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 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

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

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).

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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

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

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

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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 electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Cefuroxime IV 1.5g 8-hourly

Avoid in penicillin allergy (unless known to tolerate cephalosporins)

2nd line

Aztreonam electronic Medicines Compendium information on Aztreonam2 IV 1g 8-hourly

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

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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

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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 electronic Medicines Compendium information on Amoxicillin IV 1g 8-hourly

Avoid in penicillin allergy

2

Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5 g 8-hourly

Avoid in penicillin allergy (unless known to tolerate cephalosporins)

3

Aztreonam electronic Medicines Compendium information on Aztreonam2 IV 1g 8-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 electronic Medicines Compendium information on 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 30 weeks gestation

Avoid in patients with a history of abnormal renal function1

2

Trimethoprim PO 200mg 12-hourly 

Yes

Avoid before 12 weeks

3

Amoxicillin electronic Medicines Compendium information on Amoxicillin PO 500mg 8-hourly

Yes

Avoid in penicillin allergy

4

Cefalexin electronic Medicines Compendium information on 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

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FOOTNOTES

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

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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 electronic Medicines Compendium information on Amoxicillin

50.3%

7739

Trimethoprim

70.8%

7741

Cefalexin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Cefuroxime

80.61%

820

Amoxicillin electronic Medicines Compendium information on Amoxicillin

37.52%

821

Aztreonam electronic Medicines Compendium information on Aztreonam

83.17%

820

Piperacillin/tazobactam electronic Medicines Compendium information on 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

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.2

Related information

Not supplied

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