Recurrent bacteriuria in pregnancy is common and a serious cause of maternal and perinatal morbidity and mortality. Clinical presentations include asymptomatic bacteriuria, acute cystitis and pyelonephritis.

1. RECURRENT UTI:
A CLINICIAN’S PERSPECTIVE

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. INTRODUCTION
• URINARY TRACT INFECTIONS are the most
common bacterial infections during pregnancy. *
• It can occur as : Asymptomatic Bacteriuria
: Acute Cystitis
: Acute Pyelonephritis
* Williams Obstetrics, 24th Edition, p.2213 (Chapter 53)

4. INTRODUCTION
• Recurrent UTI may be defined as 3 or more UTIs in
pregnancy.
• Recurrent UTIs occur due to bacterial reinfection or
bacterial persistence.
• Persistence involves the same bacteria not being
eradicated in the urine 2 weeks after sensitivity-adjusted
treatment.
• A reinfection is a recurrence with a different organism,
the same organism in more than 2 weeks, or a sterile
intervening culture.

5. EPIDEMIOLOGY
• Asymptomatic Bacteriuria 10–13%
• Acute Cystitis 1 – 4 %
• Acute Pyelonephritis 0.5% - 2%
• Though, incidence of bacteriuria in pregnant
women is only slightly higher than non
pregnant women, the chances of progression to
pyelonephritis is significantly higher i.e. 40%*
• The rate of recurrence has not been calculated
by any RCT or major study.
* Cochrane Database Syst Rev. 2015;

6. WHY UTI IS MORE COMMON IN
PREGNANCY?
The answer lies in the physiological changes occurring
in the Urinary Tract during pregnancy ?

7. PHYSIOLOGICAL CHANGES IN KIDNEYS
• Kidney size increases approximately by 1.5 cm .
• There is dilatation of renal calyces giving a
Hydronephrosis like picture. It may cause urinary
stasis , thus increasing the risk of pyelonephritis.
• There is increase in GFR and Renal flow rate.
These changes affects the pharmacokinetics of the
drugs used in treatment.

8. PHYSIOLOGICAL CHANGES IN URETERS
• Growing uterus compresses and Laterally
displaces the Ureters at Pelvic Brim.
• Ureteral compression and effects of
progesterone causes significant Ureteral
lengthening , dilatation and kinking.
• These structural changes may give rise to
hydroureter and sometimes obstructive
nephropathy, increasing the risk of infections.

9. PHYSIOLOGICAL CHANGES IN BLADDER
• Due to persistent pressure of gravid uterus on
the bladder, there is marked thickening of
bladder trigone.
• There is also increases in bladder pressure from
8 to 20 cm of water.
• Due to above reasons, there is significant Vesico
ureteral refluxes during pregnancy, causing
ascending Urinary tract infections

11. OTHER RISK FACTORS FOR RECURRENCE
• Pre-pregnancy history of UTI
• Lower socioeconomic status
• Sexual activity
• Older age
• Multiparity
• Anatomical urinary tract abnormalities
• Sickle cell disease
• Diabetes

12. MOST IMPORTANT RISK FACTORS
A large retrospective analysis with logistic regression modelling, embracing
8037 women from North Carolina, revealed that the two strongest predictors
of bacteriuria at prenatal care at prenatal care initiation were: UTI prior to
prenatal care initiation and a pre-pregnancy history of UTI.

13. SCREENING METHODS
• Urine routine and microscopy (practised in our
setup due to the huge patient load).
• Leukocyte esterase-nitrite dipstick are when the
prevalence is 2 percent or less.
• Dipstick culture technique
• Urine culture sensitivity.(Gold Standard)

14. Leukocyte esterase-nitrite dipstick

15. MICROBIOLOGY
• Escherichia coli (63–85%)
• Klebsiella pneumoniae (∼8%)
• Coagulase-negative Staphylococcus (up to 15%)
• S. aureus (up to 8%)
• Group B streptococci (GBS) (2–7%).

