Lower urinary tract infections ( Lower UTI ) in pregnancy and asymptomatic bacteriuria of pregnancy in adults ( ≥ 16 years of age ) - Guideline for the management of in secondary care

Publication: 25/10/2013  --
Last review: 08/09/2017  
Next review: 08/09/2020  
Clinical Guideline
CURRENT 
ID: 3515 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
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Lower urinary tract infections in pregnancy and asymptomatic bacteriuria of pregnancy in adults (≥ 16 years of age)

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Summary
Lower urinary tract infections ( Lower UTI ) in pregnancy and asymptomatic bacteriuria of pregnancy in adults ( ≥ 16 years of age )

Lower urinary tract infections (lower UTIs/Cystitis)
Diagnosis

  • The diagnosis of a lower UTI (cystitis) is primarily based on symptoms and signs, principally dysuria and frequency.
  • On a urine dipstick test:
    • A positive nitrite test is good evidence of a UTI when combined with symptoms of a UTI.
    • If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely.

Empirical Therapy

  • Antimicrobial recommendations are given in Table 1.
  • In certain individual cases, including if recent antimicrobial therapy &/or previous bacteriology results available, an alternative empiric antimicrobial may be more suitable.
  • Always check previous urine microbiology results before prescribing empirical antibiotics.
  • If there are symptoms of upper UTI please see the upper UTI guideline. Upper UTI symptoms include fever, costovertebral angle tenderness, back pain or where the severity of infection is not in keeping with a lower urinary tract infection e.g. hypotension or evidence of a Systemic Inflammatory Response Syndrome (SIRS).

Table 1: Empirical antimicrobial therapy for suspected lower UTI in pregnancy

Trimester

Antibiotic

Duration

First trimester

Cefalexin electronic Medicines Compendium information on Cefalexin+1 500mg 8-hourly
or
Nitrofurantoin ξ2 50mg 6-hourly

3 days

Second and third trimester (excluding at term)

Trimethoprim * 200mg 12-hourly
or
Nitrofurantoin ξ2 50mg 6-hourly

3 days

At term

Trimethoprim * 200mg 12-hourly
or
Cefalexin electronic Medicines Compendium information on Cefalexin+1 500mg 8-hourly

3 days

+, *, ξ - See main guideline for notes
1Avoid in severe penicillin allergy
2Do not use nitrofurantoin liquid (due to costs). Seek advice from pharmacy and microbiology if this is a problem.

Asymptomatic bacteriuria of pregnancy

Diagnosis

  • A clinical diagnosis is not possible as this presentation is by definition asymptomatic.
  • All patients should be screened for asymptomatic bacteriuria of pregnancy at booking with a urine dipstick test. If positive for leucocytes or nitrites an MSU sample should be sent to microbiology for culture and sensitivity testing.
  • In patients with recurrent UTIs or who have had a pre-term pregnancy previously send an MSU sample to microbiology for culture and sensitivity testing.
  • MSU samples suggestive of asymptomatic bacteriuria of pregnancy should be repeated to confirm the diagnosis before treating. To confirm the diagnosis the same bacterial strain should be isolated on both the initial and repeat MSU.

Empirical therapy

  • Empirical therapy is not recommended. Susceptibility results should be available to guide therapy.

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Background

The urinary tract is exposed to bacteria from the environment e.g. E. coli from the bowel. These can ascend the urethra to the bladder. This may result in an infection of the urethra (urethritis) or bladder (cystitis). Both urethritis and cystitis are lower urinary tract infections (lower UTIs).

Aetiology [Evidence level B]1:

  • Over 95% of UTIs are caused by a single bacterial species.
  • The frequency of different species involved varies with the clinical setting, e.g. community or hospital acquisition.
  • The predominant organism in acute infection is Escherichia coli (75-85%).
  • Other relatively common pathogens include Proteus spp (which can be associated with renal stone formation), Klebsiella spp, and Enterococcus spp.
  • Staphylococcus saprophyticus accounts for 5-15% cases of cystitis in young women of sexually active age. S. saprophyticus is a coagulase negative staphylococcus.
  • Pseudomonas spp, Staphylococcus aureus and yeasts are uncommon causes of lower UTI.
  • Yeasts cultured in an MSU may suggest vaginal candidiasis.

