What to do about recurrent Urinary Tract Infection (UTI) in pregnancy?

From the Guidelines

Pregnant women with recurrent Urinary Tract Infections (UTIs) should be treated promptly with antibiotics to prevent complications.

Treatment Options

• A commonly recommended regimen is nitrofurantoin monohydrate 100mg orally twice daily for 5-7 days or cephalexin 500mg orally three times daily for 5-7 days 1.
• In cases of severe infection or pyelonephritis, intravenous ceftriaxone 1g every 24 hours or cefazolin 1g every 8 hours may be necessary, with duration of treatment typically ranging from 10-14 days.

Prevention Strategies

• Periodic screening for recurrent bacteriuria should be undertaken following therapy 1.
• Cranberry products containing proanthocyanidin levels of 36 mg may be considered to reduce the risk of recurrent UTIs, although data for pregnant women is insufficient 1.
• Increased water intake, such as an additional 1.5L of water, may also be recommended to decrease UTIs, although more research is needed to confirm its effectiveness in pregnant women 1.

Key Considerations

• Close monitoring of urine cultures and renal function is essential to ensure resolution of the infection and prevent recurrence.
• The decision to use antibiotic prophylaxis must balance the need for prevention against the risk of adverse drug events, antimicrobial resistance, and microbiome disruption 1.
• Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive 1.

From the Research

Treatment Options for Recurrent UTI in Pregnancy

• The treatment of urinary tract infections (UTIs) in pregnancy is crucial to prevent complications for both the mother and the fetus 2.
• A study published in 1994 recommended separating pregnant subjects with UTI into two groups: those with asymptomatic bacteriuria who can be treated with a single dose of an antimicrobial to which the organism is susceptible, and those with symptomatic UTI who can be treated with amoxicillin 500 mg tid for three days 2.
• However, more recent studies have shown that the prevalence of antimicrobial resistance is increasing, making it essential to determine the antimicrobial susceptibility patterns of uropathogens isolated from pregnant women 3, 4.
• A study published in 2021 found that Gram-negative bacteria, such as Klebsiella pneumoniae and Escherichia coli, were the most common causes of UTI in pregnancy, and that these bacteria were highly resistant to commonly used antibiotics 3.
• Another study published in 2020 found that E. coli was the most common cause of UTI in pregnancy, and that it displayed significant resistance to trimethoprim-sulfamethoxazole, cephalothin, cefuroxime, ciprofloxacin, and amoxicillin-clavulanic acid 4.
• A literature review of international guidelines for the treatment of UTI in pregnancy found that there was concordance between guidelines regarding the use of certain antibiotics, but also areas of discordance, such as the use of fluoroquinolones in lower or upper UTI 5.
• A study published in 2024 found that cephalosporins were the most commonly used antibiotics for the treatment of UTI in pregnancy in China, followed by enzyme inhibitors and penicillins 6.

Antibiotic Resistance and Treatment

• The increasing prevalence of antimicrobial resistance makes it essential to determine the antimicrobial susceptibility patterns of uropathogens isolated from pregnant women 3, 4.
• The use of antibiotics such as amoxicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin may not be effective in treating UTI in pregnancy due to high levels of resistance 3, 4.
• Cephalosporins, such as ceftriaxone and cefuroxime, may be effective alternatives for the treatment of UTI in pregnancy, but their use should be guided by antimicrobial susceptibility testing 3, 4.
• The use of fluoroquinolones in pregnancy is controversial, and their use should be avoided unless absolutely necessary 5.

Prevention and Management

• The prevention and management of UTI in pregnancy require a comprehensive approach, including the use of antimicrobials, as well as measures to prevent recurrence, such as increased fluid intake and urination after intercourse 2.
• The treatment of UTI in pregnancy should be guided by antimicrobial susceptibility testing to ensure the use of effective antibiotics and to minimize the risk of resistance 3, 4.
• Pregnant women with recurrent UTI should be monitored closely and treated promptly to prevent complications for both the mother and the fetus 2.