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Urinary Tract Infections
Asymptomatic bacteriuria (ASB)

ASB is defined as the presence of more than 100,000 colony forming units (CFU) per milliliter in 2 consecutive midstream clean-catch urine samples, OR a single specimen with one bacterial species isolated in a quantitative count of at least 100 CFUs per mL from a catheterized urine specimen [1].

  • Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive [2].

Bacteriuria may cause inflammation of the bladder leading to the clinical syndrome of cystitis (dysuria, frequency, urgency, and occasionally suprapubic pain) .

Treatment of Asymptomatic Bacteriuria (ASB) and Cystitis

Treatment of asymptomatic bacteriuria in pregnancy decreases the risk of subsequent pyelonephritis, frequency of low-birth-weight infants, and preterm delivery [7-9]

Escherichia coli and Klebsiella species are the primary pathogens in up to 90% of initial UTIs, and also account for most recurrent infections. Less common pathogens include Proteus mirabilis, Pseudomonas aeruginosa , Streptococcus agalacticae, and Staphylococcus saphrophyticus [3].

Treatment is usually started empirically based on the most likely pathogen and then adjusted as necessary when culture results return.

  • The duration of antimicrobial therapy should be 3–7 days [2] . Patients with diabetes may need longer treatment.
  • Periodic screening for recurrent bacteriuria should be undertaken following therapy [2]

Nitrofurantoin monohydrate/macrocrystals (Macrobid®):
Antiinfective

  • Treatment of ASB and cystitis due to Escherichia coli. Inactive against proteus and pseudomonas species.
    Not for use in systemic infection    .
         
         100 mg orally twice daily for 7 days.

Rare, but serious, complications of nitrofurantoin include pneumonitis or pulmonary reaction and hemolytic anemia in mothers with glucose-6-phosphate dehydrogenase deficiency [4] Because nitrofurantoin may also cause hemolytic anemia in the newborn infant,  use of nitrofurantoin is contraindicated at term (38-42 weeks gestation), during labor and delivery, or when the onset of labor is imminent

Avoid use in first trimester [10]


(100 mg opaque black and yellow capsules)

Nitrofurantoin macrocrystals (Macrodantin®):
Antiinfective

  • Treatment of ASB and cystitis due to Escherichia coli. Inactive against proteus and pseudomonas species.
    Not for use in systemic infection    .
       
         100 mg orally four times daily for 7 days.
     

  • Prevention of recurrent cystitis
            
         50 to 100 mg orally postcoitally OR at bedtime

Rare, but serious, complications of nitrofurantoin include pneumonitis or pulmonary reaction and hemolytic anemia in mothers with glucose-6-phosphate dehydrogenase deficiency [4] Because nitrofurantoin may also cause hemolytic anemia in the newborn infant,  use of nitrofurantoin is contraindicated at term (38-42 weeks gestation), during labor and delivery, or when the onset of labor is imminent.

Avoid use in first trimester [10]


(50 mg white capsules, 100 mg yellow capsules)


 

Cephalexin (Keflex®)
Antibiotic
  • Treatment of ASB and cystitis due to Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae, group B streptococci

          250 to 500 mg orally four times daily for 7 days.
  • Prevention of recurrent cystitis
            
         250 to 500 mg orally postcoitally OR at bedtime

(250 mg white and dark green capsules, 333 mg light green capsules, 500 mg light ant dark green capsules)            

Cefuroxime axetil (Ceftin®)
Antibiotic

  • Treatment of ASB and cystitis due to Escherichia coli and and Klebsiella pneumoniae

          250 mg orally two times daily for 7 days.

(250 and 500 mg blue oblong tablets)
    

Amoxicillin-clavulanate(Augmentin®)

Combination antibiotic and β-lactamase inhibitor

  • Treatment of ASB and cystitis caused by β-lactamase-producing strains of E. coli, Klebsiella spp., and Enterobacter spp.

    •      250 mg orally three times or 500 mg orally twice daily for seven days

(Tablets (white oval):
250 mg amoxicillin /125 mg clavulanic acid,
500 mg amoxicillin /125 mg clavulanic acid
875 mg amoxicillin /125 mg clavulanic acid
Chewable tablets:
125 mg amoxicillin/31.25 mg clavulanic acid,
200 mg amoxicillin/28.5 mg clavulanic acid,
250 mg amoxicillin/62.5 mg clavulanic acid,
400 mg amoxicillin/57 mg clavulanic acid
Powder for oral suspension:
125 mg amoxicillin/31.25 mg clavulanic acid/5 mL, 200 mg amoxicillin/28.5 mg clavulanic acid/5 mL,
250 mg amoxicillin/62.5 mg clavulanic acid per 5 mL,
400 mg amoxicillin/57 mg clavulanic acid per 5 mL
Augmentin ES-600
Powder for oral suspension: 600 mg amoxicillin/42.9 mg clavulanic acid per 5 mL )

    

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REFERENCES
1. Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infect Dis Clin North Am 2003;17:367-94

2. Nicolle LE,et al.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. Epub 2005 Feb 4. Erratum in: Clin Infect Dis. 2005 May 15;40(10):1556.  PMID: 15714408

3. Mittal P and Wing DA Urinary tract infections in pregnancy. Clin Perinatol 2005 Sep;323749-64. PMID: 16085031

4.  Gilstrap , 3rd , 3rdL.C., Ramin S.M.:Urinary tract infections during pregnancy.Obstet Gynecol Clin North Am;28. (3): 581-591.2001;

 

6. Systematic review of the safety of trimethoprim-sulfamethoxazole for prophylaxis in HIV-infected pregnant women: implications for resource-limited settings.AIDS Rev. 2006 Jan-Mar;8(1):24-36PMID:16736949
 

7. Smaill F. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev 2001;(2):CD000490.

8. Mittendorf R, Williams MA, Kass EH. Prevention of preterm delivery and low birth weight associated with asymptomatic bacteriuria. Clin Infect Dis 1992;14: 927-32. 

9. Romero R, Oyarzun E, Mazor M, Sirtori M, Hobbins JC, Bracken M. Meta-analysis of the relationship between asymptomatic bacteriuria and preterm delivery/low birth weight. Obstet Gynecol 1989;73:576-82.

10. American College of Obstetricians and Gynecologists. Sulfonamides, nitrofurantoin, and risk of birth defects. Committee Opinion No. 494. . Obstet Gynecol 2011;117:1484–5. PMID: 21606771

 

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