Urinary tract infections in pregnancy

Urinary tract infections in pregnancy - Secondary care management

Publication: 25/10/2013

Next review: 19/03/2024

Clinical Guideline

CURRENT

ID: 3515

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

URINARY TRACT INFECTIONS IN PREGNANCY

Diagnostics
Empirical treatment (whilst awaiting MSU result)
Review antibiotics by 72 hours
Directed therapy (once MSU result is confirmed)
Footnotes
Appendices

Lower UTIs are usually caused by gastrointestinal tract bacteria ascending the urethra to the bladder. They are normally caused by a single pathogen.

Signs and symptoms include acute dysuria, frequency, urgency and suprapubic pain/discomfort without upper UTI features (back/loin pain, fever) or systemic signs of infection.

If painful uterine activity is present, then treat as upper UTI (discuss with obstetrician)

Upper UTIs can include symptoms of a lower UTI with fever (≥38C) and systemic signs of infection, such as rigors and back/loin pain.

Urosepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection originating from the urinary tract and/or genital organs.

For treatment of asymptomatic bacteriuria in pregnancy please see the separate guidance.

If the patient has recurrent UTIs caused by the same bacteria in the current pregnancy consider antibiotic prophylaxis (based on susceptibilities) and review in antenatal clinic.

Postnatal women should be managed by the upper UTI or lower UTI guidelines for non-pregnant adults (check breastfeeding status and if the chosen antibiotic is appropriate prior to prescribing).

DIAGNOSTICS

Whilst the diagnosis of a UTI is largely clinical, an appropriate sampling process will enable appropriately-targeted treatment.

All urine samples for Microbiology must be freshly collected and sent in a sterile red top (boric acid) container, as per usual MSU collection instructions.

Requesting on ICE: select symptomatic from the antenatal urine culture (reason for testing) menu.

All patients	Cloudy/smelly urine on its own is not an indication for culture
All patients	Check previous MSU sample results prior to any treatment
Dipsticks	Dipstick results that are negative for both nitrites and leucocytes should prompt consideration of an alternative diagnosis
Dipsticks	Proteinuria alone is not an indication for culture
Patients with lower UTI symptoms and dipstick screen positive for infection markers	MSU should be sent for MC&S if UTI is deemed likely following near patient testing (dipstick) prior to starting antibiotics (do not delay antibiotics if severe sepsis).
Patients with symptoms of upper UTI or urosepsis	Blood cultures should be sent prior to starting antibiotics, in addition to the MSU.
Patients with severe sepsis	Carry out a full BUFALO screen
All women with an episode of symptomatic UTI	Send a ‘test of cure’ MSU on completion of treatment (within seven days of finishing antibiotics), and repeat in four weeks
All women who have Group B Strep (10⁵ CFU) isolated in their urine	Initial course of oral antibiotics as per UTI and then ensure intrapartum antibiotic prophylaxis is offered to all these women

EMPIRICAL TREATMENT (whilst awaiting MSU result)

If the woman has had a recent urine culture, please use the sensitivity results to provide directed therapy (see table for order of preference)
Ensure adequate fluids and offer appropriate (simple) analgesia
If she has a catheter in situ, this should be changed as part of treatment
Prescribing options (assuming normal renal and hepatic function)

Lower UTI with no signs of sepsis or concomitant upper UTI
	Recommended treatment	Notes
Duration: 7 days
1st line	Nitrofurantoin PO 50mg 6-hourly	Avoid after 36 weeks gestation³ Avoid in patients with a history of abnormal renal function1
2nd line	Cefalexin PO 500mg 8-hourly	Avoid in penicillin allergy (unless known to tolerate cephalosporins)
IV antibiotics are not normally required for lower UTIs. If there are signs of sepsis, concomitant upper UTI, or unable to take oral medication then please refer to following table

If >30 weeks gestation and unable to tolerate cephalosporins, please contact Microbiology to discuss alternative options.

Upper UTI or Urosepsis
	Recommended treatment	Notes
Duration: 10-14 days
1st line	Cefuroxime IV 1.5g 8-hourly	Avoid in penicillin allergy (unless known to tolerate cephalosporins)
2nd line	Aztreonam ² IV 2g 12-hourly inc to 8-hourly if Pseudomonas aeruginosa susceptible	Suitable in penicillin-allergic patients
If the patient has a known history of ESBL or other multi drug-resistant bacteria then please refer to the directed antimicrobial table if the result is recent or contact Microbiology to discuss

REVIEW ANTIBIOTICS BY 72 HOURS

By 72 hours of antibacterial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.

You should document the outcome of the review in the maternity notes.

