Urinary Tract Infections - UpToDate-2022

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Urinary tract infections and asymptomatic bacteriuria in

pregnancy
Authors: Thomas M Hooton, MD, Kalpana Gupta, MD, MPH
Section Editors: Stephen B Calderwood, MD, Charles J Lockwood, MD, MHCM
Deputy Editor: Allyson Bloom, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2022. | This topic last updated: Jun 15, 2022.
INTRODUCTION
Urinary tract infections (UTIs) are common in pregnant women. By convention, UTI is defined
either as a lower tract (acute cystitis) or upper tract (acute pyelonephritis) infection. UTIs (acute
cystitis and pyelonephritis) and asymptomatic bacteriuria in pregnant women will be reviewed
here.
Issues related to UTIs or asymptomatic bacteriuria in other populations are discussed in detail
elsewhere. (See "Acute simple cystitis in women" and "Acute simple cystitis in men" and "Acute
complicated urinary tract infection (including pyelonephritis) in adults" and "Asymptomatic
bacteriuria in adults" and "Catheter-associated urinary tract infection in adults".)
EPIDEMIOLOGY
Incidence and risk factors — The incidence of bacteriuria in pregnant women is approximately

the same as that in nonpregnant women; however, recurrent bacteriuria is more common
during pregnancy. Additionally, the incidence of pyelonephritis is higher than in the general
population, likely as a result of physiologic changes in the urinary tract during pregnancy. (See
'Pathogenesis' below.)
Asymptomatic bacteriuria occurs in 2 to 7 percent of pregnant women [1,2]. It typically occurs

during early pregnancy, with only approximately a quarter of cases identified in the second and
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third trimesters [3]. Factors that have been associated with a higher risk of bacteriuria include a
history of prior urinary tract infection, pre-existing diabetes mellitus, and low socioeconomic
status [4,5].
Without treatment, as many as 20 to 35 percent of pregnant women with asymptomatic

bacteriuria will develop a symptomatic urinary tract infection (UTI), including pyelonephritis,
during pregnancy [6,7]. This risk is reduced by 70 to 80 percent if bacteriuria is eradicated (see
'Rationale for treatment' below). Although a study from the Netherlands suggested a low rate
of pyelonephritis among 208 women with untreated asymptomatic bacteriuria (2.4 percent
versus 0.6 percent among 4035 women without bacteriuria), this study included only low-risk
women with uncomplicated singleton pregnancies without diabetes mellitus or urinary tract
abnormalities, and it is uncertain whether these results are generalizable [8].
Acute cystitis occurs in approximately 1 to 2 percent of pregnant women, and the estimated
incidence of acute pyelonephritis during pregnancy is 0.5 to 2 percent [9-12]. Most cases of
pyelonephritis occur during the second and third trimesters. As an example, the incidence of
acute pyelonephritis in pregnancy in the setting of routine prenatal screening for asymptomatic
bacteriuria was examined in a prospective study of a general obstetric population [11]. During
the two year study period, 440 cases of acute pyelonephritis were identified in 32,282 pregnant
women (14 per 1000 deliveries). The majority of cases occurred in the second trimester (53
percent). In addition to prior untreated bacteriuria, other clinical characteristics that have been
associated with acute pyelonephritis during pregnancy include age <20 years, nulliparity,
smoking, late presentation to care, sickle cell trait, and pre-existing (not gestational) diabetes
[11-13]
Pregnancy outcomes — Many studies have described a correlation between maternal urinary

tract infection, particularly asymptomatic bacteriuria, and adverse pregnancy outcomes.
Studies have also suggested that acute pyelonephritis has a similar association, but there are
several variables that potentially confound this association, such as socioeconomic status and
previous preterm delivery.
Untreated bacteriuria has been associated with an increased risk of preterm birth, low birth
weight, and perinatal mortality in most [1,6,14-19], but not all [8,20], studies. As an example, in
a meta-analysis of 19 studies, among women without bacteriuria, the risks of preterm birth and
a low birth weight infant were one-half and two-thirds the risks among women with
asymptomatic bacteriuria [19]. Other pregnancy complications have also been associated with
bacteriuria. As an example, a case control study of over 15,000 pregnant women found an
increased risk of preeclampsia with either asymptomatic bacteriuria or symptomatic UTI [21].

No correlation has been clearly established between acute cystitis of pregnancy and increased
risk of low birth weight, preterm delivery, or pyelonephritis [16], perhaps because pregnant
women with symptomatic lower UTI usually receive treatment.
Pyelonephritis, however, has been associated with adverse pregnancy outcomes. In an 18-year
retrospective study of over 500,000 singleton pregnancies followed at a large health care
system in the United States, the rate of preterm birth, primarily between weeks 33 and 36, was
higher among the 2894 women who had pyelonephritis during pregnancy (10.3 versus 7.9
percent among those who did not, OR 1.3, 95% CI 1.2-1.5) [12]. There were no differences in
stillbirth or neonatal death. Other complications of pyelonephritis include anemia, sepsis, and
respiratory distress [11]. Maternal morbidity and obstetric outcomes with pyelonephritis do not
appear to differ by trimester [22].
PATHOGENESIS
The organisms that cause bacteriuria and urinary tract infections (UTI) in pregnant women are
of the same species and have similar virulence factors as in nonpregnant women. Thus, the
basic mechanism of entry of bacteria into the urinary tract is likely to be the same for both
groups [23]. However, the smooth muscle relaxation and subsequent ureteral dilatation that
accompany pregnancy are thought to facilitate the ascent of bacteria from the bladder to the
kidney, resulting in the greater propensity for bacteriuria to progress to pyelonephritis during
pregnancy [14,24]. (See "Maternal adaptations to pregnancy: Renal and urinary tract
physiology".)
Pressure on the bladder and ureters from the enlarging uterus may also increase the risk of
progression to pyelonephritis. In addition, the immunosuppression of pregnancy may
contribute. As an example, mucosal interleukin-6 levels and serum antibody responses to
Escherichia coli antigens appear to be lower in pregnant women [25].
MICROBIOLOGY
As in nonpregnant women, E. coli is the predominant uropathogen found in both asymptomatic

bacteriuria and urinary tract infection (UTI) in pregnant women. As an example, in a study of
over 400 cases of pyelonephritis, E. coli accounted for approximately 70 percent of cases [11].
Other organisms responsible for infection included Klebsiella and Enterobacter species (3
percent each), Proteus (2 percent), and gram-positive organisms, including group B
Streptococcus (10 percent). Group B Streptococcus in pregnancy is discussed in detail

elsewhere. (See "Group B streptococcal infection in pregnant individuals", section on 'Urinary

tract'.)
As in other community-acquired infections, antimicrobial resistance is an increasing concern.

