eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Pregnancy, Urinary Tract Infections: Treatment & Medication
Updated: Aug 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
Because of the dangers of maternal and fetal complications, care in the ED should be focused on identifying and treating patients with asymptomatic and symptomatic bacteriuria. Treatment of asymptomatic bacteriuria in pregnant patients is important because of the increased risk of urinary tract infection (UTI) and its associated sequelae.8 ED care may involve the following:
- Administration of appropriate antibiotics
- Administration of fluid if the patient is dehydrated
- Admission if any indication of UTI involvement exists
Consultations
An obstetrician may be consulted.
Medication
Antibiotic therapy for urinary tract infection should be initiated after all necessary cultures are obtained. If significant nausea or pain is present, appropriate medication may be indicated. Treatment of all symptomatic and asymptomatic patients with bacteriuria is important.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Empiric coverage for E coli and Klebsiella, Proteus, and Enterobacter species should be provided.3
Penicillins and cephalosporins are safe for use during pregnancy. Ceftriaxone should be withheld close to parturition due to the possibility of neonatal kernicterus secondary to bilirubin displacement. Trimethoprim is a folic acid antagonist and should be avoided, especially during the first trimester. Fluoroquinolones and tetracyclines are known teratogens and are contraindicated in pregnancy.
Amoxicillin (Amoxil, Polymox, Trimox)
DOC and interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
Asymptomatic bacteriuria (ASB): 500 mg PO tid for 3 d
Acute cystitis: 250-500 mg PO q8h for 10 d
Acute pyelonephritis: 1-2 g PO q6h plus gentamicin, 1 mg/kg PO q8h
Pediatric
20-50 mg/kg/d PO divided q8h
Reduces the efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduces efficacy of oral contraceptives; adjust dose in renal impairment; may enhance chance of candidiasis
Nitrofurantoin (Macrobid, Furadantin)
Synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. Bacteriostatic at low concentrations (5-10 mcg/mL) and bactericidal at higher concentrations.
Adult
ASB or cystitis: 100 mg PO bid for 5-7 d
Recurrent infections: 100 mg PO q6h for 21 d
Pediatric
5-7 mg/kg/d PO divided q6h
Anticholinergics may delay gastric emptying and increase absorption, increasing bioavailability; antacids made of magnesium salts may decrease effects, decreasing absorption; high doses of concurrent probenecid decreases renal clearance and increases nitrofurantoin toxicity
Documented hypersensitivity; renal insufficiency (<60 mL/min CrCl); anuria; oliguria
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause severe and irreversible peripheral neuropathy that can be fatal; renal impairment, diabetes, electrolyte imbalance, anemia, and vitamin B deficiency increase risk for adverse effects; prolonged use of antibiotics may result in fungal or bacterial overgrowth of resistant or nonsusceptible organisms
Trimethoprim and sulfamethoxazole (Bactrim, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
ASB or cystitis: 160/800 mg PO q12h for 10 d
Pyelonephritis: 160/800 mg PO q12h
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg/kg/d, based on TMP dose, PO tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, patients with chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Cephalexin (Keflex)
First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures.
Adult
ASB: 250 mg PO q6h for 3 d
Cystitis: 250-500 mg PO q6h for 10 d
Pediatric
25-50 mg/kg/d PO q6h; not to exceed 3 g/d
Coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Cefpodoxime (Vantin)
Third-generation cephalosporin with broad-spectrum gram positive and gram-negative activity. Arrests bacterial growth by binding to one or more penicillin-binding proteins thus inhibiting bacterial cell wall synthesis.
Adult
ASB or cystitis: 100 mg PO bid for 7d
Pediatric
5 mg/kg/d PO q12h for 5 d
Coadministration with probenecid, aminoglycosides (gentamicin), cyclosporine, or diuretics (furosemide, hydrochlorothiazide) may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
Acute pyelonephritis: 1-2 g IV q24h
Pediatric
50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
Cefazolin (Ancef)
First-generation semi-synthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including Staphylococcus aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.