Lower UTIs2

Classifications [Evidence level B]

  • Uncomplicated lower UTI: Lower UTI in a structurally normal urinary tract.
  • Complicated lower UTI: Lower UTI in the presence of functional or structural abnormalities of the genitourinary tract. These include the presence of a calculus, vesicoureteric reflux, reflux nephropathy, indwelling catheter, urinary obstruction; or recent instrumentation. It also includes infection in a patient with certain underlying host factors, such as immune system compromise or impaired renal function.
  • Lower UTI in Pregnancy is not classed as a complicated UTI in this guideline (although pregnancy is sometimes used as marker of complicated infection).

Natural history3

Acute cystitis occurs in approximately 1 to 2 percent of pregnant women. No correlation has been established between acute cystitis of pregnancy and increased risk of low birth weight, preterm delivery or pyelonephritis, perhaps because pregnant women with symptomatic urinary tract infection (UTI) usually receive treatment.

Asymptomatic bacteriuria of pregnancy4

Classifications [Evidence level B]

Bacteriuria is the presence of bacteria in the urine. It is common to find bacteria in the urine of people who do not have symptoms of a urinary tract infection. These people are said to have asymptomatic bacteriuria. Asymptomatic bacteriuria is not associated with adverse outcomes except in pregnancy. Therefore there is a specific medical condition called asymptomatic bacteriuria of pregnancy.

Natural History [Evidence level B]

  • Asymptomatic bacteriuria occurs in 2 to 7 percent of pregnancies, particularly in multiparous women, a similar prevalence as seen in non-pregnant women. The organisms are also similar in species and virulence factors in pregnant and non-pregnant women.
  • Asymptomatic bacteriuria often develops in the first month of pregnancy. 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.
  • As a result, asymptomatic bacteriuria during pregnancy has a greater propensity to progress to pyelonephritis (up to 40 percent) than in non-pregnant women.
  • Bacteriuria has been associated with an increased risk of upper UTI in pregnancy. Treatment of asymptomatic bacteriuria has been associated with a reduction in the progression of asymptomatic bacteriuria to pyelonephritis.

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Clinical Diagnosis

Lower UTI

Recommendation: The diagnosis of a lower UTI is primarily based on symptoms and signs.

Symptoms and signs to classify a UTI are [Evidence level B]5:

Lower UTI: Dysuria and frequency without other features e.g. fever, back pain, loin pain or systemic features of infection.

Upper UTI: Dysuria, frequency and fever with other features including rigors, back pain, costovertebral angle (loin) pain which is usually unilateral and may worsen on micturition, nausea, vomiting and diarrhoea. Dysuria and frequency are not present in all cases of upper UTI. [Evidence level C]

If there are symptoms of upper UTI please see the upper UTI guideline. Upper UTI symptoms include costovertebral angle tenderness, back pain or where the severity of infection is not in keeping with a lower urinary tract infection e.g. hypotension or evidence of a Systemic Inflammatory Response Syndrome (SIRS).

If vaginal itch and/or discharge are present, consider alternative diagnoses such as vulvovaginitis (usually secondary to Candida) or chlamydial infection [Evidence level B].

Asymptomatic bacteriuria of pregnancy

A clinical diagnosis is not possible as this presentation is by definition asymptomatic [Evidence level B].

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Severity Assessment

Recommendation: If a lower UTI is associated with systemic inflammatory response syndrome (SIRS) or severe sepsis please manage according to the upper UTI guideline.

Lower UTIs are not normally associated with SIRS [Evidence level B].

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Investigation

Recommendations:

Lower UTI

  • A urine dipstick test should be performed in patient in whom lower UTI is being considered. [Evidence level B]
  • On a urine dipstick test:
    • A positive nitrite test is good evidence of a UTI when combined with symptoms of a UTI.
    • If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely, with a negative predictive value ≥ 95%. [Evidence level B]
  • All patients with suspected lower UTI should have a urine sample sent for microbiological analysis except those where there is poor clinical evidence of a UTI and a negative urine dipstick result [Evidence level D].