Infections caused by extended-spectrum beta-lactamase (ESBL)-producing strains are
increasing in number [26,27]. In India, ESBL-producing uropathogens are a particular problem,
even in pregnant women [28].
Isolation of more than one species or the presence of Lactobacillus or Cutibacterium (formerly
Propionibacterium) acnes may indicate a specimen contaminated by vaginal or skin flora.
However, repeated isolation of Lactobacillus with high colony counts and without other
organisms in consecutive urine cultures may not represent simple contamination, although the
significance of this finding in pregnancy is not known.
ASYMPTOMATIC BACTERIURIA
Diagnosis — The diagnosis of asymptomatic bacteriuria is made by finding high-level bacterial

growth on urine culture in the absence of symptoms consistent with urinary tract infection
(UTI). Details on the timing of screening, specimen collection, and diagnostic criteria are
discussed below.
Screening — We agree with the guidelines from the Infectious Diseases Society of America
that recommend screening all pregnant women for asymptomatic bacteriuria at least once in
early pregnancy [2]. Other expert groups make a similar recommendation [29,30]. The rationale
for screening is the same as for treatment of bacteriuria and is discussed elsewhere. (See
'Rationale for treatment' below.)
Screening for asymptomatic bacteriuria is performed at the first prenatal visit with a urine
culture [2,31]. Rescreening among those who did not have bacteriuria on the initial test is
generally not performed in low-risk women. It is reasonable to rescreen women at high risk for
infection (eg, history of UTI or presence of urinary tract anomalies, diabetes mellitus,
hemoglobin S, or preterm labor), however the optimal target populations for this is uncertain.
There is minimal evidence informing the benefits and harms of repeat screening following an
initial negative culture.(See "Prenatal care: Initial assessment".)
Specimen collection — The diagnosis of asymptomatic bacteriuria should be based on culture

of a urine specimen collected in a manner that minimizes contamination. Although the optimal
method for collecting voided urine is uncertain, instructing women to spread their labia and
collect a midstream urine (the second portion of the voided urine after discarding the initial
stream) without requiring a clean-catch (local cleansing of the urethral meatus and surrounding
mucosa) seems most reasonable. Routine catheterization to screen for bacteriuria is not
warranted due to the risk of introducing infection. (See "Sampling and evaluation of voided
urine in the diagnosis of urinary tract infection in adults".)
Several studies suggest that local cleansing is of little value, as it does not reduce contamination
when a midstream urine is collected [32-34]. As an example, in a study of 113 asymptomatic
pregnant women, each was instructed to collect a sample from the first concentrated morning
urine, a midstream sample, and a clean-catch midstream sample, in that order, over the course
of a day [32]. Rates of mixed growth and growth of skin flora on culture in midstream urine
were comparable with those observed in the morning and clean-catch samples. Overall rates of
contamination were high in all three samples, and the women were tested at a mean of 32
weeks of gestation as opposed to the recommended period of 16 weeks.
Proper handling and processing of the specimen is crucial to avoid false-positive results. (See
"Microbiology specimen collection and transport".)
Diagnostic criteria — For asymptomatic women, bacteriuria is formally defined as two

consecutive voided urine specimens with isolation of the same bacterial strain in quantitative
counts of ≥105 colony-forming units (cfu)/mL or a single catheterized urine specimen with one
bacterial species isolated in a quantitative count of ≥102 cfu/mL [2]. In clinical practice, however,
only one voided urine specimen is typically obtained, and diagnosis (and treatment initiation) is
made in women with ≥105 cfu/mL without obtaining a confirmatory repeat culture. The
diagnosis (and treatment) of asymptomatic bacteriuria due to group B streptococcus during
pregnancy is discussed in detail elsewhere. (See "Group B streptococcal infection in pregnant
individuals", section on 'Asymptomatic bacteriuria'.)
If bacteria that are not typical uropathogens (such as lactobacillus) are isolated, treatment
should be reserved for patients in whom the organism grows as a single isolate on consecutive
cultures.
Rapid screening tests, such as dipstick, enzymatic screen, reagent strip, or interleukin-8 testing,
do not come close to urine culture in terms of sensitivity and specificity for detecting
asymptomatic bacteriuria in pregnant women and should not be used [35-37]. In addition,
cultures are useful in guiding therapy. This can be particularly important in pregnancy, during
which the number of safe treatment alternatives is reduced.
Management

Rationale for treatment — Asymptomatic bacteriuria during pregnancy increases the risk of

pyelonephritis and has been associated with adverse pregnancy outcomes, such as preterm
birth and low birth weight infants (see 'Epidemiology' above). Antimicrobial treatment reduces
the risk of subsequent development of pyelonephritis and is associated with improved
pregnancy outcomes [6,38-43]. This was illustrated in a meta-analysis of 15 randomized trials of
antibiotic treatment versus placebo or no treatment for pregnant women with asymptomatic
bacteriuria [6]. Antibiotic therapy was more likely to clear asymptomatic bacteriuria (odds ratio
[OR] 0.30, 95% CI 0.18-0.53) and to lower the incidence of pyelonephritis (OR 0.24, 95% CI 0.13-
0.41). There was also a reduction in the incidence of low birth weight infants with antibiotic
treatment. However, the included studies that evaluated these outcomes were deemed to be of
poor quality.
The meta-analysis described above included a trial of pregnant women in the Netherlands
(where screening for asymptomatic bacteriuria is not performed routinely), which suggested
generally similar effects of treatment [8]. Women with asymptomatic bacteriuria between 16
and 22 weeks gestation who were not treated or received placebo treatment had a higher rate
of pyelonephritis (2.4 percent of 208 women) compared with both those who received
nitrofurantoin treatment for asymptomatic bacteriuria (0 percent of 40 women) and those who
did not have asymptomatic bacteriuria (0.6 percent of 4035 women). Likewise, low birth weight
occurred in 17 of 208 untreated or placebo-treated women with asymptomatic bacteriuria (8
percent) compared with 1 of 40 of nitrofurantoin-treated women (2.5 percent). While this
difference was not statistically significant, the study was under-powered for this outcome.
Preterm birth did not differ between these two groups. Notably, the study included only women
who were at low risk for UTI, pre-term birth, or other complications, and the pyelonephritis rate
was lower than in previous studies of pregnant women with asymptomatic bacteriuria [20].
Antimicrobial treatment — Asymptomatic bacteriuria is treated with an antibiotic tailored to

