UTI IN PREGNANCY

OUTLINE
Introduction
Pathophysiology
Risk Factors
Asymptomatic Bacteriuria
Acute Cystitis
Acute Pyelonephritis
Antibiotic use in UTI in pregnancy
Interpretation of urinalysis
Recurrent UTI In Women
 Urinary tract infection
Most common infection in pregnancy
5 10% of pregnancy
Classified as
Asymptomatic bacteriuria
Symptomatic UTI
Acute cystitis
Acute pyelonephritis
 Pathophysiology
Urine is bacteriostatic to most local commensal bacteria and
this is thought to result from its relatively acidic pH, high
osmolality and high urea concentration.
In an anatomically normal urinary tract, sterility is maintained
by free antegrade flow through the ureteral and urethral valves
Infections result from ascending colonization of the urinary
tract, primarily by existing vaginal, perineal, and fecal flora
Various maternal physiologic and anatomic factors predispose
to ascending infection

 Pathophysiology
Bladder volume increases and detrusor tone decreases
Relaxation of ureteric smooth muscle induced by progesterone and
pressure from the expanding uterus result in ureteric dilatation. This
leads to increased urinary stasis, compromised ureteric valves and
vesicoureteric reflux
Immunocompromised
Short urethra - approximately 3-4 cm in females
Difficulty with hygiene due to a distended pregnant belly
Glycosuria and aminoaciduria and fall in urinary osmolality
Sexual activity - Intercourse can traumatise the urothelium of the distal
urethra
Urinary Tract Infections in Pregnancy, emedicine, updated may 2016
Review Urinary tract infection in pregnancy, Timothy McCormick, The Obstetrician & Gynaecologist, 2008;10:156162
 Aetiology
E coli is the most common (80-90%)
Other pathogens include the following
Klebsiella pneumoniae (5%)
Proteus mirabilis (5%)
Enterobacter species (3%)
Staphylococcus saprophyticus (2%)
Group B beta-hemolytic Streptococcus (GBS; 1%)
Proteus species (2%)

Urinary Tract Infections in Pregnancy, emedicine, updated may 2016

 Risk factors
Low socio-economic status
Sickle cell trait
Diabetes mellitus
Neurogenic bladder retention
History of previous urinary tract infections
Structural abnormality of urinary tract
Presence of renal stones

South Australian Perinatal Practice Guidelines urinary tract infections in pregnancy

 Complications
Maternal Fetal
Acute cystitis (30%) IUGR
Acute pyelonephritis IUD
(50%) Low birth weight
Hypertension Prematurity
Pre eclampsia
Anemia
Chorioamnionitis
KY Loh, N Sivalingam. Urinary tract infections in
pregnancy. http://www.ejournal.afpm.org.my
 Case 1
1. Mrs A, G2P1 at 10 week POA come for booking.
Your staff nurse refers to you for routine medical
check up
BP 110/70, PR 72
Urine dipstick
- glucose negative
- Protein +ve

How would you approach?

History
LMP
Sure of date
No known medical illness
Family history of hypertension
First pregnancy uneventful, SVD, BW 3 kg
No nausea or vomiting
No PV discharge / PV bleeding
No UTI symptoms
No fever
Physical examination
Pink
PA soft, non tender, UT not palpable
Thyroid, breast, lungs, heart examinations
unremarkable

What would you do next?

 Investigation
Ufeme nitrite - +, protein - +, wbc 10 15
wbc/hpf, rbc 0-1 rbc/hpf, cast - nil, bacteria - seen
FBC wbc 5, hb 12, mcv - , mch - , plt
HIV rapid test negative
ABO grouping O positive
VDRL

What is your impression?

Would you treat the patient? How?
 Asymptomatic bacteriuria
Definition
Persistent colonisation of the urinary tract by
significant numbers of bacteria in women without
urinary symptoms1
presence of a positive urine culture in an
asymptomatic person2

1.Review Urinary tract infection in pregnancy, Timothy McCormick, The Obstetrician & Gynaecologist,
2008;10:156162
2.CPG Management Of Urinary Tract Infections In Pregnancy. Institute Of Obstetricians And
Gynaecologists, Royal College Of Physicians Of Ireland And The Clinical Strategy And Programmes
Division, Health Service Executive
 Asymptomatic bacteriuria
Diagnostic criteria
2 consecutive voided urine specimen with isolation of the
same bacterial strain in quantitative count of 105 colony
forming units (cfu)/mL or a single catheterized urine
specimen with 1 bacterial species isolated in a quantitative
count of 102 cfu/mL

