II. Epidemiology

  1. Asymptomatic Bacteriuria in 2 to 7% of pregnancies
  2. Significant cause of Preterm Labor

III. Etiology

  1. Escherichia coli (most common)
  2. Klebsiella
  3. Proteus miribilis
  4. Pseudomonas aeruginosa
  5. Enterobacter
  6. Staphylococcus saprophyticus
  7. Enterococcus
  8. Group B Streptococcus

IV. History

  1. Dysuria
  2. Urinary Frequency
  3. Urinary Urgency
  4. Suprapubic Pain
  5. Symptoms suggestive of Pyelonephritis
    1. Flank pain
    2. Fever
    3. Nausea or Vomiting
  6. Past Medical History
    1. Kidney stones
    2. Cystitis
    3. Pyelonephritis
    4. Sickle Cell Trait
      1. Predisposes to Pyelonephritis

V. Signs of cystitis (Contrast with Pyelonephritis)

  1. Afebrile
  2. Suprapubic Pain
  3. No Costovertebral angle (CVA) tenderness

VI. Complications

  1. Pyelonephritis (20-40% of untreated bacteriuria)

VII. Labs

  1. Urinalysis
    1. Screen all women at first Prenatal Visit
    2. If negative, then screen later only for symptoms
  2. Urine Culture with Sensitivity
    1. Strongly consider Urinary Catheter specimen
      1. Indicated for recurrent mixed Bacterial species
    2. UTI or Asymptomatic Bacteriuria criteria
      1. Single Bacterial species >50,000 colonies
      2. Group B Streptococcus at any count

VIII. Management: Acute Cystitis and Asymptomatic Bacteriuria

  1. Antibiotic Course:
    1. Initial 10 days
    2. Recurrent 14-21 days
  2. Repeat Urine Culture one month after treatment
  3. Asymptomatic bacteruria found on repeat Urine Culture
    1. Confirm not vaginal contaminant
      1. Especially for mixed Bacterial flora
      2. Consider Urinary Catheter specimen
    2. Repeat Urine Culture monthly
    3. Treat with antibiotics for an additional 10 days
    4. Consider low dose prophylaxis to 2 weeks postpartum
      1. Indicated for 2 episodes Asymptomatic Bacteriuria
  4. First Line Antibiotics in Pregnancy
    1. Macrodantin 100 mg PO tid-qid (avoid after 38 weeks)
    2. Macrobid 100 mg PO bid (avoid after 38 weeks)
    3. Keflex (Cephalexin) 250 mg PO qid
    4. Ceftin (Cefuroxime) 125-250 mg PO bid
  5. Other agents with lower efficacy (60% against E. coli)
    1. Ampicillin 250-500 mg PO qid
    2. Amoxicillin 250-500 mg PO tid or
    3. Amoxicillin 3 grams PO for 1 dose
    4. Sufisoxazole (Gantrisin) 500-1000 mg PO qid

IX. Management: Urinary Tract Infection Prophylaxis

  1. Ampicillin 250 mg PO qhs
  2. Macrodantin 100 mg PO qhs (do not use after 38 weeks)
  3. Cephalexin (Keflex) 250 mg PO qhs
  4. Erythromycin 250 mg PO qhs

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