the susceptibility pattern of the isolated organism, which is generally available at the time of
diagnosis. Potential options include beta-lactams, nitrofurantoin, and fosfomycin ( table 1).
Although nitrofurantoin is generally avoided during the first trimester, it is an appropriate
alternative when other options cannot be used. Safety of antimicrobial agents used for
bacteriuria during pregnancy is discussed elsewhere. (See 'Antibiotic safety in pregnancy'
below.)
The optimal duration of antibiotics for asymptomatic bacteruria is uncertain. We typically give
five to seven days of therapy. Short courses of antibiotics are preferred to minimize the
antimicrobial exposure to the fetus. Short course antibiotic therapy is usually effective in
eradicating asymptomatic bacteriuria of pregnancy, although single-dose regimens may not be

as effective as slightly longer regimens [44-46]. As an example, in a meta-analysis of 13 studies

comparing single-dose treatment with four to seven day treatments, there was a trend towards
lower rates of bacteriuria clearance with the single-dose regimen [46].
An exception is single-dose fosfomycin, which successfully treats bacteriuria. In three trials

comparing this drug with other therapies administered for a longer time, eradication of the
organism was comparable (77 to 94 percent versus 68 to 94 percent with other agents) [47].
Uncertain role of follow-up testing — Up to 30 percent of women fail to clear asymptomatic

bacteriuria following a short course of therapy [1]. However, given the paucity of data, it is not
clear that there is any clinical benefit to performing a follow-up culture after an initial episode of
asymptomatic bacteriuria or retreating recurrent asymptomatic bacteriuria. Thus, we do not
recommend repeat urine culture following treatment for asymptomatic bacteriuria or repeat
treatment if asymptomatic bacteriuria is detected on repeat screening.
Statements from expert groups also highlight the uncertain value of repeat screening for
asymptomatic bacteriuria. The 2019 Infectious Diseases Society of America (IDSA) guidelines
reported that there is no direct evidence evaluating the benefit of repeated screening following
an initial episode of asymptomatic bacteriuria and that it is not known whether retreatment of
recurrent or persistent bacteriuria improves outcomes [2]. They also note insufficient evidence
evaluating the benefits or risks of prophylactic antimicrobial therapy for the duration of the
pregnancy to prevent recurrent asymptomatic bacteriuria. The American College of
Obstetricians and Gynecologists (ACOG) guidelines on perinatal care state that follow-up urine
culture after treatment of asymptomatic bacteriuria is recommended in the literature but
indicate that more data are needed to determine the effectiveness of this strategy [48].
ACUTE CYSTITIS
Clinical manifestations — Cystitis is a symptomatic infection of the bladder. The typical

symptoms of acute cystitis in the pregnant woman are the same as in nonpregnant women and
include the sudden onset of dysuria and urinary urgency and frequency. Hematuria and pyuria
are also frequently seen on urinalysis. (See "Acute simple cystitis in women", section on 'Clinical
manifestations'.)
Systemic symptoms, such as fevers and chills, are absent in acute cystitis ( table 2).
Diagnosis — Acute cystitis should be suspected in pregnant women who complain about

dysuria. Although urinary frequency and urgency are typical findings of acute cystitis, they are
also frequently a normal physiologic change of pregnancy and reported by pregnant women
without cystitis or bacteriuria [49,50]. The presence of fever and chills, flank pain, or
costovertebral angle tenderness should raise suspicion for pyelonephritis (see 'Acute
pyelonephritis' below). A urinalysis and urine culture should be performed in pregnant women
who have new onset dysuria. Specimen collection is the same as for asymptomatic bacteriuria.
(See 'Specimen collection' above.)
The diagnosis of acute cystitis is confirmed by finding of bacterial growth on urine culture. Prior
to confirming the diagnosis, empiric treatment is typically initiated in a patient with consistent
symptoms and pyuria on urinalysis (see 'Management' below). As in nonpregnant women,
pyuria is usually present in almost all pregnant women with symptomatic urinary tract
infection, and its absence strongly suggests an alternative diagnosis. (See "Sampling and
evaluation of voided urine in the diagnosis of urinary tract infection in adults", section on
'Interpretation of pyuria'.)
Studies defining the threshold of bacterial growth on voided urine that represents significant
bacteriuria in pregnant women have not been performed, but based on studies in nonpregnant
women, relatively low colony counts can reflect true bacteriuria in the presence of symptoms. In
nonpregnant women with acute simple cystitis, coliform colony counts in voided urine as low as
102 colony-forming units (cfu)/mL have been noted to reflect bladder infection [51-53]. As most
clinical laboratories do not routinely quantify urine isolates to 102 cfu/mL, it is reasonable to use
a quantitative count ≥103 cfu/mL in a symptomatic pregnant woman as an indicator of
symptomatic UTI. If bacteria that are not typical uropathogens (such as lactobacillus) are
isolated, the diagnosis of cystitis is typically made only if they are isolated in high bacterial
counts (≥105 cfu/mL). (See "Sampling and evaluation of voided urine in the diagnosis of urinary
tract infection in adults", section on 'Definition of a positive culture'.)
Differential diagnosis — As in nonpregnant women, dysuria in pregnant women can be a

result of other infectious and noninfectious processes, such as vaginitis or urethritis. Similarly,
urinary frequency and urgency may be symptoms of normal pregnancy in the absence of
urinary tract infection. However, true bacteriuria is typically not present in these settings and
thus distinguishes acute cystitis. If not already performed, testing for sexually transmitted
infections (such as chlamydia and gonorrhea) is warranted for pregnant women with dysuria
without bacteriuria or women who have persistent dysuria despite successful treatment of
bacteriuria. (See "Acute simple cystitis in women", section on 'Differential diagnosis'.)
Management
Antimicrobial treatment — Antibiotic treatment of acute cystitis in pregnant women is often

empiric, initiated at the time of complaints of dysuria, and then tailored to the susceptibility

pattern of the isolated organism once urine cultures return.
● Empiric regimen selection – For empiric therapy, we typically choose between