Asymptomatic bacteriuria of pregnancy [Evidence level B]

  • All patients should be screened for asymptomatic bacteriuria of pregnancy at booking with a urine dipstick test. If positive for leucocytes or nitrites an MSU sample should be sent to microbiology for culture and sensitivity testing. See flowchart in Appendix 1.
  • In patients with recurrent UTIs or who have had a pre-term pregnancy previously send an MSU sample to microbiology for culture and sensitivity testing.
  • MSU samples suggestive of asymptomatic bacteriuria of pregnancy should be repeated to confirm the diagnosis (same bacterial strain isolated in the second sample) before treating.

Evidence review/justification for recommendations

Lower UTI6/7

Interpretation of microbiology results

The interpretation of microbiology investigations for UTIs is heavily dependent upon the pre-test probability i.e. the probability of infection based on the clinical examination and history. For example, where there is a high probability of infection based on the clinical history negative microbiology results do not exclude a diagnosis of urinary tract infection.

Urine dipstick testing [Evidence level B]

Near patient testing using a commercially available dipstick test is rapid and reliable. It has a good negative predictive value i.e. if all the results are negative it is unlikely a patient has a UTI.

Dipstick results that have been used in the assessment of UTI include nitrite, leukocyte esterase, blood and protein.

  • Nitrite is produced by the action of the bacterial enzyme nitrite reductase. If this test is positive it is good evidence of a UTI. This enzyme is not present in all bacteria therefore a negative result does not exclude a UTI.
  • Leucocyte esterase is detected if intact and lysed leucocytes are present. This enzyme indicates inflammation but inflammation may or may not be caused by infection. If this test is positive it is suggestive of, but does not confirm a UTI.
  • Blood and protein: haematuria and proteinuria can occur with UTIs, but are also present in many other conditions. Their presence in urine is not well associated with UTIs.

Interpreting the urine dipstick result

Urine samples can be easily contaminated at the time of sampling. It is not possible to know this at the time of sampling although it may be suggested by the patient’s ability to provide a clean catch MSU. Contamination may be indicated when the sample is analysed in the laboratory, by a mixed growth and/or the presence of epithelial cells. [Evidence level B]

Nitrite positive: Evidence of UTI when combined with symptoms of a UTI.

Leucocyte esterase positive: Possible UTI though other causes of inflammation equally as likely.

Blood and/or protein positive: Not diagnostic of a UTI.

If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely, with a negative predictive value ≥ 95. If negative, urine sample should only be sent for microbiological investigations if there is high clinical suspicion of urinary tract infection, or from patients at particular risk of urinary tract infection/asymptomatic bacteriuria.

Laboratory urinary analysis (including culture) [Evidence level B]

The interpretation of urine samples is heavily dependent upon the clinical details and the method of urine collection. For example, in the absence of urinary symptoms any growth of bacteria is likely to represent asymptomatic bacteriuria or contamination. Asymptomatic bacteriuria is not a disease entity outside pregnancy and normally requires no treatment.

In the microbiology laboratory urine samples may undergo the following tests:

  • White cell count
  • Red cell count
  • Epithelial cell count
  • Bacterial culture and identification
  • Antibiotic susceptibility testing

White cell count

  • A raised white cell count in urine is called a pyuria.
  • At LTHT we define pyuria as ≥ 104 leukocytes/mL of urine (>40 leukocytes/microlitre).
  • Pyuria can be present without UTI, but its presence does increase the probability that a UTI is present.
  • Causes of pyuria in the absence of detectable bacteriuria (“sterile pyuria”) commonly include concurrent antibiotics, the presence of a foreign body (e.g. catheter), urinary calculus or neoplasm, lower genital tract infections (including urethritis, such as caused by Chlamydia). Renal tract tuberculosis is a rare cause. Early morning urine specimen(s) for acid fast bacilli (AFB) investigations should NOT be sent solely on the basis of one urine sample with “sterile” pyuria.

