Dr. med. Dirk Manski



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Urinary tract infection in pregnancy

Review literature: (Chaliha and Stanton, 2002 ) (S3 Guidelines UTI of the DGU).

Epidemiology of urinary tract infections during pregnancy

The frequency of bacteriuria in the pregnancy is 4–7%, comparable to the rate of bacteriuria without pregnancy. Approximately 20–30% of pregnant women with bacteriuria develop acute pyelonephritis, especially in the third trimester.

Etiology of UTI in Pregnancy

Signs and Symptoms

Diagnostic Work-Up

Urine culture:

If possible, a mid-stream urine analysis and urine culture is recommended in pregnant women. Catheter specimen of urine should be avoided to prevent iatrogenic urinary tract infection. ≥105 CFU/ml (colony-forming units) in a clean midstream urine sample indicates a urinary tract infection (Kass, 2002). If urine culture reveals 103 to 104 CFU/ml of typical uropathogens, treatment is recommended in patients with symptoms for a urinary tract infection. Many guidelines recommend screening for bacteriuria (urine culture) in early pregnancy (12th–16th week). In order to avoid unnecessary antibiotic treatment, asymptomatic bacteriuria should be confirmed by a second urine sample. In case of history for recurrent urinary tract infections and vesicoureteral reflux, additional urine cultures should be obtained, even without symptoms. Some authors doubt the need for urine cultures in pregnancy without symptoms.

Sonography:

Abdominal sonography is done to exclude hydronephrosis or residual urine.

Laboratory tests:

Acute pyelonephritis leads to systemic inflammation (leukocytosis, CRP). Blood cultures should be obtained in case of high fever.

Obstetric evaluation

Pelvic examination and fetal heart rate. Exclusion of premature labor.

Treatment of Urinary Tract Infection in Pregnancy

Asymptomatic bacteriuria and acute cystitis:

Asymptomatic bacteriuria and acute cystitis in pregnancy should be treated with oral antibiotics. This reduces the risk for febrile pyelonephritis and probably also the risk of preterm births. After completion of antibiotic therapy, urine culture is repeated to demonstrate the eradication of the pathogen.

The following antibiotics may be used in pregnancy: Pivmecillinam, oral amoxicillin (possibly with clavulanic acid), oral cephalosporins and fosfomycin single dose. Significant differences in effectiveness or side effects are not known. The duration of treatment for asymptomatic bacteriuria is usually three days. The duration of treatment for acute cystitis is usually 3–7 days.

Acute pyelonephritis in pregnancy:

Hospitalization and intravenous antibiotics are necessary, if high fever or other symptoms prevent successful oral treatment. Antibiotics of first choice are cephalosporins of the second, third or fourth generation, e.g. Cefuroxime 1.5 g i.v. every 12 h, ceftriaxone 1–2 g i.v. every 24 h or cefotaxime 1–2 g i.v. every 12 hours. Treatment with ampicillin is an option, if urine culture demonstrates sensitivity. In severe pyelonephritis, cephalosporins or ampicillin might be combined with gentamicin.







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References

Chaliha und Stanton 2002 CHALIHA, C. ; STANTON, S. L.:
Urological problems in pregnancy.
In: BJU Int
89 (2002), Nr. 5, S. 469–76


S-3 Leitlinie Harnwegsinfektionen der DGU
Epidemiologie, Diagnostik, Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten
AWMF, 2010, Register-Nr. 043/044



  Deutsche Version: Harnwegsinfektionen in der Schwangerschaft