What is the recommended treatment for urinary tract infections (UTIs) in pregnancy?

Treatment of UTIs in Pregnancy

For pregnant women with UTIs, use nitrofurantoin (except near term), fosfomycin trometamol, or cephalosporins as first-line therapy for 5-7 days, with specific agent selection based on trimester and local resistance patterns. 1

First-Line Antibiotic Options

Nitrofurantoin

• Safe and effective throughout most of pregnancy but must be avoided in the last trimester due to risk of hemolytic anemia in the newborn 1
• Demonstrates low resistance rates and is preferred for re-treatment when needed 1
• Typical dosing: 100 mg for 5 days 2

Fosfomycin Trometamol

• Single-dose administration (3 grams) improves compliance and is equally effective as multi-day regimens for uncomplicated cystitis 1
• Comparable efficacy to nitrofurantoin with no significant difference in clinical or microbiological cure rates 2
• Particularly useful option for asymptomatic bacteriuria in pregnancy 1

Cephalosporins

• Cefixime and other third-generation cephalosporins are appropriate, particularly when resistance to other agents is suspected 1, 3
• Cefixime specifically shows high sensitivity against E. coli (the main uropathogen), with good safety profile in pregnancy 3
• Cephalexin is also commonly used and effective 4

Treatment Duration

• 5-7 days of treatment is recommended for symptomatic UTIs in pregnancy 1
• Shorter courses (1-3 days) are generally not recommended for pregnant women 1
• Single-dose therapy may be appropriate for asymptomatic bacteriuria 1

Critical Medications to Avoid

Trimethoprim-Sulfamethoxazole

• Contraindicated in the first trimester due to potential teratogenic effects (anencephaly, heart defects, orofacial clefts) 1, 4
• Contraindicated in the third trimester due to risk of neonatal hyperbilirubinemia and kernicterus 1
• Should only be used when other antimicrobial therapies are deemed clinically inappropriate 4

Fluoroquinolones

• Absolutely contraindicated during pregnancy 1
• Despite ciprofloxacin being frequently prescribed in practice, it should not be used 4

Diagnostic Approach

• Urine culture must be performed in pregnant women with UTI symptoms to confirm diagnosis and guide treatment 1
• Pregnancy is classified as a "complicated UTI" scenario, requiring more careful antibiotic selection than in non-pregnant women 1
• Review prior culture data and local antibiogram patterns for community resistance rates when choosing empiric therapy 1

Special Populations

Asymptomatic Bacteriuria

• Screen for and treat asymptomatic bacteriuria in pregnant women with standard short-course treatment or single-dose fosfomycin 1
• This differs from non-pregnant populations where asymptomatic bacteriuria is generally not treated 1
• Untreated bacteriuria can lead to pyelonephritis, preterm labor, low birth weight, and sepsis 4

Recurrent UTIs in Pregnancy

• Daily low-dose antibiotics can be used in select cases with frequent recurrences 1
• Consider rotating antibiotics at 3-month intervals to prevent antimicrobial resistance development 1
• Postcoital prophylaxis with cephalexin (250 mg) or nitrofurantoin (50 mg) has proven highly effective in preventing recurrent UTIs during pregnancy 5

Common Pitfalls to Avoid

• Do not use antibiotics that fail to achieve adequate urinary concentrations (e.g., certain macrolides) 1
• Do not automatically prescribe broad-spectrum antibiotics for all pregnant women with UTIs; prioritize narrow-spectrum agents when susceptibility allows 1
• Do not prescribe nitrofurantoin near term or at delivery due to neonatal hemolysis risk 1
• Verify pregnancy status before prescribing sulfonamides or nitrofurantoin to women of reproductive age, as unrecognized early pregnancy poses teratogenic risks 4