Red cell count

  • A raised red cell count is called haematuria
  • At LTHT we define haematuria as >140 red cells/microlitre.
  • There are many causes of haematuria one of which includes infection. Haematuria is a poor indicator of bacterial infection.

Epithelial cells

  • Epithelial cells are found on the surface of internal and external body surfaces.
  • Types of epithelial cells found in urine samples include vaginal epithelial cells, urethral epithelial cells and bladder epithelial cells.
  • Epithelial cells from these different sites have different physical appearances. When microscopy of urine samples was performed manually it was possible to report the cell type.
  • If vaginal epithelial cells were seen this indicated the urine sample was contaminated by vaginal contents and so the results of the test were unreliable. This is because vaginal contents may contain white cells, red cells and bacteria.
  • Microscopy is now automated i.e. completed by machine. Automated microscopy cannot differentiate between the different types of epithelial cell. Therefore, when epithelial cells are reported it suggests there may be vaginal contamination but does not confirm it.

Bacterial count and culture

  • An estimate of the quantity of bacteria is made based on the number of bacteria growing on urine culture.
  • At LTHT we define a significant growth of bacteria as ≥105 colony forming units of pure growth/mL mid-stream specimen of urine (MSU). Urinary tract infections, principally lower UTIs, may be associated with lower bacterial counts.
  • Mixed growth from a midstream urine sample can occur e.g. E. coli and Enterococcus spp. This increases the probability that the sample is contaminated.
  • Patients with UTI often have a significant growth of bacteria. Bacterial counts below this level do not exclude the diagnosis of upper UTI.
  • Rapid transport and culture, or special measures to assure preservation of the sample are essential for reliable laboratory diagnosis.
  • Delays and storage at room temperature allow organisms to multiply which generates results that do not reflect the true clinical situation. Where delays in processing are unavoidable, refrigeration at 4°C or the use of a boric acid preservative is essential.
  • Over 95% of UTIs are caused by a single bacterial species.
  • The frequency of different species involved varies with the clinical setting, e.g. community or hospital acquisition.
  • The predominant organism in acute infection is Escherichia coli (75-85%).

Antibacterial susceptibility testing

Routine susceptibility testing of urines is standardised i.e. it is not different depending upon if a patient has upper or lower tract infection. Therefore not all antibiotics reported on urine culture results are suitable for the treatment of upper UTI. For example, Nitrofurantoin is suitable for the treatment of lower UTI but not upper UTI. The susceptibility testing completed and reported may be modified if clinical details provided by the requester reporting pregnancy.

Collecting urine sample(s) for Microbiology

  • Urine cultures are positive in around 90% of cases of lower UTI
  • Therefore for all suspected UTIs, if possible, a urine sample should be collected prior to starting empiric antimicrobial therapy.
  • The preferred sample is the mid-stream urine. This should be collected half way through urination preferably without interruption of flow to reduce contamination with urethral or peri-urethral flora.
  • Prior cleansing with water does not reduce contamination rates; and use of an antiseptic may lead to a false negative culture result.
  • For patients from whom a mid-stream urine specimen cannot be obtained, a clean-catch urine sample should be taken. After peri-urethral cleaning, the whole voided urine is collected into a sterile container; and a sample for examination is then taken from this.
  • For catheterised patients, the specimen should be obtained aseptically from a sample port in the catheter tubing. The specimen should not be taken from the collection bag.
  • The urine sample for Microbiology should normally be sent in a red-topped (boric acid containing) sterile universal container. Boric acid inhibits bacterial growth in the container post sample collection. The container should ideally be filled to the line as directed – a false negative culture result can occur with a small urine volume.

Blood cultures [Evidence level B]

Both upper and lower tract UTI are likely to have urinalysis which suggests UTI.

Where patients have sepsis blood cultures should be taken.

