlike non-pregnant populations 1
Single-dose therapy may be considered only for asymptomatic bacteriuria in select cases 6
Special Considerations for Asymptomatic Bacteriuria
All pregnant women with asymptomatic bacteriuria require treatment, as it serves as a marker for heavy genital tract colonization and carries risk of progression to pyelonephritis 1
This differs from non-pregnant women with recurrent UTIs, where asymptomatic bacteriuria should not be treated 3
Prophylaxis for Recurrent UTIs in Pregnancy
Daily low-dose antibiotic prophylaxis can be considered for pregnant women with frequent recurrences 1
Post-coital prophylaxis with cephalexin (250 mg) or nitrofurantoin (50 mg) as a single dose has demonstrated high effectiveness in preventing recurrent UTIs during pregnancy 7
Common Pitfalls to Avoid
Do not prescribe fluoroquinolones, which remain commonly dispensed despite contraindication (ciprofloxacin was the second most prescribed antibiotic for pregnant women with UTIs in 2014) 5
Do not use nitrofurantoin in late pregnancy (third trimester), even though it is first-line earlier 1
Do not use unnecessarily long antibiotic courses beyond 7 days, as this promotes resistance without improving outcomes 1
Do not treat based on symptoms alone—always obtain culture confirmation given the complicated nature of UTI in pregnancy 3, 1