cefpodoxime, amoxicillin-clavulanate, and fosfomycin, given their safety in pregnancy and
the somewhat broader spectrum of activity compared with other agents (such as
amoxicillin or cephalexin) ( table 1). Nitrofurantoin and trimethoprim-sulfamethoxazole
are typically avoided during the first trimester (and also near term for trimethoprim-
sulfamethoxazole); however, overall evidence suggests that they are appropriate
alternatives, even during these periods, if other options cannot be used (eg, because of
drug allergy). This is consistent with a statement from ACOG [54]. The choice between the
options should be individualized on the basis of several factors, including prior
microbiological data, patient allergy history, local practice patterns, local community
resistance prevalence, availability, and cost [55]. Safety of antimicrobial agents used for
cystitis during pregnancy are discussed elsewhere. (See 'Antibiotic safety in pregnancy'
below.)
For women who are thought to be at risk for or have documented infection with extended-
spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, nitrofurantoin and
fosfomycin are active in vitro against many such strains and are potential oral options
[27,56].
Although there are limited data in pregnant women, a meta-analysis suggested that there
are no large differences in outcomes between different antibiotic regimens in terms of
cure rates, recurrent infection, incidence of preterm delivery, and the need for a change of
antibiotics [57]. All of the antibiotics studied were very effective and complications were
rare. There was not enough evidence to recommend a particular treatment scheme.
● Duration – The optimal duration of treatment for acute cystitis during pregnancy is
uncertain. As with asymptomatic bacteriuria, short courses of antibiotics are preferred, to
minimize the antimicrobial exposure to the fetus. Our approach depends on the agent
used and ranges from a single dose of fosfomycin to a three- to seven-day course for
other antibiotics ( table 1), as long as there are no symptoms suggestive of
pyelonephritis (eg, flank pain, nausea/vomiting, fever [>38°C], and/or costovertebral angle
tenderness). Based on data among nonpregnant individuals, there appear to be no
differences between short antibiotic courses (three to seven days) and longer ones
[1,55,58].
Follow-up — As long as symptoms have resolved with treatment, we do not routinely check a
follow-up culture. As above, the benefits of repeated screening and treatment of asymptomatic

bacteriuria are uncertain. (See 'Uncertain role of follow-up testing' above.)
If the initial urine culture isolate is resistant to the empirically selected agent and the patient
continues to have cystitis symptoms, we adjust the antibiotic regimen to target the pathogen.
For those whose symptoms have resolved, we do not routinely adjust the empiric antibiotic
regimen. However, there are no direct data informing the risks or benefits of this approach, and
other clinicians may reasonably opt to adjust the regimen in this setting.
Management of recurrent cystitis — The optimal approach to recurrent cystitis during

pregnancy is uncertain. For individuals who have three or more episodes of recurrent cystitis
during pregnancy, we favor antimicrobial prophylaxis for the duration of pregnancy to prevent
additional episodes. Other clinicians may reasonably opt to give prophylaxis following two
episodes of cystitis, particularly if the time to recurrence is short. Prophylaxis can be postcoital
if the cystitis is thought to be sexually related (which it commonly is) or continuous. There are
no data to guide whether treatment of isolated recurrent episodes or prophylaxis is a better
approach in terms of risks versus benefits.
The choice of antimicrobial used for prophylaxis should be based on the susceptibility profile of
the pathogens causing the cystitis. Ideally, daily or postcoital prophylaxis with low-dose
nitrofurantoin (50 to 100 mg orally postcoitally or at bedtime) or cephalexin (250 to 500 mg
orally postcoitally or at bedtime) can be used.
ACUTE PYELONEPHRITIS
Clinical manifestations — Acute pyelonephritis is a manifestation of infection of the upper

urinary tract and kidneys. The typical symptoms of acute pyelonephritis in the pregnant woman
are the same as in nonpregnant women and include fever (>38°C or 100.4°F), flank pain,
nausea, vomiting, and/or costovertebral angle tenderness. However, focal symptoms of
pyelonephritis (eg, flank pain) or of cystitis (eg, dysuria) are not always present. Pyuria is a
typical finding.
Most cases of pyelonephritis occur during the second and third trimesters. (See 'Incidence and
risk factors' above.)
Pregnant women may become quite ill and are at risk for both medical and obstetrical
complications from pyelonephritis. It has been estimated that as many as 20 percent of women
with severe pyelonephritis develop complications that include septic shock syndrome or its
variants, such as acute respiratory distress syndrome (ARDS) [59-61]. As an example, in a
prospective study of 440 cases of acute pyelonephritis identified among 32,282 pregnant
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women in a general obstetric population, complications included anemia (23 percent),

bacteremia (17 percent in the minority of patients who were tested), respiratory insufficiency (7
percent), and renal dysfunction (2 percent) [11]. The mechanism of anemia is not well
understood, but hemolysis, perhaps mediated by endotoxin, may be important [62]. Acute renal
failure associated with microabscesses and suppurative pyelonephritis has been described in
isolated cases, independent of sepsis [63]. (See "Acute kidney injury in pregnancy".)
Diagnosis and evaluation — Acute pyelonephritis is suggested by the presence of flank pain,

nausea/vomiting, fever (>38°C or 100.4°F), and/or costovertebral angle tenderness, with or
without the typical symptoms of cystitis, and is confirmed by the finding of bacteriuria in the
setting of these symptoms. (See "Acute simple cystitis in women".)
For pregnant women who present with such symptoms, we check a urinalysis and urine culture.
Pyuria is present in the majority of women with pyelonephritis, and its absence should prompt
consideration of an alternative diagnosis or complete obstruction. However, absence of pyuria
does not rule out UTI if symptoms and urine culture are consistent with the diagnosis. Although
many pregnant women have back or flank pain without pyelonephritis, we have a low threshold
for evaluation for bacteriuria and a diagnosis of pyelonephritis in pregnant women with these
symptoms, given the risk of complications and adverse pregnancy outcomes with untreated
pyelonephritis. (See 'Pregnancy outcomes' above.)
Some investigators have questioned the value of obtaining routine blood cultures in pregnant
women with pyelonephritis [64], and data on the impact of blood cultures on outcomes are
limited [65]. Although there is no evidence that bacteremia portends a worse prognosis or
requires longer therapy in an otherwise healthy pregnant woman with pyelonephritis, we
recommend obtaining blood cultures in those with signs of sepsis or serious underlying
medical conditions such as diabetes. Other tests, such as a serum lactate level, can also be
useful in women with suspected sepsis to inform the severity of disease [66].
Imaging is not routinely used to diagnose pyelonephritis. However, in patients with