Non microbiological investigation

  • Blood tests:
  • C-reactive protein testing is not routinely required in patients unless the diagnosis of upper UTI is uncertain e.g. renal stones. In most patients response to therapy can be assessed by monitoring clinical signs and symptoms and the neutrophil count. In selected patients the CRP may be useful to assess response to therapy.
  • Radiological imaging of the urinary tract is not normally indicated in patients with lower UTI. In patients with recurrent lower UTIs (≥3 per annum or ≥2 per 6 months) or upper UTI renal ultrasound is recommended.

Urine appearance: Production of turbid urine is reported to have a sensitivity of 90% and a specificity of 66% for the presence of symptomatic bacteriuria. This means if a patient has clear urine it is unlikely they have a UTI, but does not exclude it. It also means many patients with turbid urine do not have a UTI. Turbid urine should not in itself be used to diagnose a UTI. [Evidence level B]

Asymptomatic bacteriuria of pregnancy [Evidence level B] 8

  • All patients should be screened for asymptomatic bacteriuria of pregnancy at booking with a urine dipstick test. If positive for leucocytes or nitrites an MSU sample should be sent.
  • MSU samples suggestive of asymptomatic bacteriuria of pregnancy should be repeated to confirm the diagnosis (same bacterial strain isolated in the second sample) before treating.
  • In patients with recurrent UTIs or who have had a pre-term pregnancy previously send an MSU sample to microbiology for culture and sensitivity testing.

Screening for asymptomatic bacteriuria

Screening for asymptomatic bacteriuria with urine dipsticks has an estimated sensitivity of 92%9. This sensitivity estimate is based on one study which compared urine dipsticks to two mid-stream urine samples. There are a number of studies which have compared the sensitivity of urine dipsticks to single mid-stream urine samples to estimate the sensitivity of dipsticks as a screen for asymptomatic bacteriuria. These studies estimate the sensitivity of urine dipsticks to be low at levels of 50-80%10. These estimates are low as using a single MSU sample to confirm asymptomatic bacteriuria is more likely to give a false positive result (the MSU result represents contamination), so underestimating the sensitivity of the urine dipstick. We therefore recommend patients should be screened for asymptomatic bacteriuria with urine dipsticks, and diagnosed using two MSU samples, as below. This recommendation is against a NICE recommendation which suggests MSU samples should be used to screen patients for asymptomatic bacteriuria. This has been declared by the trust as a NICE non-compliance,

Diagnosing asymptomatic bacteriuria

Asymptomatic bacteriuria is diagnosed by microbiological testing as there are no symptoms on which to make a diagnosis.

Asymptomatic bacteriuria is microbiologically diagnosed by confirming the growth of bacteria in the urine.

A growth of ≥104 bacteria/ml is a laboratory diagnosis of bacteriuria.

Asymptomatic bacteriuria may be associated with a normal or raised white cell count in the urine.

It is common for urines to be contaminated with uropathogens therefore a second urine demonstrating bacteriuria is required to confirm the diagnosis of asymptomatic bacteriuria. This proves the first sample did not represent contamination.

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Treatment
Non-Antimicrobial Treatment
None

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Empirical Antimicrobial Treatment

Lower Urinary Tract Infection in Pregnancy11/12

Antimicrobial recommendations are given in Table 1[Evidence level B-C]

In certain individual cases, including if recent antimicrobial therapy &/or previous bacteriology results available: an alternative empiric antimicrobial may be more suitable (consider discussing with Microbiology).

Empirical therapy

Table 1: Empirical antimicrobial therapy for suspected lower UTI in pregnancy

Trimester

Antibiotic

Duration

First trimester

Cefalexin electronic Medicines Compendium information on Cefalexin+1 500mg 8-hourly
or
Nitrofurantoin ξ2 50mg 6-hourly

3 days

Second and third trimester (excluding at term)

Trimethoprim * 200mg 12-hourly
or
Nitrofurantoin ξ2 50mg 6-hourly

3 days

At term

Trimethoprim * 200mg 12-hourly
or
Cefalexin electronic Medicines Compendium information on Cefalexin+1 500mg 8-hourly

3 days

1Avoid in severe penicillin allergy

2Do not use nitrofurantoin liquid (due to costs). Seek advice from pharmacy and microbiology if this is a problem.