16. CLINICAL PRESENTATION
• The most common form recurrent UTI is
recurrent or persistent Asymptomatic
Bacteriuria.
• However, it may also present as Acute
Cystitis or Acute Pyelonephritis after an
untreated primary Asymptomatic
Bacteriuria.

17. ASYMPTOMATIC BACTERIURIA:
DEFINITION
According to recommendations developed by the IDSA
(Infectious Diseases Society of America), significant
bacteriuria in asymptomatic women is defined as
• Bacterial monoculture in the quantity of ≥
105 colony-forming units (CFU) per ml in two
consecutive mid-stream clean-catch urine specimens
• Or ≥ 102 CFU/ml in urine collected from single
urinary bladder catheterization

18. ASYMPTOMATIC BACTERIURIA:
SCREENING
• American Academy of Paediatrics and the American College of
Obstetricians and Gynaecologists (2012), as well as a U.S.
Preventive Services Task Force (2008), recommend screening
for bacteriuria at the first prenatal visit or at 12 weeks,
whichever is earlier.

19. ASYMPTOMATIC BACTERIURIA:
SIGNIFICANCE
• If asymptomatic bacteriuria is not
treated, approximately 40 percent of
infected women will develop
symptomatic infection during
pregnancy.

20. ACUTE CYSTITIS
• Acute cystitis affects
approximately 1% of all pregnant
women.
• Acute cystitis in pregnancy almost
always result from ascending
infection in long standing
asymptomatic bacteriuria.

21. SYMPTOMS OF ACUTE CYSTITIS
• Dysuria
• Frequency
• Urgency
• Suprapubic pain in the absence of systemic illness
• Haematuria
• Lower urinary tract symptoms with pyuria accompanied by a
sterile urine culture may be from urethritis caused by
Chlamydia trachomatis.

22. ACUTE PYELONEPHRITIS
• It is the most common serious medical
complication of pregnancy.
• Pyelonephritis was the leading cause of
septic shock during pregnancy.*
• Pyelonephritis is unilateral and right-sided
in more than half of cases, and it is bilateral
in a fourth of cases.
* Snyder CC, Barton JR, Habli M, et al: Severe sepsis and septic shock in pregnancy: indications for
delivery and maternal and perinatal outcomes. J Matern Fetal Neonatal Med 26(5):503, 2013

23. SIGN AND SYMPTOMS
• Abrupt onset with fever, shaking chills
• Aching pain in one or both lumbar regions
• Anorexia
• Nausea, and vomiting
• Tenderness elicited at costovertebral angles

24. MICROORGANISM IN ACUTE
PYELONEPHRITIS
• E coli 70 to 80 %,
• Klebsiella pneumoniae 3 to 5 %
• Enterobacter or Proteus 3 to 5%
• Gram-positive organisms, including
group B Streptococcus and S
aureus10%

25. ACUTE PYELONEPHRITIS: DIAGNOSIS
• The diagnostic gold standard in pyelonephritis
is renal biopsy but this is impractical in clinical
practice.
• A combination of symptoms, full blood count,
inflammatory markers, renal function tests,
blood culture, urine culture and sensitivity
testing are used.

26. ACUTE PYELONEPHRITIS: MEDICAL
COMPLICATIONS
• Endotoxin-induced alveolar injury are
manifest in up to 10 %of women and may
result in frank pulmonary oedema. It may be
severe enough to cause ARDS (Acute
Respiratory Distress Syndrome)
• Endotoxin also causes Haemolysis, also
causes Anaemia 23%.
• Bacteraemia is demonstrated in 15 to 20 %.
• Transient renal dysfunction (2%).