pyelonephritis who are severely ill or who also have symptoms of renal colic or history of renal
stones, diabetes, history of prior urologic surgery, immunosuppression, repeated episodes of
pyelonephritis, or urosepsis, imaging of the kidneys can be helpful to evaluate for
complications. In pregnant women, renal ultrasound is the preferred imaging modality in order
to avoid contrast or radiation exposure.
Differential diagnosis — Nephrolithiasis can present with significant flank or back pain and
abnormal findings on the urinalysis, but fever is uncommon with uncomplicated stone disease.
This can also be distinguished from pyelonephritis by visualization of the stones on renal
ultrasound. (See "Kidney stones in adults: Diagnosis and acute management of suspected
nephrolithiasis".)
For pregnant women presenting with fever and/or flank or back pain, certain obstetric
complications are important to consider in the differential:
● Intraamniotic infection, with or without preterm labor, is an important diagnostic

consideration in pregnant women who have fever and abdominal pain. The following
features suggest intraamniotic infection over pyelonephritis: presentation with premature
rupture of membranes, uterine tenderness and/or foul odor of the amniotic fluid, and the
absence of bacteriuria. Other potential causes of fever and back or flank pain in the
absence of bacteriuria include other infections (eg, influenza, pneumonia, appendicitis).
(See "Intraamniotic infection (clinical chorioamnionitis)", section on 'Diagnosis'.)
● Placental abruption is a key differential diagnosis of acute back or abdominal pain during
pregnancy. Back pain is prominent with abruption when the placenta is on the posterior
wall of the uterus. Fever is absent and vaginal bleeding is classically present with
abruption, in contrast to pyelonephritis. The uterus is often firm and may be rigid and
tender in patients with abruption, but is usually soft in patients with pyelonephritis. Both
conditions can be associated with uterine contractions. If present, a retroplacental
hematoma on ultrasound supports the diagnosis of abruption. (See "Placental abruption:
Pathophysiology, clinical features, diagnosis, and consequences".)
Management
Site of care — Based upon the higher risk of complications in pregnant women, pyelonephritis
has traditionally been treated with hospitalization and intravenous antibiotics until the woman
is afebrile for 24 to 48 hours and symptomatically improved [67]. Initial outpatient therapy of
pregnant women with pyelonephritis has been attempted in carefully selected populations (eg,
no underlying serious medical conditions, renal or urologic abnormalities, pregnancy
complications, signs of sepsis, or recent antibiotic use). However, we suggest not initiating
therapy of pyelonephritis in pregnant women in the outpatient setting given the limited data
evaluating its safety and the need for close monitoring of the patient.
Evidence on the safety of outpatient initiation of pyelonephritis treatment during pregnancy is

limited to two trials by the same group [68,69]. Although the studies suggested that outpatient
treatment resulted in similar outcomes as inpatient management, several limitations of the
studies create uncertainty about the safety and practicality of outpatient management:
● In the first trial, 120 pregnant women with pyelonephritis prior to 24 weeks gestation were
randomly assigned to receive an outpatient regimen consisting of intramuscular
ceftriaxone for 2 days followed by oral cephalexin for 10 days or an inpatient regimen
consisting of IV cefazolin followed at discharge by oral cephalexin for 10 days [68]. Clinical
responses to therapy and birth outcomes were similar for both outpatients and inpatients.
However, six patients initially treated with ceftriaxone were ultimately admitted to the
hospital for intravenous therapy, and one woman developed septic shock during the
emergency department observation period. Of note, the outpatient regimen included
initial parenteral antibiotics, and home health nurses monitored patients assigned to the
outpatient strategy.
● In the second trial, 92 women who presented after 24 weeks gestation were hospitalized
for intramuscular ceftriaxone for 24 hours and then randomly assigned to early discharge
on oral cephalexin or continued hospitalization until afebrile for 48 hours [69]. Clinical
response and birth outcomes were similar for those who completed the assigned strategy.
However, 51 percent of patients either did not qualify for outpatient management based
upon study criteria or developed complications, which precluded early discharge from the
hospital.
Empiric antibiotics — Parenteral, broad spectrum beta-lactams (eg, ceftriaxone or

piperacillin-tazobactam) are the preferred antibiotics for initial empiric therapy of pyelonephritis
( table 3). The choice between them should be guided by local microbiology and susceptibility
data as well as expected patient tolerance. Fluoroquinolones and aminoglycosides, which are
often used for pyelonephritis in nonpregnant individuals, should be avoided in pregnancy if
possible. (See 'Antibiotic safety in pregnancy' below.)
The efficacy of beta-lactams was demonstrated in a randomized trial of 179 pregnant women
with acute pyelonephritis before the 24th week of gestation: intravenous cefazolin or
intramuscular ceftriaxone had equivalent efficacy to intravenous ampicillin plus gentamicin
[70]. Although rates of resistance to first generation cephalosporins have generally been less
than 10 percent in surveillance studies [71-74], beta-lactams (including first generation
cephalosporins) have been less effective than trimethoprim-sulfamethoxazole or the
fluoroquinolones for treatment of cystitis in studies of nonpregnant individuals [75]. Given
these data and the paucity of data evaluating narrow spectrum cephalosporins in the treatment
of pyelonephritis [75], we favor third generation cephalosporins over first or second generation
cephalosporins, such as cefazolin, for the empiric treatment of acute pyelonephritis.
For women with a history of infections with extended-spectrum beta-lactamase (ESBL)-

producing Enterobacteriaceae (or other risk factors), a carbapenem is an appropriate choice for
empiric therapy. Of note, some animal studies have shown adverse fetal effects with imipenem,
so meropenem and ertapenem are the preferred carbapenems for use during pregnancy. (See
'Antibiotic safety in pregnancy' below.)
Directed antibiotic therapy and follow-up — As with nonpregnant patients with

pyelonephritis, pregnant women generally have definite improvement within 24 to 48 hours of
appropriate antibiotic therapy. Once afebrile for 48 hours, pregnant patients can be switched to
oral therapy guided by culture susceptibility results and discharged; we typically suggest a total
of 7 to 10 days of treatment for patients who have had good clinical response. Data on
antibiotic duration for UTI in pregnancy are limited, but evidence in the general population
suggest that shorter durations (such as seven days) have comparable clinical outcomes as
longer ones. This is discussed elsewhere. (See "Acute complicated urinary tract infection
(including pyelonephritis) in adults", section on 'Directed antimicrobial therapy'.)
Oral options are mainly limited to beta-lactams or, if in the second trimester, trimethoprim-
sulfamethoxazole. Nitrofurantoin and fosfomycin are not appropriate for treatment of
pyelonephritis due to inadequate tissue levels. General principles regarding the safety of
antibiotics in pregnancy are discussed elsewhere. (See 'Antibiotic safety in pregnancy' below.)
If symptoms and fever persist beyond the first 24 to 48 hours of treatment, a repeat urine
culture and renal ultrasound should be performed to rule out persistent infection and urinary
tract pathology.
As discussed elsewhere, low-dose antimicrobial prophylaxis following an episode of

