URINARY TRACT INFECTIONS
IN PREGNANCY
JEFFREY PRADEEP RAJ
INTRODUCTION
Pregnant women easily develop urinary tract infections
(UTIs) because of functional, hormonal and anatomical
changes
Location of the urethral meatus also allows
uropathogenic bacteria (found in rectal flora) access
from the vagina to the lower urinary tract.
[Conolly A, Thorp JM.1999]
INTRODUCTION
Dilation of the renal calyces, pelves & ureters occurs.
Dilation on the right side is greater than the left.
-Dextrorotation of uterus
-Dilated ovarian venous plexes
This along with increased vesicoureatal reflex predispose
to urinary tract infections
NORMAL FLORA OF URINARY TRACT
Coagulase negative staphylococcus
Streptococci viridans
Non haemolytic strept
Lactobacilli
Diphtheriods
Non pathogenic neisseria
Commensal mycobacterium & Mycoplasma
CLASSIFICATION OF UTI
Based on symtometology:
Asymptomatic bacteriuria.
Symptomatic bacteriuria
Anatomical classification:
- Lower tract infections – Cystitis
Urethritis
-Upper tract infections – Pyelonephritis
It can be complicated UTI or uncomplicated UTI
RISK FACTORS
Diabetes mellitus
AIDS
Urinary system anomalies
Sickle cell haemoglobinopathy [Pastore
LM, Savitz DA, Thorp JM. Predictors of urinary tract infection at the first prenatal visit.
Epidemiology 1999; 10:282±287.]
Less education (<12 years)
History of Chlamydia trachomatis
Illicit drug use [Pastore LM,
Savitz DA, Thorp JM, et al. Predictors of symptomatic urinary tract infection after 20
weeks' gestation. J Perinatol 1999; 19:488±493.]
Other risk factors are: sexual activity, increasing age,
parity and low socioeconomic conditions
CAUSATIVE AGENTS
COMMUNITY ACQUIRED HOSPITAL ACQUIRED
GNB GNB
E.coli E.coli
Klebsiella spp
Pseudomonas aeruginosa
Proteus spp
Klebsiella spp
Enterobacter spp
GPC Enterobacter spp
Enterococci Serratia spp
Staph aureus GPC
Staph saprophyticus Enterococci
Beta Streptococci-GrpB
Fungi-
Candida spp.
Parasites-
Trihcomonas vaginalis
Schistosoma haemotobium
Sexually transmitted urethritis-
Neisseria gonorrhoea
Non gonococcal urethritis -
Chlamydia trachcomatis
Ureaplasma urealyticum
(ref. Jawetz textbook of microbiology,24th edn)
E-COLI IS HOWEVER THE MOST COMMONEST CAUSE(80-90% of UTI’s)
ETIOLOGICAL AGENTS IN PREGNANCY
However the most important pathogens that are known to
cause UTI in pregnant women are
-E. Coli in 80-90% of UTIs and up to 95% of acute
pyelonephritis.
-Proteus mirabilis
-Klebsiella pneumoniae.
-Streptococcus agalactiae (grp B)
-Coagulase negative staphylococcus (CONS)
-Enterococci
-Gardnerella vaginalis
-Ureaplasma ureolyticum
-Mycoplasma hominis
VIRULENCE FACTORS
Toxins produced
Structures that help in adherance of the organism to the
uro-epithelium.
E-coli has adhesins, pili or fimbriae(type1, fimbriae P)
that help in attachment to the epithelium.
On the other hand, the host has specific receptors for
these groups.
[Sobel JD. Pathogenesis of urinary tract infection. Infect Dis Clin North Am 1997;
11:531±549. ]
[Kaul AK, Khan S, Martens MG, et al. Experimental gestational pyelonephritis
induces preterm births and low birth weights in C3H/HeJ mice. Infect Immun 1999;
67:5958±5966.]
PATHOGENICITY
CLINICAL FEATURES
Asymptomatic-
5% adult women(2-7% during pregnancy)
1-3% young girls
0.3% male
[Hooton et.all,2000]
Symptomatic-
frequency of micturition
Urgency
dysuria
pyuria
suprapubic pain
Fever ,rigors &Loin pain
ASYMPTOMATIC BACTERIURIA
Can be defined as persistent, actively multiplying
bacteria within the the urinary tract without symptoms.
( ref. William’s Obstetrics, 21st edn.)
Highest incidence has been reported in african-american
multiparas with sickle cell anaemia.
Lowest incidence has been found in affluent white
women of low parity.
If not treated, about 25% of the infected women
subsequently develop acute symtomatic infection during
that pregnancy.
SYMTOMATIC BACTERIURIA
Will be covered in the following presentations by Mr.