*Trimethoprim should be avoided in women with a low folate status (i.e. women with established folic acid deficiency, low dietary intake or already on folate antagonists) unless also taking a folate supplement. For women with a normal folate status, short term use of Trimethoprim is unlikely to induce folate deficiency.

The use of Trimethoprim should be considered carefully in the first trimester and should not be first line however: “In women with normal folate status, short-term use of Trimethoprim is unlikely to induce folate deficiency. Note: women who are pregnant, or at risk of pregnancy, should be taking folic acid until week 12 of their pregnancy in order to prevent neural tube defects in the foetus.

However, the BNF cautions against the use of Trimethoprim in the first trimester of pregnancy because the manufacturers recommend that it not be used then. The manufacturer's information leaflet also advises against the use of Trimethoprim for women who are pregnant or planning to become pregnant.”

ξ Nitrofurantoin : significant placental transfer of Nitrofurantoin does not occur. Nitrofurantoin has not been associated with an increased risk of congenital malformations. Nitrofurantoin has been associated with haemolysis in people with glucose-6-phosphate dyhydrogenase (G6PD) deficiency. However, the risk seems very small because placental transfer is so low. There is only one reported case of haemolytic anaemia in a new-born whose mother was treated at term with Nitrofurantoin .

Avoid in patients with suspected or known glucose-6-phosphate dehydrogenase (G-6-PD) deficiency.

Avoid Nitrofurantoin in patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min.

+Cephalexin

Children have high rates of Clostridium difficile carriage e.g. 80% in <2 year olds. Pregnant women caring for children are therefore commonly exposed to C. difficile and the use of cephalosporins should be avoided where possible.

Some antimicrobials are contra-indicated in pregnancy – the British National Formulary (BNF) should be consulted, as required.

Asymptomatic bacteriuria of pregnancy13

A range of antibiotic regimens achieve cure of asymptomatic bacteriuria of pregnancy. There is insufficient data to show any particular antibiotic(s) have an advantage or comparing the efficacy of a three day vs. a seven day antimicrobial course in pregnancy [Evidence level B-C]

Most complications from asymptomatic bacteriuria occur late in pregnancy, and screening normally takes place in the first trimester. There is normally time to confirm the diagnosis with a second MSU before treating. On occasion it may not be possible to confirm the diagnosis and an individual decision is required to decide if treatment is indicated.

Table 2  Empirical antibiotic therapy for asymptomatic bacteriuria of pregnancy

Empirical treatment

Note

Not recommended

Empirical therapy is not recommended. Susceptibility results should be available.

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Directed Antimicrobial Treatment (when microbiology results are known)

Lower UTI in pregnancy and asymptomatic bacteriuria of pregnancy

Directed therapy

When susceptibility results are available, therapy can be directed by the culture and susceptibility results. Select from the following antibiotics which are listed in order of preference (Table 3).

Table 3: Directed antimicrobial therapy for lower UTI in pregnancy and asymptomatic bacteriuria of pregnancy.

 

Treatment

Note

1ST line

Amoxicillin electronic Medicines Compendium information on Amoxicillin PO 250mg 8-hourly

Avoid in penicillin allergy

2nd line

Nitrofurantoin PO 50mg 6-hourly

Avoid at term in pregnancy (>37 weeks)
Avoid in patients with suspected or known glucose-6-phosphate dehydrogenase (G-6-PD) deficiency.
Avoid Nitrofurantoin in patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min.
Do not use liquid (due to costs).

3rd line

Trimethoprim PO 200mg 12-hourly

Avoid in the first trimester and with folate deficiency.

4th line

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav PO 625mg 8-hourly

Avoid unless the recommended treatments are not indicated: C. difficile risk.
Avoid in penicillin allergy

5th line

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

Avoid unless the recommended treatments are not indicated: C. difficile risk.
Avoid if severe penicillin allergy

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Duration of Treatment

Lower urinary tract infection in pregnancy and asymptomatic bacteriuria of pregnancy [Evidence level B]

Durations are given in Table 4.

