# Urinary Tract Infection in Pregnancy - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE Guideline NG109 UTI in Pregnancy 2018 · Egyptian National Drug Formulary - Antimicrobial 2023 (nitrofurantoin monograph, prophylaxis for recurrent cystitis) · Selexid 200 mg Film-coated Tablets (pivmecillinam hydrochloride) SmPC sections 4.1, 4.2, 4.3, 4.4 and 4.6 (eMC product 3799) · Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy-full.txt) · PARACETAMOL = ACETAMINOPHEN oral - MSF Medical Guidelines (Essential drugs), Dosage - Verified date: 2026-08 ## Verified against - Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy-clinical.txt) - Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy-full.txt) - Egyptian National Drug Formulary - Antimicrobial 2023 (Version 1.0), p. 246, ceftriaxone monograph, Prescribing Limits: "Pediatric Patients Endocarditis or meningitis: Maximum 4 g daily. Most other infections: Maximum 2 g daily." - Egyptian National Drug Formulary - Antimicrobial 2023 (nitrofurantoin monograph, prophylaxis for recurrent cystitis) - Selexid 200 mg Film-coated Tablets (pivmecillinam hydrochloride) SmPC sections 4.1, 4.2, 4.3, 4.4 and 4.6 (eMC product 3799) ## Treatment metadata - Nitrofurantoin — 100 mg — oral.solid - Cefalexin — 500 mg — oral.solid - Referral & safety-netting (no drug therapy) - Ceftriaxone — 1000 mg — injection - Amoxicillin + Clavulanic acid — 625 mg — oral.solid - Fosfomycin — 3000 mg — oral.solid - Pivmecillinam — 200 mg — oral.solid - Nitrofurantoin — 50 mg — oral.solid - Paracetamol — 500 mg — oral.solid ## Complete treatment card ```text URINARY TRACT INFECTION IN PREGNANCY Sources: NICE Guideline NG109 UTI in Pregnancy 2018 · Egyptian National Drug Formulary - Antimicrobial 2023 (nitrofurantoin monograph, prophylaxis for recurrent cystitis) · Selexid 200 mg Film-coated Tablets (pivmecillinam hydrochloride) SmPC sections 4.1, 4.2, 4.3, 4.4 and 4.6 (eMC product 3799) · Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy-full.txt) · PARACETAMOL = ACETAMINOPHEN oral - MSF Medical Guidelines (Essential drugs), Dosage Review status: REVIEWED against Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy-clinical.txt), Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy- full.txt), Egyptian National Drug Formulary - Antimicrobial 2023 (Version 1.0), p. 246, ceftriaxone monograph, Prescribing Limits: "Pediatric Patients Endocarditis or meningitis: Maximum 4 g daily. Most other infections: Maximum 2 g daily.", Egyptian National Drug Formulary - Antimicrobial 2023 (nitrofurantoin monograph, prophylaxis for recurrent cystitis), Selexid 200 mg Film-coated Tablets (pivmecillinam hydrochloride) SmPC sections 4.1, 4.2, 4.3, 4.4 and 4.6 (eMC product 3799) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Cystitis in pregnancy looks much like in non-pregnant patients, with dysuria in about 55% and frequency common [burning on passing urine · urinary frequency] - Only around 26% of symptomatic pregnant patients actually culture positive, so symptoms alone are unreliable - A fever of at least 38.0°C with flank pain, chills, and vague systemic symptoms such as malaise or nausea points to pyelonephritis in pregnancy [abdominal pain · chills · fever · loin pain · malaise · nausea] - A urinary infection in pregnancy often brings on uterine irritability with contractions [irritability · uterine contractions] - New tachycardia and hypotension in this setting can signal evolving sepsis [hypotension · sepsis · tachycardia] SIGNS - what you find (2) - Costovertebral angle tenderness on exam points toward pyelonephritis rather than simple cystitis [abdominal pain · loin pain] - Suprapubic or diffuse abdominal tenderness may be found on exam [abdominal tenderness] TESTS (5) - Dipstick screening at every prenatal visit is discouraged because of its high false-positive rate - A nitrite-positive dipstick is highly specific, around 98.6%, for infection in a symptomatic pregnant patient - A higher maternal BMI is linked to more contaminated urine cultures - Cleaning the