Urinary Tract Infection
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Cystitis & asymptomatic bacteriuria
CYSTITIS & ASYMPTOMATIC BACTERIURIA
Cystitis presents with severe urinary discomfort &/or frequency. There may be some lower abdominal tenderness. There is usually no fever & little malaise. Urine dipstick testing may show nitrites, or leukocytes with/without blood. Urine MCS may identify the infecting organism.
Asymptomatic bacteriuria (AB) is defined as a positive culture of a single organism with ≥105 colonies/mL with no symptoms. The prevalence is about 5-10% in pregnancy, with a 40% probability of developing symptomatic urinary tract infection later in pregnancy. Routine case-finding for asymptomatic bacteriuria is not practiced in public hospitals.
Management
- For symptomatic women, send a midstream urine specimen for MCS
- Empiric therapy:
- Nitrofurantoin 100 mg orally 6 hourly for 5 days
- OR
- Cefuroxime 500 mg orally 12 hourly for 5 days
- Nitrofurantoin 100 mg orally 6 hourly for 5 days
- Encourage a high oral fluid intake
- MCS results will guide further treatment & antibiotic choice
- Consider follow-up urine culture after treatment, especially in women with asymptomatic bacteriuria
- Women with recurrent urinary tract infections may need prophylactic continuous antimicrobial treatment
Taking a midstream urine specimen
Explain the procedure well to the patient, or ask a nurse to assist her with taking such a specimen, using a sterile plastic container
- Separate the labia
- Wipe the urethral opening from front to back with a sterile water swab
- Avoid touching or contaminating the rim or the inside of the container & lid
- Hold the container ready, & do not allow it to touch the vulva or thighs
- Pass urine, & after a few seconds of urine passing out into the toilet, catch fresh urine from the stream in the container
- Close the container tightly & submit it as soon as possible for culture
ACUTE PYELONEPHRITIS
This is a common & serious cause of pyrexia in pregnancy. The patient usually appears ill and has pyrexia & tachycardia, with renal angle tenderness.
Management
- Admit to hospital
- Send a midstream urine specimen for MCS
- Take blood for FBC, U&E & blood culture
- Assess the patient for evidence of preterm labour
- Start ceftriaxone 1 g IV daily, changing to oral treatment 24-48 hours after the fever subsides. Adjust the antibiotic if necessary according to the MCS results. Total duration of treatment should be 7 days
- Give Ringer-Lactate solution 3 L/day, or more if the woman is vomiting
- Following recovery, retest urine for MCS to confirm clearance of the infection
- Follow up for urine MCS result at antenatal clinic