Antepartum Urinary Tract Infection
Four to 8% of pregnant women will develop asymptomatic bacteriuria, and 1-3% will develop symptomatic cystitis with
dysuria. Pyelonephritis develops in 25-30% of women with untreated bacteriuria.
I. Asymptomatic bacteriuria is diagnosed by prenatal urine culture screening, and it is defined as a colony count $105
organisms per milliliter. Patients with symptomatic cystitis should be treated with oral antibiotics without waiting for
urine culture results.
A. Approximately 80% of infections are caused by Escherichia coli; 10-15% are due to Klebsiella pneumonia or
Proteus species; 5% or less are caused by group B streptococci, enterococci, or staphylococci.
B. Antibiotic therapy
1. Cystitis or asymptomatic bacteriuria is treated for 3 days. A repeat culture is completed after therapy.
2. Nitrofurantoin monohydrate (Macrobid) 100 mg PO bid OR
3. Nitrofurantoin (Macrodantin) 100 mg PO qid OR
4. Amoxicillin 250-500 mg PO tid OR
5. Cephalexin (Keflex) 250-500 mg PO qid.
II. Pyelonephritis
A. In pregnancy, pyelonephritis can progress rapidly to septic shock and may cause preterm labor. Upper tract
urinary infections are associated with an increased incidence of fetal prematurity. Pyelonephritis is characterized
by fever, chills, nausea, uterine contractions, and dysuria.
B. Physical exam usually reveals fever and costovertebral angle tenderness.
C. The most common pathogens are Escherichia coli and Klebsiella pneumoniae.
D. Patients should be hospitalized for intravenous antibiotics and fluids. Pyelonephritis is treated with an intravenous
antibiotic regimen to which the infectious organism is sensitive for 7-10 days.
E. Cefazolin (Ancef) 1-2 gm IVPB q8h OR
F. Ampicillin 1 gm IVPB q4-6h AND
G. Gentamicin 2 mg/kg IVPB then 1.5 mg/kg IV q8h OR
H. Ampicillin/sulbactam (Unasyn) 1.5-3 gm IVPB q6h.
I. Bedrest in the semi Fowler’s position on the side opposite affected kidney may help to relieve the pain. Patients
with continued fever and pain for more than 48 to 72 hours may have a resistant organism, obstruction, perinephric
abscess, or an infected calculus or cyst.
J. Oral antibiotics are initiated once fever and pain have resolved for at least 24 hours.
1. Nitrofurantoin monohydrate (Macrobid) 100 mg PO bid x 7-10 days, then 100 mg PO qhs OR
2. Nitrofurantoin (Macrodantin) 100 mg PO qid x 7-10 days, then 100 mg PO qhs OR
3. Cephalexin (Keflex) 500 mg PO qid x 7-10 days OR
4. Amoxicillin, 250 mg tid; sulfisoxazole, 500 mg qid x 7-10 days
5. Contraindicated Antibiotics. Sulfonamides should not be used within four weeks of delivery because
kernicterus is a theoretical risk. Aminoglycosides should be used for only short periods because of fetal
ototoxicity and nephrotoxicity.
6. Nitrofurantoin and sulfonamides may cause hemolysis in patients with glucose 6-phosphate dehydrogenase
Antepartum Urinary Tract Infection
7. After successful therapy, cultures are rechecked monthly during pregnancy, and subsequent infections are
treated. Antibiotic prophylaxis is recommended for women with two or more bladder infections or one episode
of pyelonephritis during pregnancy. Reinfection is treated for 10 days, then low dose prophylaxis is initiated
until 2 weeks postpartum. Prophylactic therapy includes nitrofurantoin (Macrodantin), 100 mg at bedtime or
sulfisoxazole (Gantrisin) 0.5 gm bid.
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