Mithun Raam & Mr.Sam Jenkins
LABORATORY DIAGNOSIS
SAMPLE: Mid stream clean catch urine in a wide
mouthed universal container taking precaution not to
contaminate with the natural flora of the genitalia.
Sample should be transported immediately and
processed within 2 hours. Stored at 4C.
After 5 hours the sample should be discarded and not
processed.
NOTE: for gonococcal urethritis the first few drops of
urine are collected. For mycobacterium the entire sample
is collected.
PROCESSING OF SAMPLE
Microscopy- Pus cells, Bacteria, Epithelial cells
Culture- Semi-quantitative
• Media used- Blood agar, Mac conkey agar
• Dilution – 1/100- 9.9ml normal saline
+0.1ml of urine –
1/10- 4.5ml normal saline +0.5ml
of urine
• Amount inoculated onto media- 0.01ml
• Incubation - 37ºC –24-48hrs
PROBABLE UTI
Fungal urinary tract
infection-
papanicolaoa stain
200X magnification.
Polyoma
virus. Papanicolao
u Stain, 600X
magnification.
FINAL REPORT
SIGNIFICANT BACTERURIA
In a midstream clean catch urine which has
been processed immediately a colony count
of more than 100,000 cols / ml
Probably Significant – 1000- 100,000
cols/ml
OTHER METHODS OF DIAGNOSIS
OTHER SEMIQUANTITATIVE METHODS
• Standard loop method
• Filter paper method
• Dip slide method
RAPID METHODS
• Griess nitrate test
• Catalase test
• Triphenyltetrazolium chloride
• Glucose test paper
TREATMENT REGIMENS
Single dose(Andriole & Patterson,1991)
Amoxicillin 3g, Ampicillin 2g,
Cephalosporin 2g, Nitrofurantoin 200mg,
Sulfonamide 2g, Trimethoprim- Sulfamethoxazole
320/1600mg
Three day course
Amoxicillin500mg t.i.d
Ampicillin250 mg, cephalosporin 250mg,
Nitrofurantion 50-100mg, sulfonamide 500mg Q6H
The recurrence rates for all of these regimens is 30%
Treatment failure (lucas & cunningham,1994)
Nitrofurantion, 100mg Q6H x 21 days
Suppression for bacterial persistence or recurrence-
Nitrofurantion, 100mg at bedtime for
reminder of pregnancy
Because of the risks associated with recurrence,it is
advisable to treat pregnant patients who have a UTI with
appropriate antibiotic therapy for a period of 7 to 10
days.
RESISTANCE TO ANTIMICROBIAL
THERAPY
The current resistance of E. coli to antibiotics is:
Ampicillin between 28 and 39%,
Trimethoprim-sulfamethoxazole 31%
First-generation Cephalosporins between9 and 19%
Cefuroxime 1%
Antibiotic suceptibilty test is important before
administering drugs
[Ovalle A, MartõÂnez MA, Wolff M, et al. Efficacy, safety and cost of cefuroxime
compared with cephradine in the treatment of acute pyelonephritis during
pregnancy. Rev Med Chile 2000; 128:749±757]
[Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary
tract infection. Infect Dis Clin North Am 1997; 11:551±581.]
FOLLOW-UP
Urine cultures should be done monthly to detect relapses
Long-term antibiotic supression is often advised to
decrease relapses
Frequent relapses may mandate an intavenous urogram
which can be done only after pregnancy in puerperium.
SIGNIFICANCE
Increased incidence of pre-term delivery and perinatal mortality.
[kass,1962]
Increased incidence of low birth weight infants. [kincaid-smith,
bullen,1965]
Increased risk for low birth weight, pre-term delivery, hypertension
or pre-eclampsia*, and maternal anaemia. [schieve and
colleagues,1994]
Amnionitis
Premature neonate
Neonatal sepsis and pneumonia
* Studies contradicting the relation of increased risk of
hypersensitive disorders with UTI in pregnancy have also been
published
[ref. William’s obstetrics,21st edn.]
TAKE HOME MESSAGE
All pregnant women should be routinely checked for
bacteriuria specially in the 1st and 3rd trimester. Thus
routine urine analysis should be made a complsory part
of ANC package.
Prophylactic treatment should be given in case of
recurrent infections.
Antibiotic suceptibility should be ensured before
prescribing a drug.
A change in the antibiotic used is indicated only
clinically and not by culture.
REFERENCES
William’s obstetrics, 21st edn.
Daftary & Chakravarty’s manuel of obstetrics
Harrison’s principle of internal medicine, 13th edition
Jawetz’s textbook of microbiology,24th edn.
Ananthanarayan & paniker’s microbiology
Tripathi’s essentials of medical pharmacology
Urinary tract infections in pregnancy(review)-Alfredo Ovalle
and Marco Levancini
Urinary Tract Infections During pregnancy(review)-John E.
Delzell and Michael L. Lefevre
THANK YOU