27. ACUTE PYELONEPHRITIS: OBSTETRICS
COMPLICATION
• Preterm labour
• Pre eclampsia
• Chorioamniotis
• Postpartum endometritis

28. ACUTE PYELONEPHRITIS: FOETAL
COMPLICATIONS
• Low birthweight (2.5 kg)
• Prematurity (37 weeks of gestation)
• Developmental delay/mental retardation
• Perinatal mortality

29. DIFFERENTIAL DIAGNOSIS OF ACUTE
PYELONEPHRITIS
• Chorioamnionitis
• Appendicitis
• Placental abruption
• Infarcted leiomyoma

30. MANAGEMENT

31. ASYMPTOMATIC BACTERIURIA:
TREATMENT

32. FOLLOW UP ASYMPTOMATIC
BACTERIURIA
• All pregnant women with ASB should
have periodic screening after therapy,
since as many as one third of them
experience a recurrent infection.
• Follow-up cultures should be obtained 1–2
weeks after treatment and then repeated
once a month.

33. MANAGEMENT OF PERSISTENT
RECURRENT BACTERIURIA
• Nitrofurantoin 50–100 mg at bed time
until the end of the pregnancy. *
• A postpartum urologic evaluation may
be necessary in patients with
recurrent infections because they are
more likely to have structural
abnormalities of the renal system.
* Hooton TM. Urinary tract infections and asymptomatic bacteriuria in pregnancy; 2011.
UpToDate.com; updated.

34. ACUTE CYSTITIS: MANAGEMENT
• Increasing oral fluid intake is frequently advocated as
a first-line treatment for pregnant women with
features of symptomatic urinary infection.
• Nitrofurantoin 100mg BD for 7 days
• Urine alkalinising agents
• Cranberry juice also act as Urine alkaliser and is used
to treat urinary infection and inhibit the symptoms.

35. ACUTE PYELONEPHRITIS: MANAGEMENT
• Hospitalize patient.
• Obtain urine and blood cultures.
• Evaluate hemogram, serum creatinine, and
electrolytes.
• Monitor vital signs frequently, including urinary
output— consider indwelling catheter.
• Establish urinary output ≥ 50 mL/hr with
intravenous crystalloid solution.

36. ACUTE PYELONEPHRITIS: MANAGEMENT
• Administer intravenous antimicrobial therapy
• Obtain chest radiograph if there is dyspnea or
tachypnea
• Repeat hematology and chemistry studies in 48 hours
• Change to oral antimicrobials when afebrile Discharge
when afebrile 24 hours,
• consider antimicrobial therapy for 7 to 10 days
• Repeat urine culture 1 to 2 weeks after antimicrobial
therapy completed

37. ACUTE PYELONEPHRITIS: MANAGEMENT
• Nonsteroidal anti inflammatory drugs (NSAIDs) can be
added for symptomatic relief.
• Thromboprophylaxis should be used if the woman has
reduced mobility or a period of bedrest. The use of graduated
compression stockings and low molecular weight heparin is
advocated.
• Tocolysis is frequently necessary.
• Antenatal steroids for fetal lung maturity should be
considered if there is evidence of threatened preterm labour

38. ANTIMICROBIAL OF CHOICE
* Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM, Infectious Diseases Society of
America., American Society of Nephrology. 2005, reaffirmed 2015

40. NEWER ANTIBIOTICS
• Fosfomycin (Monurol) is a new antibiotic that is taken
as a single dose.
• It is a broad-spectrum antibiotic produced by
certain Streptomyces species, and has bactericidal
action
• Administered as a single dose of 3 gram sachet.
• Category B drug.
• Better compliance, Cost Rs 280/sachet

41. WHAT IF ACUTE PYELONEPHRITIS
DOES NOT RESPOND TO TREATMENT?

42. PERSISTENT ACUTE PYELONEPHRITIS
INFECTION
• Generally, intravenous hydration and
antimicrobial therapy are followed by stepwise
defervescence of approximately 1°F per day.
• With persistent spiking fever or lack of clinical
improvement by 48 to 72 hours, Urinary tract
obstruction or another complication, it is
considered to be PERSISTENT INFECTION.*
* Williams Obstetrics, 24th Edition, p.2214 (Chapter 53)