pyelonephritis is a reasonable option to prevent recurrent pyelonephritis (see 'Preventing
recurrence' below). For women who do not use antimicrobial prophylaxis, some clinicians
perform monthly urine cultures to evaluate for recurrent bacteriuria and treat as indicated
because of the risk of recurrent pyelonephritis. However, the utility of this practice is unclear.
Obstetric management — Pyelonephritis is not itself an indication for delivery. If induction of

labor or cesarean delivery for standard obstetrical indications is planned in a patient on
treatment for pyelonephritis, we favor waiting until the patient is afebrile, as long as delaying
the delivery is relatively safe for the mother and fetus.
Since pyelonephritis is associated with preterm birth, an important obstetric consideration is

whether tocolysis should be used when pyelonephritis triggers preterm labor at various
gestational ages. Tocolysis is typically not administered after 34 weeks gestation. If a woman
with pyelonephritis prior to that gestational age experiences preterm labor, administration of
tocolysis and steroids is reasonable to attempt to prolong the pregnancy. However, if the
patient is septic, tocolysis is generally avoided. Pregnant women with pyelonephritis are at
increased risk of pulmonary edema and acute respiratory distress syndrome (ARDS), which may
be exacerbated by administration of tocolysis with or without corticosteroids. Detailed
discussion of the benefits and risks of tocolysis for acute preterm labor are found elsewhere.
(See "Inhibition of acute preterm labor", section on 'Patient selection'.)
Preventing recurrence — Recurrent pyelonephritis during pregnancy occurs in 6 to 8 percent

of women [70,76,77]. As a result, after an initial episode of pyelonephritis, low-dose
antimicrobial preventive therapy with an agent to which the original organism is susceptible for
the remainder of the pregnancy is a reasonable strategy; but there are no randomized trials to
inform the optimal approach. If preventive therapy is utilized, reasonable options include
nitrofurantoin (50 to 100 mg orally at bedtime) or cephalexin (250 to 500 mg orally at bedtime)
[67,78].
For individuals who use preventive antibiotics following pyelonephritis, we do not perform
surveillance urine cultures to ensure effective prophylaxis; data informing this approach are
limited.
PREVENTION IN WOMEN WITH HISTORY OF RECURRENT UTI
A separate issue is the management of pregnant women with a history of recurrent urinary
tract infections (UTIs) prior to pregnancy, which is often related to sexual intercourse. It is
reasonable to use postcoital prophylaxis in pregnant women who have recurrent UTIs that
appear to be temporally related to sexual intercourse. The preferred regimen is a single
postcoital dose of either cephalexin (250 mg) or nitrofurantoin (50 mg). (See "Recurrent simple
cystitis in women", section on 'Initial approach to prevention'.)
The potential efficacy of postcoital prophylaxis to prevent UTIs during pregnancy was evaluated
in a report of 33 women with a history of recurrent UTIs who had 39 pregnancies [79]. The
women were treated with a single postcoital dose of either cephalexin (250 mg) or
nitrofurantoin (50 mg). Only one UTI occurred during pregnancy; this was in sharp contrast to
130 UTIs during a mean observation period of seven months before prophylaxis.
ANTIBIOTIC SAFETY IN PREGNANCY
Penicillins (with or without beta-lactamase inhibitors), cephalosporins, the carbapenems

meropenem and ertapenem, aztreonam, and fosfomycin are generally considered safe in
pregnancy [80]. Nitrofurantoin and trimethoprim-sulfamethoxazole are typically avoided during
the first trimester because of uncertain associations with congenital anomalies [8,81,82], and
trimethoprim-sulfamethoxazole is also often avoided near term because of a theoretical risk of

kernicterus; however, overall evidence suggests they are appropriate alternatives, even during
these periods, if other options cannot be used. Aminoglycosides have been associated with
ototoxicity following prolonged fetal exposure [83], and fluoroquinolones are generally not
used during pregnancy. Details on antibiotic safety during pregnancy are found elsewhere. (See
"Prenatal care: Patient education, health promotion, and safety of commonly used drugs",
section on 'Antibiotics'.)
Much of the information regarding the safe use of antibiotics during pregnancy was obtained
decades ago, before pregnant women were excluded from drug studies because of concerns
about risk to the fetus. Thus, there is little direct information about the safety of many newer
antibiotics (including many antibiotics that are used for UTI) in pregnancy, and concern about
the use of certain antibiotics generally arises from indirect evidence (eg, animal studies) or
observational studies that may have numerous confounders. Overall, the safest course is to use
the antibiotics that have well-established safety profiles in pregnancy and limit the use of
antibiotics of potential concern to cases in which no safer alternative exists.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Urinary tract infections
in adults" and "Society guideline links: Asymptomatic bacteriuria in adults".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Urinary tract infections in pregnancy (The Basics)")
● Beyond the Basics topics (see "Patient education: Urinary tract infections in adolescents
and adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Risk of bacteriuria – Bacteriuria is common during pregnancy. Without treatment, as

many as 30 to 40 percent with asymptomatic bacteriuria develop a symptomatic urinary
tract infection (UTI). The smooth muscle relaxation and ureteral dilatation that occurs in
pregnancy may facilitate the ascent of bacteria from the bladder to the kidney and
increase the risk of pyelonephritis. Additionally, untreated bacteriuria may be associated
with an increased risk of preterm birth, low birth weight, and perinatal mortality. (See
'Epidemiology' above and 'Pathogenesis' above.)
● Microbiology – As in nonpregnant women, Escherichia coli is the predominant

uropathogen found in both asymptomatic bacteriuria and UTI in pregnant women. (See
'Microbiology' above.)
● Asymptomatic bacteriuria
• Screening – We screen all pregnant women at least once for asymptomatic bacteriuria.
Screening for asymptomatic bacteriuria is performed at 12 to 16 weeks gestation with
a midstream urine for culture. The diagnosis is made by finding high-level bacterial
growth (≥105 colony-forming units [cfu]/mL) on urine culture in the absence of
symptoms consistent with UTI. (See 'Diagnosis' above.)
• Management – Management of asymptomatic bacteriuria in pregnant women