Nicolle LE, Bradley S, Colgan R et al (2005) Infectious diseases society of America guidelines for the
diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40: 64354
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
 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.
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016

The original criterion for diagnosing asymptomatic bacteriuria

was > 105 cfu/mL of a single uropathogen on two consecutive
clean catch samples, with a 95% probability that the woman
has true bacteriuria. The detection of > 10 5 cfu/mL in a single
voided midstream urine is accepted as a more practical and
adequate alternative, although there is only an 80% probability
the woman has true bacteriuria
Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. J. Schnarr and F. Smaill. Eur J
Clin Invest 2008; 38 (S2): 5057
 Screening
Women who are pregnant should be screened for
asymptomatic bacteriuria in the first trimester and treated,
if positive
Screening of asymptomatic bacteriuria should be advocated
as it is cost-effective if incidence >2%
Urine dipstick and urinalysis are commonly used for
screening
Although the test are cheap, easily available and rapid,
they have relatively poor predictive values and false
negative result
 The gold standard is still urine culture with it additional
value in identification of an appropriate antibiotic for
treatment using antibiotic sensitivity testing.

The limiting factor is high cost and delay in results (it take
24 to 48 hrs to culture the organism)

Therefore, it is recommended that physicians will have to

balance between cost effectiveness of the screening test
before deciding on it

KY Loh, N Sivalingam. Urinary tract infections in pregnancy. http://www.ejournal.afpm.org.my

In Malaysia, practically we screen patient by
Asking signs and symptoms of UTI at every visit
opportunity
Testing the urine using urine dipstick and
urinalysis

But how accurate of diagnosing and treating

asymptomatic bacteriuria based on urine dipstick
and urinalysis?
 Dipstick testing (LE or nitrate) is not sufficiently
sensitive to be used as a screening test. Urine
culture should be the investigation of choice.
A - Standard quantitative urine culture should
be performed routinely at first antenatal visit.
A - Confirm the presence of bacteriuria in
urine with a second urine culture.
A - Do not use dipstick testing to screen for
bacterial UTI at the first or subsequent
antenatal visits.

SIGN 2012
Urinalysis
Nitrites, leukocytes esterase UTI
Specificity of 97-100%
Sensitivity of only 25-67%

Urine dipstick test

Nitrites and LE UTI
Sensitivity of 50-92%
Specificity from 86 97%

Urinary Tract Infections in Pregnancy, emedicine, updated may 2016

References Screening Diagnosis Repeat Follow Up
Culture Post
Treatment
IDSA 2005 Urine culture @ Single urine Periodic
early pregnancy culture screening after
therapy for
recurrent
bacteriuria
USPSTF 2008 Urine culture @
12 16 wk GA
or first
antenatal visit
SIGN 88 2006 First antenatal Second urine 1/52 after Repeat urine
(updated JULY visit with urine culture completion culture at each
2012) culture antibiotic antenatal visit
SAPPG* revised Routine MSSU Quantitative 48 hrs after Repeat MSSU at
2013 at first visit MSSU culture completion every visit
treatment
CPG UTI in Urine culture at 1/52 after
pregnancy first antenatal completion
2015 visit, ideally @ treatment
12-16wk GA
NICE antenatal MSU culture
care for early in
uncomplicated pregnancy
 Technique
UTI: MSU With one hand, spread the labia
clean catch With the other hand, use a castile
soapmoistened towelette to
wipe the urethral meatus
downward toward the rectum,
then discard the towelette
Void the initial portion of the
bladder contents into the toilet
Catch the middle portion of the
bladder contents in the sterile
collection container, while
keeping the labia spread with the
first hand

Urinary Tract Infections in Pregnancy, emedicine, updated May 2016

 Management
Perineal hygiene
Avoid baths. Take shower
Wipe front-to-back after urinating or defecating
Wash hands before using the toilet
Use wash cloths to clean the perineum
Use liquid soap to prevent colonization from bar
soap
Clean the urethral meatus first when bathing

Urinary Tract Infections In Pregnancy, emedicine, Updated May 2016

 Treat asymptomatic bacteriuria detected during
pregnancy with an antibiotic . A recommendation
(SIGN 2012)
Ideally, asymptomatic bacteriuria should be
treated with antibiotic tailored to susceptibility
pattern of isolated organism. (UptoDate)
 Antibiotic
Preferred
Nitrofurantoin 50mg bd for 7 days or
Cefuroxime 250mg bd for 7 days

Alternative
Cephalexin 500mg bd for 7 days or
Amoxycillin/Clavulanate 625mg tds for 7 days

*Avoid trimethoprim and fluoroquinolones in

pregnancy
National antibiotic guideline 2014
 Case 2
Mr A, 34 years G2P1 at 14 wk GA complaint of
incomplete voiding, burning sensation during
urination x 3/7. She has no fever, no contraction
pain, FM is good.