perineum before collecting the sample does not meaningfully cut contamination rates - Once pyelonephritis is suspected, work-up extends to a CBC, electrolytes, and creatinine to check systemic involvement IF NOT THIS - what else fits (4) - More frequent urination from the growing uterus pressing on the bladder is a normal pregnancy change that mimics a UTI - Pelvic inflammatory disease, vaginal infection, or another STI can mimic UTI symptoms in pregnancy - Preterm labor, chorioamnionitis, or placental abruption are obstetric mimics of pyelonephritis in pregnancy - Appendicitis, pancreatitis, cholecystitis, or kidney stones are intra-abdominal mimics of pyelonephritis Source StatPearls "Urinary Tract Infection in Pregnancy" - disease-level clinical article Status traced to the source above Rx: Treatment - acute infection | Main treatment | Oral alternative for acute cystitis in pregnancy - no Egyptian product registered | Suppression - recurrent UTI through the rest of pregnancy | Antipyretic and analgesic alongside the antibiotic TREATMENT - ACUTE INFECTION - choose one 1. NITROFURANTOIN [1st line] Adult 100 mg modified-release twice daily with meals x 7 days Peds Not applicable to pregnancy entry Source Egyptian National Drug Formulary - Antimicrobial 2023 Why Urinary antiseptic antibiotic concentrated in the urine, a first-line option for urinary tract infection in pregnancy; avoided at term because of the risk of neonatal haemolysis. Caution CONTRAINDICATED at term (38-42 weeks) due to neonatal haemolysis risk. A urine culture is mandatory 7 days post-treatment to confirm clearance. CrCl <60 mL/minute: Use is contraindicated. Egypt COLIFURAN 100 MG 20 TABS. KAHIRA 2.40 EGP (0.12/unit) UVAMINE RETARD 100 MG 20 CAPS. MUP > ACINO 47.00 EGP (2.35/unit) MEPAFURAN 100 MG 20 CAPS. MEPACO 54.00 EGP (2.70/unit) MACROFURAN 100 MG 30 CAPS. KAHIRA 82.00 EGP (2.73/unit) 2. CEFALEXIN [1st line] Adult 500 mg twice daily (every 12 hours) Peds Not applicable to pregnancy entry Choice Alternatives, and G6PD deficiency decides it. Cefalexin is safe throughout pregnancy; nitrofurantoin can cause haemolysis in G6PD deficiency, which is common in Egypt, and must also be avoided at term. Source Egyptian National Drug Formulary - Antimicrobial 2023 Why Cephalosporin, and the condition's own article lists it among the regimens used in pregnancy - cephalexin, 250 mg to 500 mg by mouth twice a day, over 5 to 7 days. An option including near term, when nitrofurantoin is unsuitable. MSF Essential Drugs 2024 records no contra-indication in pregnancy. Caution Neither source splits pregnancy by trimester. The Egyptian formulary rates cephalexin Pregnancy Category B; MSF Essential Drugs 2024 is explicit on both counts, recording no contra-indication in pregnancy and none during breast-feeding. Penicillin allergy: Use with caution in patients with a history of penicillin allergy, especially IgE-mediated reactions (eg, anaphylaxis, angioedema, urticaria). Dose adjustment is required in renal impairment. Egypt CEFLODIX 500 MG 12 CAPS. ARAB CAPS > P... 9.00 EGP (0.75/unit) CEPHALEXCID 500 MG 12 CAPS. CID 10.30 EGP (0.86/unit) CEPHOXIN 500MG 12 TAB. PHARCO B 10.50 EGP (0.88/unit) CEPHALEXIN 500MG 10 CAPS. ARAB DRUG COM... 10.10 EGP (1.01/unit) MEDICEFLEXIN 500 MG 20 CAPS. T3A PHARMA > ... 25.25 EGP (1.26/unit) CEPHALEXIN 500MG 12 CAPS B.P.2007 SHIFA MEDICAL PRODUCTS > O... 27.00 EGP (2.25/unit) KEFLEX 500 MG 12 CAPS. HIKMA PHARMA 58.00 EGP (4.83/unit) CEPOREX 500MG 12 TABS. GLAXO SMITHKLINE 69.00 EGP (5.75/unit) AMTHROST 125MG/5ML SUSP. 60ML SIGMA > SABAA 4.00 EGP -> ? strength differs, ? different route - not oral solid AMTHROST 250MG/5ML SUSP. 60ML SIGMA > SABAA 4.50 EGP -> ? strength differs, ? different route - not oral solid 3. CEFTRIAXONE [1st line] Adult IV or IM: 1-2 g once or divided twice daily x 7-14 days Peds Not applicable to pregnancy entry - the patient is a pregnant adult. Any weight-based child dose for this drug belongs on the paediatric urinary tract infection entry. AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Egyptian