+, *, ξ - See main guideline for notes

1Avoid in severe penicillin allergy

Table 4: Durations of antibiotic therapy in lower urinary tract infection in pregnancy and asymptomatic bacteriuria of pregnancy

Treatment

Duration for primary treatment

Duration for failure of primary treatment

Trimethoprim *

3 days

7 days

Amoxicillin electronic Medicines Compendium information on Amoxicillin

3 days

7 days

Nitrofurantoin ξ

3 days

7 days

Cefalexin electronic Medicines Compendium information on Cefalexin1, +

3 days

7 days

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav

3 days

7 days

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Switch to oral agent(s)
See directed antimicrobial therapy above.

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Treatment Algorithm

Appendix 1: Flowchart for the Management of Urine Screening in Pregnancy

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Treatment Failure

Ensure appropriate microbiological investigation i.e. clean catch MSU.

Consider alternative diagnoses e.g. chlamydial infection, candida vaginitis (thrush).

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Referral Criteria

Consider a urological referral in patients with

  • Recurrent UTIs (≥3 per annum or ≥2 per 6 months) or who persistently fail to respond to appropriate treatment
  • Persistent haematuria
  • Features of urinary obstruction
  • Calculi
  • History of pyelonephritis or previous genito-urinary tract surgery.
  • Abnormality on renal imaging

Referral imaging

Patients meeting the criteria for urological referral should have urinary tract investigations completed prior to their specialist review. For women this normally includes a renal ultrasound.

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Provenance

Record: 3515
Objective:

Aims

  • To improve the diagnosis and management of lower urinary tract infections (lower UTIs) in pregnancy and asymptomatic bacteriuria of pregnancy in adults (≥ 16 years of age).

Objectives

  • To provide evidence-based recommendations for appropriate diagnosis and investigation of lower urinary tract infections in pregnancy and asymptomatic bacteriuria of pregnancy in adults (≥ 16 years of age).
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of lower urinary tract infections in pregnancy and asymptomatic bacteriuria of pregnancy in adults (≥ 16 years of age).
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of lower urinary tract infections in pregnancy and asymptomatic bacteriuria of pregnancy in adults (≥ 16 years of age).
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Lower urinary tract infections in pregnancy and asymptomatic bacteriuria of pregnancy

Target patient group: Adults (= 16 years of age)
Target professional group(s): Pharmacists
Secondary Care Doctors
Midwives
Adapted from:

Evidence base

Evidence base

  1. Echols RM, Tosiello RL, Haverstock DC, Tice AD. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Clin Infect Dis. 1999; 29(1):113.
  2. Johansen TE, Botto H, Cek M, Grabe M, Tenke P, Wagenlehner FM, Naber KG. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Int J Antimicrob Agents. 2011 Dec; 38 Suppl: 64-70.
  3. Gilstrap LC 3rd, Ramin SM. Urinary tract infections during pregnancy. Obstet Gynecol Clin North Am. 2001; 28(3):581.
  4. Delzell JE Jr, Lefevre ML. Urinary tract infections during pregnancy. Am Fam Physician. 2000;61(3):713
  5. Sobel J D and Kaye D. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R. (eds) Principles and Practice of Infectious Diseases 7th Edn 2009 875-905.
  6. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947404720
  7. SIGN Management of suspected bacterial urinary tract infection in adults A national clinical guideline July 2006]
  8. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; Infectious Diseases Society of America; American Society of Nephrology; American Geriatric Society. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1; 40(5):643-54.
  9. Robertson AW, Duff P. The nitrite and leukocyte esterase tests for the evaluation of asymptomatic bacteriuria in obstetricpatients. Obstet Gynecol 1988; 71(6 Pt 1):878-81.
  10. NICE Antenatal care: Routine care for the healthy pregnant woman. CG62. 2008.
  11. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1; 52(5):e103-20.
  12. BNF
  13. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1; 40(5):643-54.

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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