UTI in pregnancy: 6 questions to guide therapy

Expect recurrence

One third of pregnant women diagnosed with UTI will have recurrence.¹ Recurrence is either relapse (same strain, within 2 weeks of completing initial treatment for the original infection) or reinfection (different strain or same strain after more than 2 weeks).

2 UTIs or pyelonephritis warrant suppressive therapy

I recommend suppressive therapy if a pregnant woman is diagnosed with 2 lower urinary tract infections or acute pyelonephritis (TABLE).

Nitrofurantoin is the preferred agent, as it has high concentrations in the urinary tract but induces minimal resistance in gram-negative organisms.

Start only after eradication of the acute infection, as evidenced by a negative test-of-cure urine culture at least 1 to 2 weeks after treatment is discontinued.²³

Monthly urine cultures until delivery

I recommend monthly follow-up urine cultures until delivery.

Periodic follow-up screening is often recommended, but opinions differ on which test to use or how often to screen.

THE CASE: DIAGNOSIS, TREATMENT, FOLLOW-UP, AND OUTCOME

The patient with upper urinary tract symptoms had a white blood cell count of 15, a urine dipstick positive for leukocyte esterase and nitrites, and a urine sediment analysis indicating pyuria.

She was diagnosed with acute pyelonephritis and started on ampicillin and gentamicin intravenously. Her urine culture drawn upon admission grew >100,000 CFU/mL of sulfonamide-resistant E. coli.

Within 48 hours, she showed clinical improvement and was discharged home with a 10-day course of nitrofurantoin. One week after completing treatment, her test-of-cure urine culture was negative and she was started on nitrofurantoin 50 mg every night at bedtime.

For the rest of pregnancy, she underwent monthly screening urine cultures, which remained negative. She had an uncomplicated delivery at 38 weeks of gestation.

TABLE

Suppressive therapy to prevent UTI recurrence