Adult
1-2 g IV/IM q8h
Pediatric
25-100 mg/kg/d IV/IM divided q6-8h depending on the severity of the infection; not to exceed 6 g/d
Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may cause false-positive results at urine dip testing for glucose
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Cefuroxime (Ceftin)
Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have. Adds activity against Proteus mirabilis, Haemophilus influenzae, E coli, Klebsiella pneumoniae, and Moraxella catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determines proper dose and route of administration.
Adult
Acute pyelonephritis: 750-1500 mg IV/IM q8h
250-500 mg PO bid
Pediatric
Not established
Disulfiram-like reactions may occur when alcohol is consumed within 72 h after administration; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Administer half dose if creatinine clearance is 10-30 mL/min and quarter dose if it is <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
Ceftibuten (Cedax)
By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult
400 mg PO daily
Pediatric
Not established
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding and allergy to penicillin
More on Pregnancy, Urinary Tract Infections |
| Overview: Pregnancy, Urinary Tract Infections |
| Differential Diagnoses & Workup: Pregnancy, Urinary Tract Infections |
 Treatment & Medication: Pregnancy, Urinary Tract Infections |
| Follow-up: Pregnancy, Urinary Tract Infections |
| References |
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References
[Guideline] American Academy of Pediatrics and American College of Obstetricians and Gynecology. Guidelines for Perinatal Care. American Academy of Pediatrics. 6th ed. 2007.
Duarte G, Marcolin AC, Quintana SM, Cavalli RC. [Urinary tract infection in pregnancy]. Rev Bras Ginecol Obstet. Feb 2008;30(2):93-100. [Medline].
[Guideline] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. Mar 1 2005;40(5):643-54. [Medline].
Smaill F. Asymptomatic bacteriuria in pregnancy. Best Pract Res Clin Obstet Gynaecol. Jun 2007;21(3):439-50. [Medline].
Hill JB, Sheffield JS, McIntire DD, Wendel GD Jr. Acute pyelonephritis in pregnancy. Obstet Gynecol. Jan 2005;105(1):18-23. [Medline].
Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome?. J Matern Fetal Neonatal Med. Feb 2009;22(2):124-8. [Medline].
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Krcmery S, Hromec J, Demesova D. Treatment of lower urinary tract infection in pregnancy. Int J Antimicrob Agents. Apr 2001;17(4):279-82. [Medline].
Lucas MJ, Cunningham FG. Urinary infection in pregnancy. Clin Obstet Gynecol. Dec 1993;36(4):855-68. [Medline].
Manka W, Solowiow R, Okrzeja D. Assessment of infant development during an 18-month follow-up after treatment of infections in pregnant women with cefuroxime axetil. Drug Saf. Jan 2000;22(1):83-8. [Medline].
Miller JM, Raimer KA. Urinary tract infection and pyelonephritis in pregnancy. In: Obstetrics and Gynecologic Infectious Disease. 1994:283-93.
Schieve LA, Handler A, Hershow R, Persky V, Davis F. Urinary tract infection during pregnancy: its association with maternal morbidity and perinatal outcome. Am J Public Health. Mar 1994;84(3):405-10. [Medline].
Sweet RL, Gibbs RS. Urinary tract infection. In: Infectious Disease of the Female Genital Tract. 3rd ed. 1995:429-64.
Zinner SH. Management of urinary tract infections in pregnancy: a review with comments on single dose therapy. Infection. 1992;20 Suppl 4:S280-5. [Medline].
Further Reading
Keywords
UTI in pregnancy, urinary tract infection in pregnancy, UTI symptoms, UTI treatment, complications of UTI in pregnancy, UTI causes, bacteriuria, UTI, bacterial infection, vesicoureteral reflux, acute pyelonephritis, urinary stasis, low birth weight, prematurity, premature labor, hypertension, preeclampsia, maternal anemia, amnionitis, cystitis, Escherichia coli, E coli, Klebsiella species, Proteus species, Enterobacter species
