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