43. CAUSES OF PERSISTENT INFECTION
• Urinary tract obstruction
• Abnormal ureteral or pyelocaliceal
dilatation
• Intrarenal or perinephric abscess
• Nephrolithiasis

44. MANAGEMENT OF PERSISTENT
INFECTION
• USG KUB, or one-shot intravenous pyelogram
or MRI may be used to detect the cause of
persistent infection.
• Obstruction relief is important, and one
method is cystoscopic placement of a double-J
ureteral stent.
• Percutaneous nephrostomy
• Surgical removal of stones.

45. WHAT IS THE CAUSE OF RECURRENCE IN
LOW COUNT BACTERIURIA OR EVEN
NEGATIVE CULTURES?
• Answer lies in
Intracellular Bacterial
Colonies forming
BIOFILM

46. BIOFILMS
• Uropathogenic E Coli (UPEC) like E. coli CFT073,
UTI89, and 536 invades urothelial cells lining the
urinary bladder which forms intracellular bacterial
communities (IBCs) or BIOFILM.
• This infection remains undetected in normal urine
cultures and causes recurrence.
• These culture negative infections presents as
unexplained dysuria and urgency and are termed as
INTERSTITIAL CYSTITIS/ BLADDER PAIN
SYNDROME.

48. PREVENTION OF RECURRENT INFECTION
• Continued Antibiotic Prophylaxis till the end of
pregnancy, in the form T. Nitrofurantoin 50 – 100mf OD
HS
• Intake of 150 to 750 mL of cranberry juice or
concentrated equivalent is effective in preventing
recurrent UTIs*
• Maintaining local hygiene.
• Drinking at least 3 -4 litres of water.
• Women who are sexually active, can be advised to
practise Post Coital Voiding.
* Jepson RG, et al. Cranberries for preventing urinary tract infections. Cochrane
Database Syst Rev. 2008;(1):CD001321.

49. CONCLUSION
• Recurrent bacteriuria in pregnancy is common and a
serious cause of maternal and perinatal morbidity and
mortality.
• Clinical presentations include asymptomatic bacteriuria,
acute cystitis and pyelonephritis.
• Screening urine culture at 1st visit or at 12 weeks of
pregnancy is recommended by both ACOG and RCOG for
detection of asymptomatic bacteriuria.
.

50. CONCLUSION
• When choosing an antimicrobial, the pharmacokinetics
and bioavailability of the individual drug in pregnancy
must be considered along with the resistance profiles of
microorganisms.
• Simple behavioural changes and continuous antibiotic
prophylaxis can prevent recurrence of UTI in pregnancy.

51. REFERNCES
• Williams Obstetrics, 24th Edition
• Hooton TM. Urinary tract infections and asymptomatic bacteriuria in pregnancy; 2011. UpToDate.com; updated.
• Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev 2015;
:CD000490.
• Greentop Guidelines no 36, 2012, Preventtion of early onset Gropu b Streptococcus infection in neonates.
• Farkash E, Wientraub AY, Sergienko R, et al. Acute antepartum pyelonephritis in pregnancy: a critical analysis of
risk factors and outcomes. Eur J Obstet Gynecol Reprod Biol. 2012;162:24–7.
• 3. Gravett MG, Martin ET, Bernson JD, et al. Serious and life-threatening pregnancy-related infections:
opportunities to reduce the global burden. Plos Med. 2012;9:e1001324.
• Bolton M, Horvath DJ, Li B, et al. Intrauterine growth restriction is a direct consequence of localized maternal
uropathogenic Escherichia coli cystitis. Plos ONE. 2012;7:1–9.
• Jolley JA, Wing DA. Pyelonephritis in pregnancy: an update on treatment options for optimal
outcomes. Drugs. 2010;70:1643–55