UTI in pregnancy (Diagnosis + Management).

Most common pathogens of UTI in pregnancy:

- E. Coli (most common 70-80%)
- Klebsiella
- Eneterobacter species
- Proteus species
- Group B streptococcus

Main investigations of UTI in pregnancy:

❖ Clean catch urine culture.
❖ Urine analysis.
❖ CBC, RFT, inflammatory markers, electrolytes. (ordered in case of pyelonephritis and
hospitalization).

1. Asymptomatic bacteriuria:
a. Symptomless, screening is performed at 12 to 16 weeks gestation or the first prenatal
visit with a urine culture.
b. Diagnosed by urine culture with isolation of the same bacterial strain counts of more
than or equal to 105 colony forming units (cfu)/ml in midstream clean catch urine
sample.
c. Management includes:
o Antibiotic therapy according to culture results (5-7 days).
o Follow-up cultures (a week after completion of therapy) to confirm sterilization
of the urine.

2. Acute cystitis:
a. Should be suspected in pregnant lady who complains of dysuria.
b. Diagnosed by:
o Symptoms of sudden onset of dysuria and urinary urgency and frequency with
associated suprapubic or low back pain.
o Urine analysis by presence of WBC ≥10 leukocytes/microL (Pyuria)
o Urine culture of midstream clean catch urine to identify the pathogen (no cut-off
point is needed)
c. Management:
o Start empiric antibiotic treatment immediately before the results of culture, then
change based on isolated organism once urine culture result return.
 o Fluid hydration
o Analgesia (if painful)
o Follow-up cultures (a week after completion of therapy) to confirm sterilization
of the urine.
o In case of recurrent cystitis: antimicrobial prophylaxis for the remaining of
pregnancy (low-dose nitrofurantoin or cephalexin daily).

3. Acute pyelonephritis:
a. Diagnosed by:
o Symptoms of flank pain, nausea/vomiting, fever (>38°C), chills, and/or
costovertebral angle tenderness, septic shock (dyspnea, confusion, rigors/V)
o Order CBC, electrolytes, inflammatory markers, RFT.
o Urine analysis by presence of WBC ≥10 leukocytes/microL (Pyuria), WBC casts.
o Urine culture of midstream clean catch urine to identify the pathogen (no cut-off
point is needed).
o Blood culture in patients with signs of sepsis or not responding to treatment.
o Ultrasound (in recurrent pyelonephritis, renal colic or history of renal stones,
sepsis)
b. Management:
o Hospital admission for parenteral antibiotics until patient improves and is
afebrile and stable for 24 to 48 hours, then switch to oral antibiotics for 10-14
days.
o Fluid hydration
o Analgesia, antipyretics.
o Suppressive therapy or antimicrobial prophylaxis for the remaining of pregnancy
(low-dose nitrofurantoin or cephalexin daily).

Antibiotics for UTI:

Oral AB Parenteral AB for pyelonephritis (B lactams)
B lactams (Amoxicillin, Augmentin) Cephalosporin IV
Nitrofurantoin Ceftriaxone IM
Cephalexin Cefazolin IV
Fosfomycin

Good luck!! You got this!

References:
https://www.uptodate.com/contents/urinary-tract-infections-and-asymptomatic-bacteriuria-
in-pregnancy
UTI in pregnancy lecture
Medscape.