Review Question - QID 108573

This patient has asymptomatic bacteriuria in pregnancy. The next best step in management is to treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery.

If a pregnant woman has had multiple UTIs and/or episodes of asymptomatic bacteriuria, she should continue antibiotic therapy for the duration of her pregnancy to prevent recurrence and possible progression to pyelonephritis. In general, a 7-10 days of a course of oral nitrofurantoin is the treatment of choice in pregnancy and can be continued as prophylaxis though cephalexin and ampicillin are also acceptable choices. Screening urinalysis is not recommended for the general population but should be performed in pregnant women. This population is at increased risk of ascending urinary tract infections (UTIs) due to ureteral smooth muscle relaxation from increased progesterone. E. coli, enterobacteraceae, and group B streptococcus are the most common organisms. This patient’s diabetes further predisposes her to bacteriuria and UTI. A follow-up urine culture should be obtained as a test of cure. Treatment and prophylaxis (if needed) decrease the risk of preterm delivery and low birth weight.

Incorrect Answers:
Answer 1: No treatment is needed for asymptomatic bacteriuria in the general population. However, pregnant women are at increased risk of ascending UTIs and pyelonephritis and should be treated with antimicrobials.

Answer 2: Admission to the hospital and intravenous ceftriaxone would be appropriate for the treatment of acute pyelonephritis. If this patient had signs and symptom of pyelonephritis, such as fever, chills, and flank pain, pyelonephritis would be the likely diagnosis and warrant this course of treatment.

Answer 3: Trimethoprim-sulfamethoxazole is an option for treating bacteruria and UTI in pregnancy. However, it is considered Pregnancy Category C (no adequate well-controlled studies in pregnant women) and has been linked to congenital malformation (neural tube defects, cleft palate, etc.) in the first trimester and kernicterus in the third trimester. It should therefore be avoided in this patient.

Answer 4: Oral nitrofurantoin is first-line for treatment of bacteriuria and UTI in pregnancy. However, this patient has already been treated twice but has persistent bacteriuria. At this point, prophylaxis with continuous nitrofurantoin therapy until delivery is indicated to prevent recurrence and progression of infection.

Bullet Summary:
Both UTI and asymptomatic bacteriuria in pregnancy should be treated with nitrofurantoin, ampicillin, or cephalexin. Recurrent UTI and/or asymptomatic bacteriuria should be treated with antimicrobial prophylaxis (i.e., nitrofurantoin) for the duration of the pregnancy.