What is your differential diagnosis?

Acute cystitis
Vaginitis
urethritis
 Case 2
On examination
Alert, consious
BP 119/72, PR 82
T 37.4 c
PA soft, non tender, UT not palpable, renal
punch negative bilaterally

What would you do next?

Investigations
FBC?
Urine dipstick?
Urine feme?
Urine C+S?
 Ufeme LE +2, Nitrite +

What is your diagnosis?

How do you manage this patient?

1. Drink plenty of water

2. Perineal hygiene
3. Take urine C+S before empirical antibiotic
4. T. Cefuroxime 250mg bd x 1/52
5. TCA 2/52 to review symptoms and urine culture

Would repeat culture post treatment?

 Acute Cystitis
Cystitis symptomatic infection of bladder
Signs & Symptoms
dysuria
Urgency
Frequency
Hematuria
Suprapubic discomfort
No evidence of systemic illness
* although frequency and urgency are typical finding in cystitis,
they are also frequently a normal physiological change of
pregnancy
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016

 Acute Cystitis
Diagnosis
- Symptomatic + pyuria (WBC/leukocytes) +
presence of 102 cfu/ml

In non-pregnant symptomatic patients, a colony

count of 102103 cfu/mL may indicate infection,
but this cut-off has not been evaluated for
symptomatic urinary tract infections in pregnancy
Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
 Acute Cystitis
Management
Empirical antibiotic then tailored to susceptibility pattern of isolated
organism once urine culture return

Preferred
Nitrofurantoin 50mg bd for 7 days or
Cefuroxime 250mg bd for 7 days

Alternative
Cephalexin 500mg bd for 7 days or
Amoxycillin/Clavulanate 625mg tds for 7 days

*Avoid trimethoprim in pregnancy

National Antibiotic guideline 2014
Follow up
Repeat urine C+S 1/52 after completion of
treatment
Repeat urine C+S monthly until completion of
pregnancy risk of persistent or recurrent
bacteriuria

Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
 Case 3
Mr A, G3P2 @ 30 wk POA
c/o fever and back pain x 3/7.
History of UTI at 26 wk POA. Treated with antibiotic
for 5/7.

On examination
Alert, tongue coated
BP 110/72, PR 96
Lungs clear, CVS DRNM
PA soft, tender at left illiac fossa, BS +ve, renal
punch positive at left side, negative at right side
 What investigation you would do?
FBC
UFEME
Urine C+S

What your next plan?

Put patient on IV NS
Refer for admission
 Acute pyelonephritis
Infection of upper urinary tract and kidney
Signs and symptoms
- Fever > 38c
- Flank pain
- Nausea
- Vomiting
- Costovertebral angle tenderness
Commonly occur during 2nd and 3rd trimester

Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
 Diagnosis
- Symptomatic + pyuria (WBC/leukocytes) + presence of
102 cfu/ml

Management
- Refer for admission
- Antibiotic
Preferred
Cefuroxime 750mg IV tds for 14 days
Alternative
Amoxycillin/Clavulanate 1.2gm IV tds for 14 days or
Ceftriaxone 1-2gm IV od for 14 days

National antibiotic guideline 2014

 Antibiotics In Pregnancy
Penicillin and cephalosporin can be used
regardless of its period
1st trimester
- Avoid nitrofurantoin fetal defect
- 2nd and 3rd trimester
- Nitrofurantoin can be used. Avoid during last
week of pregnancy risk of haemolytic anemia
>> neonatal jaundice and kernicterus
 Antibiotics in pregnancy
Avoid/contraindicated
- Trimethoprim/sulfonamide (FDA category C) folic acid antagonist, risk of
haemolytic anemia, jaundice and kernicterus
- Fluoroquinolone - fetal cartilage development disorders have been
reported in experimental animals, although not in human studies
- Aminoglycosides risk of ototocixity and neprotoxicity
- Tetracycline - transient suppression of bone growth and with staining of
developing teeth
1.Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems.
Arch Med Sci 1, February / 2015
2.Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. May 2016
3.Initial prenatal assessment and first-trimester prenatal care. UptoDate July 2016

Antibiotics in pregnancy

Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems.
Arch Med Sci 1, February / 2015
 UTI: Interpretation of
urinalysis
pH stone/infection/RTA
pH 4.5 - 8 Alkaline UTI urea splitting
organism/calcium oxalate/phosphate
SG 1.005 - 1.025 Acidic uric acid/cysytine calculi