Patients on IV antibiotics should be reviewed daily, and can be switched before 72 hours if appropriate

Stop	If no signs of infection and diagnostics support this decision.
Change	If diagnosis still valid, use culture results to review current antibiotic and change to directed therapy if needed. If initial diagnosis now changed - review appropriate guideline.
Continue	If the woman is improving but does not fully meet ACED criteria (see following row). Review daily until ready to switch.
Switch (IV to oral)	If your initial diagnosis is correct and the woman is improving, review whether an oral switch is appropriate using the ACED criteria. If they meet all four consider switching using the oral options listed in the table below. Afebrile for 24 hours Clinically improving Eating and drinking Not Deep seated infection

DIRECTED THERAPY (once MSU result is confirmed)

The tables below are in order of preference based on culture results.
Doses assume normal renal and hepatic function.

Table 1: Directed IV options - for use when culture results are available prior to commencing treatment or when oral switch is not yet appropriate. Please switch to PO (table 2) at the first appropriate opportunity.

	Treatment	Notes
Duration of treatment: 10 to 14 days Can be completed with PO option from table below
1	Amoxicillin IV 1g 8-hourly	Avoid in penicillin allergy
2	Cefuroxime 1.5 g 8-hourly	Avoid in penicillin allergy (unless known to tolerate cephalosporins)
3	Aztreonam ² IV 2g 12-hourly (increased to 2g 8-hourly if a susceptible Pseudomonas aeruginosa)	This is an alternative in beta-lactam allergy as recommended by Microbiology; use in pregnancy is against the Summary of Product Characteristics (SPC) recommendation
4	Piperacillin/tazobactam IV 4.5g 8-hourly, increased to 6-hourly if Pseudomonas aeruginosa has been isolated	Avoid in penicillin allergy

Table 2: Directed oral options - for use when culture results are available prior to commencing treatment where IVs are not required, or as IV to oral step-down option

	Treatment	Suitable for systemic infections	Notes
Duration of treatment: 7 days total duration for lower UTI 10-14 days total duration for upper UTI
1	Nitrofurantoin PO 50mg 6-hourly	Never use for upper UTI or urosepsis step-down	Avoid after 36 weeks gestation Avoid in patients with a history of abnormal renal function1
2	Amoxicillin PO 500mg 8-hourly	Yes	Avoid in penicillin allergy
3	Cefalexin PO 500mg 8-hourly	Yes	Avoid in penicillin allergy (unless known to tolerate cephalosporins)

Please contact Microbiology for alternative options if your patient is unable to take any of these agents

If Candida is identified in the urine culture, review for symptoms of vaginal thrush in the first instance and treat if required.

If UTI symptoms are refractory to antibacterial treatment and/or recurrent isolation of candida may indicate the need for further investigation and treatment with antifungals. Please discuss with Microbiology.

Do not use the following antibiotics at any stage in pregnancy:

Ciprofloxacin and other fluroquinolones
Doxycycline and other tetracyclines
Co-trimoxazole

FOOTNOTES

Nitrofurantoin should not be used if CrCl <45 mL/min. Do not rely on eGFR as this may overestimate renal function
This is an alternative in beta-lactam allergy as recommended by Microbiology; use in pregnancy is against the Summary of Product Characteristics (SPC) recommendation
The BNF states to “avoid at term - may produce neonatal haemolysis”. Author consensus was to use 36 weeks.

APPENDICES

LTHT resistance data (for the listed antibiotics) from E coli isolated from Urine samples in the year 1/5/2019 - 30/4/2020 are as follows:

Antibiotic	*% of E coli* isolates testing susceptible**	Number of isolates tested
Nitrofurantoin	96.3%	7741
Amoxicillin	50.3%	7739
Trimethoprim	70.8%	7741
Cefalexin	89.0%	7742

LTHT resistance data (from the listed antibiotics) from E.coli isolated from Blood cultures samples in the year 1/5/2019 - 30/4/2020 are as follows:

Antibiotic	*% of E coli* isolates testing susceptible**	Number of isolates tested
Cefuroxime	80.61%	820
Amoxicillin	37.52%	821
Aztreonam	83.17%	820
Piperacillin/tazobactam	91.47%	821

Provenance

Record:	3515
Objective:
Clinical condition:	Urinary tract infections in pregnancy
Target patient group:
Target professional group(s):	Pharmacists Secondary Care Doctors Midwives
Adapted from:

Evidence base

Public Health England: Diagnosis of urinary tract infections updated 2019 (accessed April 2020) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
attachment_data/file/829721/Diagnosis_of_urinary_tract_infections_UTI_diagnostic_flowchart.pdf
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. 2005 Mar 1;40(5):643-54
NICE: Multidrug resistant urinary tract infections: fosfomycin trometamol (accessed April 2020) https://www.nice.org.uk/advice/esuom17/chapter/key-points-from-the-evidence
SIGN 88: Management of suspected bacterial urinary tract infection in adults (accessed April 2020) https://www.sign.ac.uk/assets/sign88.pdf
Urinary tract infection (lower): antimicrobial prescribing. NICE guideline Published 31st October 2018. Nice.org.uk/guidance/ng109. (accessed April 2020)
https://www.nice.org.uk/guidance/ng109/resources/urinary-tract-infection-lower-antimicrobial-prescribing-pdf-66141546350533
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14821

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.2

Related information

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