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

Management of Recurrent UTI in Pregnancy

For pregnant women with recurrent UTIs, obtain urine culture before each acute episode, treat with nitrofurantoin 100 mg twice daily for 5-7 days (avoiding use after 37 weeks gestation), and implement non-antimicrobial preventive measures as first-line prophylaxis before considering antibiotic prophylaxis. 1

Diagnostic Confirmation

• 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
• Confirm recurrent UTI diagnosis as ≥2 culture-positive episodes within 6 months or ≥3 episodes within 12 months 1
• Verify eradication of previous UTI with negative urine culture 1-2 weeks after treatment completion before starting any prophylaxis regimen 1
• Perform thorough history examining complicating factors including congenital urinary tract abnormalities, immunosuppression, nephrolithiasis, or neurogenic bladder 2

Treatment of Acute Episodes

First-Line Antibiotic Selection

• Nitrofurantoin macrocrystals 100 mg twice daily for 5-7 days is the preferred first-line agent for acute cystitis in pregnancy 1
• Use culture-directed therapy when prior susceptibility data are available rather than empiric broad-spectrum antibiotics 2, 1
• Treat for the shortest effective duration, generally no longer than 7 days 2, 1

Critical Timing Restrictions

• Avoid nitrofurantoin after 37 weeks gestation due to hemolytic anemia risk in the newborn 1
• Do not use trimethoprim in the first trimester (folate antagonist causing neural tube defects) 1
• Avoid trimethoprim-sulfamethoxazole in the third trimester (kernicterus risk from sulfonamide component) 1
• Never use fluoroquinolones during pregnancy due to cartilage development concerns 1

Alternative Agents

• Cephalexin 250-500 mg can be used throughout pregnancy when nitrofurantoin is contraindicated 3
• Third-generation cephalosporins (cefixime) show high sensitivity against E. coli and good safety profile 4
• Fosfomycin trometamol is an acceptable alternative for uncomplicated UTI 4

Prevention Strategies

Non-Antimicrobial Measures (First-Line)

Implement behavioral modifications before considering antibiotic prophylaxis: 1

• Increase fluid intake to maintain adequate hydration
• Void immediately after sexual intercourse
• Avoid prolonged urinary retention by regular, complete bladder emptying
• Discontinue spermicide-containing contraceptives
• Control blood glucose strictly in diabetic patients 2
• Cranberry products containing minimum 36 mg/day proanthocyanidin A may reduce recurrence, though evidence quality is low 1

Antibiotic Prophylaxis (When Non-Antimicrobial Measures Fail)

Post-coital prophylaxis is highly effective for pregnancy-associated recurrent UTI: 3

• Single oral dose of either cephalexin 250 mg or nitrofurantoin macrocrystals 50 mg within 2 hours of sexual activity 3
• This regimen reduced UTI incidence from 130 episodes pre-prophylaxis to only 1 episode during 39 pregnancies (highly significant reduction) 3
• Both agents reach high bactericidal concentrations in urinary tract and induce minimal resistance in introital gram-negative flora 3

Continuous daily prophylaxis considerations:

• Nitrofurantoin 50 mg daily can be used but evidence shows no significant advantage over close surveillance alone for preventing recurrent pyelonephritis (RR 0.89,95% CI 0.31-2.53) or recurrent UTI before birth (RR 0.30,95% CI 0.06-1.38) 5
• Daily prophylaxis did significantly reduce asymptomatic bacteriuria in women with high clinic attendance rates (RR 0.55,95% CI 0.34-0.89) 5
• Antibiotic choice must account for prior organism identification, susceptibility profiles, drug allergies, and antibiotic stewardship principles 2, 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria in non-pregnant women with recurrent UTI—this increases antimicrobial resistance and paradoxically increases recurrence episodes 2, 1
• Avoid classifying pregnant women with recurrent UTI as "complicated" unless true complicating factors exist (structural abnormalities, immunosuppression), as this leads to unnecessary broad-spectrum antibiotic use 2
• Do not use empiric broad-spectrum antibiotics without culture confirmation—this drives resistance patterns 1
• Never prescribe prolonged antibiotic courses exceeding 7 days for acute episodes 2, 1
• If symptoms persist despite treatment, repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics 2

Special Considerations for Breastfeeding

• Avoid sulfonamides in the first month postpartum if breastfeeding due to kernicterus risk in newborns 1
• Non-antimicrobial preventive measures remain first-line and are safe during breastfeeding 1
• Nitrofurantoin and cephalexin are generally compatible with breastfeeding after the first month 3

Monitoring and Follow-Up

• Obtain surveillance urine cultures 1-2 weeks after completing treatment to document cure 1
• Do not perform routine surveillance urine testing in asymptomatic patients—this leads to overtreatment of asymptomatic bacteriuria 2
• Regular clinic visits with culture-based monitoring are appropriate for high-risk patients 5