includes antibiotic therapy tailored to culture results, which reduces the risk of
subsequent pyelonephritis and is associated with improved pregnancy outcomes.
Potential options include beta-lactams, nitrofurantoin, and fosfomycin ( table 1). We
do not routinely perform follow-up culture to rescreen for asymptomatic bacteriuria.
(See 'Management' above.)
● Cystitis (bladder infection) – Acute cystitis should be suspected in pregnant women who
complain about new onset dysuria, frequency, or urgency. The diagnosis is made by
finding of bacterial growth on urine culture in this setting. Management of acute cystitis in
pregnant women includes empiric antibiotic therapy that is subsequently tailored to
culture results. Potential options for empiric and directed therapy include beta-lactams,
nitrofurantoin, and fosfomycin ( table 1). We do not routinely perform follow-up culture
to confirm sterilization of the urine. For those with recurrent cystitis, prophylactic or
suppressive antibiotics may be warranted in addition to retreatment. (See 'Acute cystitis'
above.)
● Pyelonephritis
• Clinical features and diagnosis – Acute pyelonephritis during pregnancy is suggested

by the presence of flank pain, nausea/vomiting, fever (>38°C), and/or costovertebral
angle tenderness, with or without the typical symptoms of cystitis, and is confirmed by
the finding of bacteriuria in the setting of these symptoms. Pregnant women may
become quite ill and are at risk for both medical (eg, sepsis, respiratory failure) and
obstetrical complications from pyelonephritis. (See 'Clinical manifestations' above and
'Diagnosis and evaluation' above.)
• Management – Management of acute pyelonephritis in pregnant women includes

hospital admission for parenteral antibiotics, preferably broad spectrum beta-lactams (
table 3). Antibiotic therapy can be converted to an oral regimen tailored to the
susceptibility profile of the isolated organism following clinical improvement. Oral
options are generally limited to beta-lactams or, if in the second trimester,
trimethoprim-sulfamethoxazole. Following the treatment course, preventive antibiotics
are a reasonable strategy for the remainder of the pregnancy to prevent recurrence.
(See 'Management' above.)
● Antibiotic safety – It is generally accepted that penicillins (with or without beta-lactamase

inhibitors), cephalosporins, aztreonam, and fosfomycin are safe in pregnancy. Because of
possible but uncertain associations with adverse birth outcomes, we generally avoid
nitrofurantoin during the first trimester and trimethoprim-sulfamethoxazole during the
first trimester and near term, but they are appropriate alternatives during those periods if
other options cannot be used. (See 'Antibiotic safety in pregnancy' above.)
Use of UpToDate is subject to the Terms of Use.
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Topic 8065 Version 61.0
GRAPHICS
Antibiotics for asymptomatic bacteriuria and cystitis in pregnancy
Antibiotic Dose Duration Notes
Nitrofurantoin 100 mg orally every 12 5 to 7 days Does not achieve

hours therapeutic levels in
the kidneys so should
not be used if
pyelonephritis is
suspected.
Typically avoided
during the first
trimester; however, it
is an appropriate
alternative during this
period when other
options cannot be
used.
Amoxicillin 500 mg orally every 8 5 to 7 days Resistance may limit its

hours or
utility among gram-
875 mg orally every 12 negative pathogens.
hours
Amoxicillin-clavulanate 500 mg orally every 8 5 to 7 days

hours or
875 mg orally every 12

hours
Cephalexin 250 to 500 mg orally 5 to 7 days

every 6 hours
Cefpodoxime 100 mg orally every 12 5 to 7 days

hours
Fosfomycin 3 g orally as single Does not achieve

dose therapeutic levels in
the kidneys so should
not be used if
pyelonephritis is
suspected.
Trimethoprim- 800/160 mg (1 double- 3 days Typically avoided

sulfamethoxazole strength tablet) every during the first
12 hours trimester and at term;
however, it is an
appropriate alternative
during these periods

when other options
cannot be used.
The durations listed in the table are based on data from studies conducted in both nonpregnant and
pregnant women.
Graphic 98083 Version 8.0
Our approach to categorizing UTI in adults and adolescents
Acute simple cystitis* Acute UTI that is presumed to be confined to the bladder
There are no signs or symptoms that suggest an upper tract or
systemic infection (refer to below)
Acute complicated UTI Acute UTI accompanied by signs or symptoms that suggest
extension of infection beyond the bladder:
Fever (>99.9°F/37.7°C)¶
Chills, rigors, significant fatigue or malaise beyond baseline, or
other features of systemic illness
Flank pain
Costovertebral angle tenderness
Pelvic or perineal pain in men
Special populations with Pregnant women

unique management Renal transplant recipients
considerations
We categorize UTI as either acute simple cystitis or acute complicated UTI based on the extent and
severity of infection. This categorization informs management and differs somewhat from other
conventions. Specifically, cystitis or pyelonephritis in a nonpregnant premenopausal woman without
underlying urologic abnormalities has traditionally been termed acute uncomplicated UTI, and
complicated UTI has been defined, for the purposes of treatment trials, as cystitis or pyelonephritis
in a patient with underlying urologic abnormalities or other significant comorbidities. Individuals
who do not fit into either category have often been treated as having a complicated UTI by default.
Rather than use this convention, we favor an approach to treatment based on the presumed extent
of infection and severity of illness. Patients categorized as having acute uncomplicated cystitis
according to traditional definitions would fall under the category of acute simple cystitis that we use
here.
UTI: urinary tract infection.
* We do not automatically consider patients with underlying urologic abnormalities (such as

nephrolithiasis, strictures, stents, or urinary diversions), immunocompromising conditions (such as
neutropenia or advanced HIV infection), or poorly controlled diabetes mellitus to have a complicated
UTI if they have no concerning symptoms for upper tract or systemic infection. However, such
patients can be at higher risk for more serious infection and have not traditionally been included in
studies evaluating the antibiotic regimens we typically use for acute simple cystitis. Thus, we follow
such patients more closely and/or have a low threshold to manage them as complicated UTI (eg, if
they have subtle symptoms other than those listed above that could be suggestive of more
extensive infection).
¶ This temperature threshold is not well defined and should be individualized, taking into account
baseline temperature, other potential contributors to an elevated temperature, and the risk of poor
outcomes should empiric antimicrobial therapy be inappropriate.
Parenteral regimens for empiric treatment of pyelonephritis in pregnancy
Antibiotic Dose, interval
Mild to moderate pyelonephritis
Ceftriaxone 1 g every 24 hours
Cefepime 1 g every 12 hours
Aztreonam* 1 g every 8 hours
Ampicillin 1-2 g every 6 hours
PLUS
Gentamicin¶ 1.5 mg/kg every 8 hours
Severe pyelonephritis with an impaired immune system and/or incomplete urinary