National Drug Formulary - Antimicrobial 2023 (Version 1.0), p. 246, ceftriaxone monograph, Prescribing Limits: "Pediatric Patients Endocarditis or meningitis: Maximum 4 g daily. Most other infections: Maximum 2 g daily." Why Third-generation cephalosporin for pyelonephritis in pregnancy requiring hospitalization; covers the common uropathogens. The Egyptian formulary treats ceftriaxone as compatible with both pregnancy and breastfeeding, provided the doses stay within the usual recommended range. The article specifies 1 g IV every 24 hours, which falls within the formulary range. Caution Do not use in hyperbilirubinemic neonates; ceftriaxone is reported to displace bilirubin from albumin binding sites. Ceftriaxone may exhibit incompatibility with calcium, causing precipitation. Ceftriaxone is considered compatible with pregnancy and breastfeeding when used in usual recommended doses. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP 4. AMOXICILLIN + CLAVULANIC ACID [2nd line] Adult Oral: Immediate release: 500 mg twice daily x 7 days Peds Not applicable to pregnancy entry Choice Amoxicillin + clavulanic acid is the first choice here; fosfomycin is an alternative. Source Egyptian National Drug Formulary - Antimicrobial 2023 Why Beta-lactam/beta-lactamase inhibitor combination, reserved for urinary tract infection when first-line agents are contraindicated or the organism is resistant to them. The condition's article lists it under alternative regimens and warns against plain amoxicillin or ampicillin as an empiric first choice, on the grounds of high E coli resistance. MSF Essential Drugs 2024 records no contra-indication in pregnancy. Caution Contraindicated in history of penicillin allergy or co-amoxiclav cholestatic jaundice. Use when first-line agents are contraindicated or the organism is resistant - not as the first empiric choice. On pregnancy MSF Essential Drugs 2024 is explicit: it records no contra-indication. Always obtain urine culture before initiating therapy. Egypt AUJED 625 MG 12 F.C. TAB. SIGMA TEC > J... 19.20 EGP (1.60/unit) E-MOXCLAV 625MG 10 TAB. EIPICO 30.00 EGP (3.00/unit) DEXICLAVE 625 MG 12 F.C. TABS. RAMEDA > NOVE... 37.50 EGP (3.12/unit) MAGNABIOTIC 625MG 8 TAB. SEDICO 37.00 EGP (4.62/unit) CLAVIMOX 625 MG 12 F.C.TABS. PHARCO 107.00 EGP (8.92/unit) CURAM 625MG 12 F.C.TAB. SANDOZ > NOVA... 108.00 EGP (9.00/unit) AUGMENTIN 625 MG 10 F.C.TABS. MUP > SMITHKL... 117.00 EGP (11.70/unit) CLAVOCILLIN 625 MG 10 DISPERSIBLE TABS. RAMEDA > ORGANOPHARMA 31.50 EGP LARYNCLAVE 125/31 PD. FOR ORAL SUSP. 70ML MISR > AL ROWAD PHARMACEUTICAL... 8.00 EGP -> ? strength differs, ? different route - not oral solid MEGACLAVOX 156MG/5ML PD. FOR SUSP. 60 ML CID 8.00 EGP -> ? strength differs, ? different route - not oral solid 5. FOSFOMYCIN [2nd line] Adult Oral: 3 g as a single dose - Single dose Peds Not applicable to pregnancy entry - the patient is a pregnant adult. Any weight-based child dose for this drug belongs on the paediatric urinary tract infection entry. Source Egyptian National Drug Formulary - Antimicrobial 2023 Why Single-dose oral alternative for acute cystitis in pregnancy when nitrofurantoin or cephalosporins are unsuitable; Pregnancy Category B and not used for pyelonephritis. Caution Hypersensitivity reactions including anaphylactic shock have been reported; discontinue at first sign. Not used for pyelonephritis due to inadequate tissue levels in the kidney. Fosfomycin is Pregnancy Category B; use during pregnancy only if clearly needed. Egypt FOSFORON 3GM 1 SACHET GLOBE INTERNA... 39.00 EGP MONURIL 3GM 1 SACHET ZAMBON > PHAR... 293.00 EGP MAIN TREATMENT 6. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Urinary Tract Infection in Pregnancy - disease-level clinical article (uti-in-pregnancy- clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Nitrofurantoin (and fosfomycin) should NOT be used to treat pyelonephritis because they do not achieve adequate kidney tissue levels - distinguish cystitis from pyelonephritis before using either. RED FLAG - Nitrofurantoin use is generally avoided at 36-37 weeks of gestation due to a theoretical risk of neonatal hemolytic anemia. RED FLAG - In G6PD deficiency, avoid nitrofurantoin and avoid the sulfa drugs: either can set off haemolysis. RED FLAG - Any detection of GBS in urine during pregnancy, regardless of colony count, requires intrapartum IV antibiotic prophylaxis to reduce early-onset neonatal GBS sepsis - separate from treating the UTI itself. ORAL ALTERNATIVE FOR ACUTE CYSTITIS IN PREGNANCY - NO EGYPTIAN PRODUCT REGISTERED 7. PIVMECILLINAM [2nd line] Adult The SmPC writes a separate pregnancy regimen, and it is the one to follow. Verbatim, under Pregnant women: "Acute cystitis: 7 day course of 2 tablets immediately followed by 1 tablet 3 times daily to a total of 22 tablets." On 200 mg tablets that is 400 mg as the first dose, then 200 mg three times a day for seven days. The disease article gives a heavier regimen for the same seven days - "pivmecillinam 400 mg 3 times a day for 7 days for uncomplicated cystitis" - and the two are printed side by side because they genuinely differ; the label's own pregnancy schedule leads. - Seven days, which is the pregnancy course rather than the three-day course used outside pregnancy. The SmPC's non-pregnant regimen is a "72 hour course"; the pregnancy entry is a "7 day course", and the disease article agrees on seven. Peds Not applicable to pregnancy entry - the patient is a pregnant adult. Any weight-based child dose for this drug belongs on the paediatric urinary tract infection entry. Source Selexid 200 mg Film-coated Tablets (pivmecillinam hydrochloride) SmPC sections 4.1, 4.2, 4.3, 4.4 and 4.6 (eMC product 3799) Why The disease article names the drug and puts it among the alternative regimens, verbatim: "Multiple randomized trials support the use of a newer antibiotic, pivmecillinam 400 mg 3 times a day for 7 days for uncomplicated cystitis. Routine use for upper urinary tract infection is not yet recommended." The SmPC's indication section names urinary tract infections, and its pregnancy section names the disease and the patient together, verbatim: "A large amount of data on pregnant women (more than 40 000 pregnancy outcomes) indicate no malformative nor feto/neonatal toxicity of pivmecillinam. Selexid can be used for treatment of acute uncomplicated cystitis during pregnancy, if clinically needed." It earns a place because resistance is the reason the card needs depth - the article's own point about pivmecillinam elsewhere is that it covers ESBL- producing organisms. Egypt registers no pivmecillinam product, so no brand and no price can be shown; the row exists so a regimen started abroad can be recognised and continued. Caution Contraindicated in more than the obvious group. SmPC verbatim: "Hypersensitivity to penicillins and/or cephalosporins. Any conditions resulting in impaired transit through the oesophagus." and "Genetic metabolism anomalies known to be leading to severe carnitine deficiency, such as carnitine transporter defect, methylmalonic aciduria or propionic acidaemia." Take it upright, with fluid and food. SmPC verbatim: "The tablets must be taken with at least half a glass of fluid, and preferably taken with or immediately after a meal." The oesophageal contraindication above is the reason this instruction carries weight. Severe skin reactions end the course. SmPC verbatim: "Severe cutaneous adverse reactions (SCAR) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) have been reported in relation to beta-lactam treatment, including Selexid. When SCAR is suspected, Selexid should be discontinued immediately". It depletes carnitine, and valproate makes that worse. SmPC verbatim: "Selexid tablets should be used with caution for long-term or frequently-repeated treatment, due to the possibility of carnitine depletion. Symptoms of carnitine depletion include muscle aches, fatigue, and confusion." and "Concurrent treatment with valproic acid, valproate or other medication liberating pivalic