Lower UTI in pregnancy presents with any of the following symptoms: frequency, urgency, dysuria, polyuria or suprapubic pain / tenderness. Fever, chills, rigors, and flank pain / tenderness are the hallmarks of upper UTI / pyelonephritis. Symptomatic UTI occurs in 17-20% of pregnancies, and is associated with pre-labour premature rupture of membranes (PPROM) and pre-term labour.
Always consider hospital admission for adults with upper UTI / pyelonephritis. Patients who are being managed in the community with acute pyelonephritis should be admitted to hospital if they have failed to respond to antibiotics within 24 hours.
Dipstick testing is only recommended in pregnant women with mild or ≤2 symptoms of UTI. In all pregnant women with symptoms of UTI send a MSSU for culture and sensitivities before starting empirical antibiotics.
A further MSSU should be obtained seven days after completion of antibiotic treatment as a test of cure. Routine monthly MSSUs are not required following an episode of symptomatic UTI in pregnancy.
Resistance rates to both nitrofurantoin and cefalexin in gram negative isolates from urines obtained in the Ayrshire Maternity Unit are low - <2% and 5% respectively.
Amoxicillin and vancomycin provide cover for enterococci only. Gram negatives like E. coli, which is the most common cause of UTI, are always resistant to vancomycin, and usually resistant to amoxicillin (65% resistance in urinary isolates from secondary care and 70% resistance in bloodstream isolates). Gentamicin resistance rates of urinary gram negatives in both secondary care urinary and bloodstream isolates are <10%.
Gentamicin should be avoided in patients with decompensated liver disease (jaundice, ascites, encephalopathy, variceal bleeding or hepato-renal syndrome). If the use of gentamicin is contraindicated, the agent should not simply be omitted, but an alternative regimen should be chosen. Gentamicin should not be used for >72 hours, due to the risk of ototoxicity associated with prolonged use. If no positive cultures are available to guide therapy at this point, an alternative empirical regimen can be discussed with an infection specialist.
Page last updated: March 2024