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Cystitis / lower uti / asymptomatic bacteriuria during pregnancy

PRODIGY Quick Reference Guide
Asymptomatic bacteriuria and UTI in
Urinary tract infection (UTI) occurs when micro-
pregnant women
organisms infect the urine, urethra, bladder, or kidney.
Lower UTI refers to cystitis with or without urethritis.

This covers the management of bacteriuria in a pregnant woman with a Based on PRODIGY guidance last revised in July 2005. normal renal tract and normal renal function. How do I make the diagnosis?
• Asymptomatic bacteriuria — detected by routine screening with urine cultures. • Cystitis — dysuria, frequency, urgency, nocturia, haematuria, suprapubic discomfort and tenderness, and cloudy or foul smelling urine. Which investigations are recommended?
• For women with symptoms of acute cystitis: ƒ Send 'clean-catch, mid-stream urine' for culture ƒ If the clinical diagnosis is uncertain, dipstick the urine while culture results are awaited ƒ If nitrite and leucocyte esterase are both negative, UTI is unlikely; await culture results ƒ If nitrite or leucocyte esterase is positive, UTI is likely; treat with an antibiotic • To screen for asymptomatic bacteriuria — culture urine; the first antenatal visit is an appropriate time to arrange this. Urine dipstick tests should NOT be used to screen for bacteriuria. How should I treat asymptomatic bacteriuria?
• Treat for 7 days with an oral antibiotic according to results of sensitivity tests. • Antibiotics that are regarded as suitable for use in pregnancy include amoxicillin, cefalexin, nitrofurantoin (do not use near term) and trimethoprim (do not use if the woman is folate-deficient, has a predisposition to folate deficiency, or is taking another folate antagonist). How should I treat acute cystitis?
• If the diagnosis of cystitis is likely, treat with an oral antibiotic4 while awaiting culture results: ƒ Nitrofurantoin (do not use near term), or ƒ Trimethoprim (do not use if the woman is folate-deficient, has a predisposition to folate deficiency, or is taking another folate antagonist) • Review results of urine culture and treat for 7 days with an antibiotic that the pathogen is • Paracetamol is recommended for symptom relief. What follow up is recommended?
• Repeat the urine culture 1–2 weeks after completing the course of antibiotics. • After an episode of cystitis or asymptomatic bacteriuria — culture urine monthly until delivery. What other advice should I give?
• Increasing fluid intake is of unproven benefit and may aggravate symptoms. • Urine-alkalinizing agents are not recommended; in particular, sodium citrate should be avoided. When should I seek further advice or refer?
• If systemically unwell or if pyelonephritis is suspected — admit. • If Group B streptococcus is isolated — refer, as prophylactic antibiotics may be required during • If urine culture is still positive 1–2 weeks after treatment — refer. • If urinary tract infection recurs in pregnancy — refer for specialist advice with regard to Version 2, Issued in May 2006
For more information see the full textPatient information leaflets (PILs) are available at: www.prodigy.nhs.uk/PILs/index.asp
PRODIGY Quick Reference Guide
Asymptomatic bacteriuria and UTI in pregnant
Prescription details
First-line antibiotics for 7 days
Quantity
Take one tablet four times a day for 7 days. Take one capsule four times a day for 7 days. Take one capsule twice a day for 7 days. Analgesic/antipyretic: use when required
Quantity
Take one to two tablets every 4 to 6 hours when required for relief of pain or high temperature. Maximum of eight tablets in 24 hours. Take two tablets every 4 to 6 hours when required for relief of pain or high temperature. Maximum of eight tablets in 24 hours. For information on contraindications, cautions, drug interactions, and adverse effects see the British National Formulary (e Medicines Compendium (). Version 2, Issued in May 2006
For more information see the full text at: Patient information leaflets (PILs) are available at: www.prodigy.nhs.uk/PILs/index.asp
PRODIGY Quick Reference Guide
Asymptomatic bacteriuria and UTI in pregnant
Supporting information
Urine dipstick tests are the most widely used near-patient test for UTI, but cannot be relied on to definitely exclude or confirm a diagnosis of UTI. Urine culture provides the definitive diagnosis and guides antibiotic treatment. • A positive nitrite test indicates bacteriuria and therefore suggests UTI. Most urinary pathogens reduce nitrate to nitrite. However, a negative test does not rule out UTI because some pathogens do not produce nitrate reductase, and frequent urination (common in cystitis) reduces the time available for the enzyme to act. • Leucocyte esterase (LE) indicates pyuria and therefore suggests UTI. However, leucocytes can contaminate the specimen, and therefore a positive test does not make a diagnosis of UTI certain. A negative LE test does not rule out the diagnosis of UTI, since the test is insensitive, and pyuria is not always found in UTI. • Blood and protein are sometimes found in the urine when there is a UTI, but their presence or absence does not help in making the diagnosis. [Hurlbut and Littenberg, 1991; Lammers et al, 2001] Treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis, pre-term delivery, and low birthweight. A Cochrane review found that treatment reduces the incidence of pyelonephritis (NNT = 7, CI 6 to 9). It also found some evidence that treatment reduces the incidence of pre-term delivery and low birthweight [Smaill, 2001]. A Cochrane review found insufficient evidence to assess the effects of different durations of treatment for asymptomatic bacteriuria in pregnancy [Villar et al, 2001]. Shorter courses of antimicrobials are therefore not recommended. Trimethoprim can be used to treat acute infections during pregnancy [Cattell, 1997; National Teratology Information Service, personal communication, 2001]. It should be avoided if the woman has a known folate deficiency, has a predisposition to folate deficiency, or is taking another folate antagonist. Nitrofurantoin can also be used during pregnancy (unless the mother is G6PD-deficient), but should be stopped before term as it can cause haemolysis in a G6PD-deficient infant. Cefalexin is not associated with any increased risk to the fetus and is effective against most urinary pathogens. Penicillins are safe in pregnancy, but are associated with a high incidence of bacterial resistance and should not be used without laboratory confirmation of sensitivity. At least 7 days of antimicrobials is recommended; a Cochrane review found insufficient evidence to favour a shorter regime [Vazquez and Villar, 2001]. Increasing fluid intake is common advice but is controversial and unproven. Theoretically it might help to ‘wash out’ the bladder, but it can distress people with dysuria [Dawson and Whitfield, 1996; Jepson et al, 2000]. Urine-alkalinizing agents, such as potassium citrate, sodium citrate, and sodium bicarbonate are popular remedies for urinary symptoms in women. However, these preparations are of unproven benefit and there is some evidence to doubt their efficacy [Brumfitt et al, 1990]. Sodium citrate should be avoided in pregnancy because of the high sodium content. If symptoms return, seek specialist advice. Prophylactic treatment with nitrofurantoin for the remainder of the pregnancy is usually recommended, although it should be stopped before term. For the bibliography see the full text: Version 2, Issued in May 2006
For more information see the full text at: Patient information leaflets (PILs) are available at: www.prodigy.nhs.uk/PILs/index.asp

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