What is the best course of treatment for a pregnant patient with a history of recurrent Urinary Tract Infections (UTIs), currently experiencing symptoms of a UTI, including dysuria and abdominal pain, who recently completed a course of Keflex (Cephalexin) and is taking progesterone?

Management of Symptomatic UTI in Pregnant Patient with Recurrent UTI History

This pregnant patient requires immediate urine culture before initiating empiric antibiotic therapy, and pregnancy classifies her UTI as complicated, necessitating a different treatment approach than her recent Keflex course. 1

Critical Classification Issue

Pregnancy automatically classifies this as a complicated UTI, not recurrent uncomplicated UTI. 1 The guidelines explicitly state to "reserve the classification of complicated UTI for those with congenital or acquired structural and/or functional abnormalities of the urinary tract and/or immune suppression or pregnancy." 1

Immediate Diagnostic Steps

• Obtain urine culture and susceptibility testing before starting antibiotics - this is mandatory given her recent antibiotic failure and pregnancy status 1, 2
• The recent Keflex course suggests potential resistance to cephalosporins, making culture-guided therapy essential 1
• Do not assume the organism is susceptible to the previously used agent (Keflex) when symptoms recur or persist 1

Empiric Treatment While Awaiting Culture

If empiric treatment must be initiated immediately, use prior culture data if available to guide selection. 1 For pregnancy-specific considerations:

Safe First-Line Options in Pregnancy:

• Nitrofurantoin 100 mg twice daily for 5-7 days (avoid at term/near delivery) 1, 3
• Fosfomycin 3g single dose 1, 3
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily - avoid in first and third trimesters 1, 4
• Beta-lactams (cephalosporins other than cephalexin) such as cefadroxil 500 mg twice daily for 3-7 days if local E. coli resistance <20% 1, 3

Why Not Repeat Keflex:

• Assume the infecting organism is NOT susceptible to cephalexin given recent treatment failure 1
• Retreatment requires a 7-day regimen with a different agent 1
• Cephalexin resistance may have developed despite its typically low resistance profile 1, 5

Treatment Duration Considerations

Pregnant patients require 7-day treatment courses, not the shorter 3-5 day regimens used in non-pregnant women. 1 This is critical because pregnancy-associated UTIs carry higher risk of progression to pyelonephritis and adverse pregnancy outcomes.

Post-Treatment Monitoring

• Obtain post-treatment urine culture to document clearance - this is essential in pregnancy unlike non-pregnant patients 1
• If symptoms don't resolve by end of treatment, repeat culture and assume resistance to the initial agent 1
• Screen for and treat asymptomatic bacteriuria throughout pregnancy - pregnancy is the one indication where asymptomatic bacteriuria requires treatment 1

Long-Term Prevention Strategy Post-Pregnancy

After delivery, address the recurrent UTI pattern:

• Document that she meets criteria for rUTI (≥2 culture-positive UTIs in 6 months or ≥3 in one year) 1
• Consider post-coital antibiotic prophylaxis if infections are temporally related to sexual activity 1
• Low-dose daily prophylaxis options: nitrofurantoin 50mg, trimethoprim-sulfamethoxazole 40/200mg, or trimethoprim 100mg nightly 1
• Non-antibiotic alternatives: methenamine hippurate, lactobacillus-containing probiotics 1

Critical Pitfalls to Avoid

• Do not treat this as uncomplicated UTI - pregnancy changes the entire management algorithm 1
• Do not use fluoroquinolones in pregnancy - these are contraindicated 1, 3
• Do not repeat the same antibiotic (Keflex) that just failed - this promotes resistance and treatment failure 1
• Do not rely on telehealth alone - she needs urine culture which requires in-person specimen collection 1
• Avoid nitrofurantoin near term (after 36-38 weeks) due to risk of hemolytic anemia in the newborn 3

Abdominal Pain Consideration

The "stomach pains" warrant careful evaluation - while suprapubic discomfort is common with cystitis, significant abdominal pain in a pregnant patient with UTI symptoms should raise concern for:

• Ascending infection/early pyelonephritis (requires hospitalization and IV antibiotics) 2
• Other pregnancy-related complications 2
• If she has fever, flank pain, nausea/vomiting, or significant abdominal pain, she requires urgent in-person evaluation, not telehealth 2