drainage
Piperacillin-tazobactam 3.375 g every 6 hours
Meropenem 1 g every 8 hours
Ertapenem 1 g every 24 hours
Doripenem 500 mg every 8 hours
Doses are for patients with normal renal function.
If methicillin-resistant S. aureus (MRSA) is known or suspected, see treatment regimens outlined

separately in topics addressing MRSA management.
* Alternative in the setting of beta lactam allergy.
¶ Aminoglycosides have been associated with fetal ototoxicity; this regimen should be used only if
intolerance precludes the use of less toxic agents.
Contributor Disclosures
Thomas M Hooton, MD Equity Ownership/Stock Options: Fimbrion Therapeutics [UTI
prevention];Sequoia Vaccines [UTI prevention].
Consultant/Advisory Boards: GlaxoSmithKline[UTI];Ocean
Spray [UTI];Sequoia Vaccines[UTI].
All of the relevant financial relationships listed have been
mitigated. Kalpana Gupta, MD, MPH Equity Ownership/Stock Options: Abbot[Antibacterials that could be
used for UTI];First Light Diagnostics [Rapid detection and antimicrobial testing of
infections];Pfizer[Antibacterials that could be used for UTI].
Grant/Research/Clinical Trial Support: Pfizer
[Staphylococcus aureus post-surgical infections].
Consultant/Advisory Boards: Glaxo-Smith Kline
[UTI];Qiagen [UTI];Spero Therapeutics [UTI];Utility Therapeutics [UTI].
All of the relevant financial
relationships listed have been mitigated. Stephen B Calderwood, MD Consultant/Advisory Boards: Day
Zero Diagnostics [Whole genome sequencing for microbial identification and determination of
antimicrobial susceptibility].
All of the relevant financial relationships listed have been mitigated. Charles J
Lockwood, MD, MHCM No relevant financial relationship(s) with ineligible companies to disclose. Allyson
Bloom, MD No relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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10/7/22, 16:26 Urinary tract infections and asymptomatic bacteriuria in pregnancy - UpToDate

Official reprint from UpToDate®

Urinary tract infections and asymptomatic bacteriuria in

Incidence and risk factors — The incidence of bacteriuria in pregnant women is approximately

Asymptomatic bacteriuria occurs in 2 to 7 percent of pregnant women [1,2]. It typically occurs

https://www-uptodate-com.ezproxy.umng.edu.co/contents/urinary-tract-infections-and-asymptomatic-bacteriuria-in-pregnancy/print?search=urinary tr… 1/30

Without treatment, as many as 20 to 35 percent of pregnant women with asymptomatic

Pregnancy outcomes — Many studies have described a correlation between maternal urinary

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As in nonpregnant women, E. coli is the predominant uropathogen found in both asymptomatic

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elsewhere. (See "Group B streptococcal infection in pregnant individuals", section on 'Urinary

As in other community-acquired infections, antimicrobial resistance is an increasing concern.

Diagnosis — The diagnosis of asymptomatic bacteriuria is made by finding high-level bacterial

Specimen collection — The diagnosis of asymptomatic bacteriuria should be based on culture

Diagnostic criteria — For asymptomatic women, bacteriuria is formally defined as two

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Rationale for treatment — Asymptomatic bacteriuria during pregnancy increases the risk of

Antimicrobial treatment — Asymptomatic bacteriuria is treated with an antibiotic tailored to

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as effective as slightly longer regimens [44-46]. As an example, in a meta-analysis of 13 studies

An exception is single-dose fosfomycin, which successfully treats bacteriuria. In three trials

Uncertain role of follow-up testing — Up to 30 percent of women fail to clear asymptomatic

Clinical manifestations — Cystitis is a symptomatic infection of the bladder. The typical

Diagnosis — Acute cystitis should be suspected in pregnant women who complain about

Differential diagnosis — As in nonpregnant women, dysuria in pregnant women can be a

Antimicrobial treatment — Antibiotic treatment of acute cystitis in pregnant women is often

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pattern of the isolated organism once urine cultures return.

● Empiric regimen selection – For empiric therapy, we typically choose between

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bacteriuria are uncertain. (See 'Uncertain role of follow-up testing' above.)

Management of recurrent cystitis — The optimal approach to recurrent cystitis during

Clinical manifestations — Acute pyelonephritis is a manifestation of infection of the upper

women in a general obstetric population, complications included anemia (23 percent),

Diagnosis and evaluation — Acute pyelonephritis is suggested by the presence of flank pain,

Imaging is not routinely used to diagnose pyelonephritis. However, in patients with

● Intraamniotic infection, with or without preterm labor, is an important diagnostic

Evidence on the safety of outpatient initiation of pyelonephritis treatment during pregnancy is

Empiric antibiotics — Parenteral, broad spectrum beta-lactams (eg, ceftriaxone or

For women with a history of infections with extended-spectrum beta-lactamase (ESBL)-

Directed antibiotic therapy and follow-up — As with nonpregnant patients with

As discussed elsewhere, low-dose antimicrobial prophylaxis following an episode of

Obstetric management — Pyelonephritis is not itself an indication for delivery. If induction of

Since pyelonephritis is associated with preterm birth, an important obstetric consideration is

Preventing recurrence — Recurrent pyelonephritis during pregnancy occurs in 6 to 8 percent

PREVENTION IN WOMEN WITH HISTORY OF RECURRENT UTI

ANTIBIOTIC SAFETY IN PREGNANCY

Penicillins (with or without beta-lactamase inhibitors), cephalosporins, the carbapenems

trimethoprim-sulfamethoxazole is also often avoided near term because of a theoretical risk of

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Risk of bacteriuria – Bacteriuria is common during pregnancy. Without treatment, as

● Microbiology – As in nonpregnant women, Escherichia coli is the predominant

• Management – Management of asymptomatic bacteriuria in pregnant women

• Clinical features and diagnosis – Acute pyelonephritis during pregnancy is suggested

• Management – Management of acute pyelonephritis in pregnant women includes

● Antibiotic safety – It is generally accepted that penicillins (with or without beta-lactamase

Use of UpToDate is subject to the Terms of Use.

Infect Dis 2019; 68:e83.

19. Romero R, Oyarzun E, Mazor M, et al. Meta-analysis of the relationship between

recommendation statement. Ann Intern Med 2008; 149:W20.