ACOG guideline update on managing UTIs in pregnancy:

UTI (urinary tract infection) is one of the most common perinatal complications. These infections range from ASB (asymptomatic bacteriuria) to symptomatic acute cystitis and, in the most severe form, pyelonephritis. Given the frequent occurrence of UTIs during pregnancy, the management of these infections is essential for pregnant women.

ASB

• A 5-7-day course of targeted antibiotics is recommended for the treatment of ASB with colony counts of ≥100,000 CFU/mL.

Acute cystitis

• Pregnant women with acute cystitis should receive treatment with a 5-7-day course of a targeted antibiotic. If empiric therapy is initiated before obtaining culture and sensitivity results, it is recommended to avoid Amoxicillin or Ampicillin regimens.
• A urine culture might be repeated 1-2 weeks after completing treatment for acute cystitis or considered only if symptoms recur.
• Following the treatment of a recurrent acute infection, antimicrobial urinary suppression might be initiated for the remainder of the pregnancy. It is preferable to utilise a lower single daily dose of an antibacterial drug to which the isolated bacterium was susceptible.

Antibiotic regimens for the treatment of ASB and acute cystitis

Drug	Dosage	Considerations
Nitrofurantoin	100 mg orally every 12 hours for 5-7 days	It can be used during the first trimester if no alternatives are available
Cephalexin*	250-500 mg orally every 6 hours for 5-7 days	-
Sulphamethoxazole-Trimethoprim	800/160 mg every 12 hours for 5-7 days	It can be used during the first trimester if no alternatives are available
	In areas with >20% resistance to Sulphamethoxazole -Trimethoprim, the treatment should not be initiated until culture results are available
Fosfomycin	3 g orally once	-
Amoxicillin*	500 mg orally every 8 hours for 5-7 days	It should not be initiated until culture results are available
	875 mg orally every 12 hours for 5-7 days
Amoxicillin-Clavulanate*	500 mg orally every 8 hours for 5-7 days	It should not be initiated until culture results are available
	875 mg orally every 12 hours for 5-7 days

*: For patients with a beta-lactam allergy, especially when other classes of antibiotics are not suitable, further investigation regarding the severity of allergic reactions is necessary. For patients at low risk for anaphylaxis, cephalosporins should be considered; however, individuals at high risk for anaphylaxis should be treated with an alternative regimen.

Pyelonephritis

• Pyelonephritis during pregnancy should initially be managed in the inpatient setting. Empiric antibiotic therapy should possess adequate renal tissue penetration and target the most likely pathogens. Antibiotic therapy should be adjusted as necessary according to urine culture and sensitivity results. Parenteral antibiotics should be continued until the patient shows clinical improvement. A total of 14 days of antibiotic therapy is recommended for patients.

Antibiotic regimens for the treatment of pyelonephritis

Drug	Dosage
Ampicillin + Gentamicin	2 g IV every 6 hours
	1.5 mg/kg IV every 8 hours 5 mg/kg IV every 24 hours
Ceftriaxone	1 g IV every 24 hours
Cefepime	1 g IV every 12 hours
Aztreonam (appropriate in patients with beta-lactam allergy)	1 g IV every 8-12 hours

• Suppressive therapy might be considered for the remainder of the pregnancy, similar to the approach for recurrent UTIs.

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