Glucose - 130 mg/d SG urine concentration and hydration. If

< 1.005 = hyrated, > 1.025 = dehydration
Glucose (+) gluosuria/DM
Ketones None Ketone (+)uncontrolled diabetes, DKA,
severe exercise, starvation, vomiting
Nitrites Negative Nitrite (+) specific, not sensitive for UTI,
Urinary nitrates are converted to nitrites
LE Negative by bacteria in the urine. Negative does not
rule out UTI
Bilirubin Negative LE (+) = pyuria = UTI WBCs lyse
Bilirubin (+) liver disease/biliary
Uro Small amount obstruction

(0.5-1 mg/dL)
Uro excessive haemolysis/ liver disease
Blood (+) hematuria, hemoglobinuria,
myoglobinuria
Blood - 3 RBCs Protein - (+) stress, strenuous exercise,
pregnancy, kidney disease. May suggest
Protein - 150 mg/d UTI
 RBCs - 2 RBCs/hpf RBC -> 3RBC/hpf
WBC - > 5WBC/hpf
WBCs - 2-5 Epithelial cell
WBCs/hpf squamous/epithelial. Squamous
> 15 cells/hpf = contaminated
epithelial cells - 15-
20 epithelial cells/hpf
Casts 0-5 hyaline
casts/hpf
Crystals Occasionally
Bacteria None
Yeast - None positive tests for nitrites,
leukocyte esterase, and
bacteria is highly suggestive of
a urinary tract infection
Urinalysis. Emedicine.medscape.com. Dec 2015
Urinalysis: A Comprehensive Review. AAFP 2005
Dr Iskandar Firzada, Uti In Pregnancy. East Coast Maternal Ch
 REFERRAL

Recurrent UTI
Acute pyelonephritis

Perinatal care manual 3rd edition

 Recurrent UTI in women
Definition
2 UTIs in 6 months/ 3 UTIs in 12 months
Reinfection
- The same bacteria may be cultured in the urine 2 weeks after
initiating sensitivity-adjusted therapy
Relapse/persistent
- Recurrence with a different organism, the same organism in more
than 2 weeks after treatment, or a sterile intervening culture
Need to be diagnosed by urine culture
dason et al. CUAJVolume5No4Oct2011.indd
 Uncomplicated
- Healthy host in the absence of structural of
functional abnormalities of urinary tract

Complicated
 Risk factors
Frequency of sexual intercourse
Age at first UTI before 15 years old
Maternal history of UTI
New sex partners
Spermicide use
 Predisposing factors for complicated
UTI
Anatomic abnormality polycystic kidney disease, urethral
valves, VUR
Urinary tract obstruction bladder outlet obstruction,
congenital abnormality, ureteral or urethral stricture,
urolithisis
Voiding dysfunction cystocele, neurogenic bladder, pelvic
floor dysfunction, high post void residual, incontinence
Inatrogenic indwelling urinary catheter, intermittent
catheterization, nephrostomy tube, urethral stent
Immunosupression DM, renal transplant, pregnancy
 Indications for Further
Investigation
Prior urinary surgery or trauma
Gross hematuria after resolution of infection
Previous bladder or renal calculi
Obstructive symptoms (straining, weak stream, intermittentcy,
hesitancy), low urometry or high PVR
Urea splitting bacteria on culture (proteus, yersinia
Bacterialpersistence after sensitivity based therapy
Prior abdominopelvic malignancy
DM or otherwise immunocompromised
Pneumaturia, fecalturia, anaerobic bacteriuria or history of
divertivulits
Repeated pyelonephritis
Asymptomic microhematuria after resolution of infection
Investigations
 American College of Radiology ACR
Appropriateness Criteria

ACR 2011
 Management Preferred
Nitrofurantoin 50mg PO nocte
for 3 12 months
OR
Trimethoprim 100mg PO nocte
for 3 12 months
Alternative
Trimethoprim/Sulphamethoxazol
e 80/400mg PO nocte for 3 12
months
OR
Cephalexin250mgPO ON for 3
12 months

Postcoital prophylaxis (a single postcoital dose)

Trimethoprim/ Sulfamethoxazole 480mg PO as a single dose
OR
Ciprofloxacin 125mg PO as a single dose
During pregnancy:
Cephalexin 250mg PO as single dose
OR
Nitrofurantoin 50mg PO as single dose
National antibiotic guidelines 2014
 Indications for referral
Risk factors for complicated UTI are present
Surgically correctable cause of UTI is suspected
Diagnosis of UTI as a cause for recurrent lower
urinary tract symptoms is uncertain