acid should be avoided due to increased risk of carnitine depletion." Caution in porphyria. SmPC verbatim: "Selexid tablets should be used with caution in patients with porphyria since pivmecillinam has been associated with acute attacks of porphyria." It can trip the newborn screen. SmPC verbatim: "The intake of pivmecillinam shortly before delivery may cause a false positive test for isovaleric acidaemia in the newborn as part of neonatal screening. This may be due to the formation of pivaloylcarnitine simulating the presence of isovalerylcarnitine." If it was given near term, say so when the baby is screened. Breastfeeding is not a reason to withhold it. SmPC verbatim: "Mecillinam is excreted in human milk, but at therapeutic doses of Selexid no effects on the breast-fed newborns/infants are anticipated. Selexid can be used during breast-feeding." Not for a kidney infection. The disease article is explicit that it is not yet recommended for routine use in an upper urinary tract infection - fever, flank pain or vomiting in a pregnant patient is a different pathway. Egypt no Egyptian brand matched - prescribe by generic name SUPPRESSION - RECURRENT UTI THROUGH THE REST OF PREGNANCY 8. NITROFURANTOIN [3rd line] Adult 50 to 100 mg once daily at bedtime as continuous prophylaxis Peds Not applicable - this row is a regimen for pregnancy. Source Egyptian National Drug Formulary - Antimicrobial 2023 (nitrofurantoin monograph, prophylaxis for recurrent cystitis) Why A different prescription from the treatment course already on this card: the disease article gives suppressive nitrofurantoin once daily through the remainder of pregnancy for recurrent UTI, and the ENDF has an explicit continuous-prophylaxis dose for recurrent uncomplicated cystitis. Because the same formulary contraindicates the drug from 38 weeks, suppression cannot simply run to delivery - it has to be stopped and, if still needed, replaced. Caution Because of the possibility of hemolytic anemia caused by immature erythrocyte enzyme systems (glutathione instability), the drug is contraindicated in pregnant patients at term (38 to 42 weeks gestation), during labor and delivery, or when the onset of labor is imminent. Anuria, oliguria, or significant impairment of renal function (creatinine clearance [CrCl] <60 mL/minute or clinically significant elevated serum creatinine) Previous history of cholestatic jaundice or hepatic dysfunction associated with prior nitrofurantoin use; hypersensitivity to drug or any component of the formulation Egypt MACROFURAN 50 MG 30 CAPS. KAHIRA 51.00 EGP (1.70/unit) MEPAFURAN 50 MG 20 CAPS. MEPACO 34.00 EGP (1.70/unit) ANTIPYRETIC AND ANALGESIC ALONGSIDE THE ANTIBIOTIC - give alongside 9. PARACETAMOL [add-on - not a substitute] Adult 1 g by mouth three to four times a day, to a maximum of 4 g daily - While febrile or in pain; stop once the fever settles on antibiotics Peds Not applicable - pregnant adults only. Source PARACETAMOL = ACETAMINOPHEN oral - MSF Medical Guidelines (Essential drugs), Dosage Why Antibiotics treat the infection but do nothing for the fever and loin pain in the first day or two. Paracetamol is the one analgesic and antipyretic that carries no contraindication in pregnancy, so it belongs on a card that otherwise offers only antibiotics. NSAIDs are not an alternative here. Caution Never exceed the daily ceiling, and count in every combination cold, flu or painkiller product the patient may also be taking, because most of them contain paracetamol too. Use it cautiously, and consider a lower dose, in a woman with liver disease. It brings the temperature down but does not treat the infection - it must never delay or replace the antibiotic. Fever with loin pain and rigors in pregnancy points to pyelonephritis, which usually needs admission; treating the fever at home is not enough on its own. Egypt FEBRIMOL 500 MG 20 TAB. PHARCO 3.50 EGP (0.17/unit) CETAMOL 500 MG 20 TABS. MEMPHIS 8.00 EGP (0.40/unit) PARACETAMOL-MUP 500MG B.P. 20 TABS. MUP 13.00 EGP (0.65/unit) CETAL 500 MG 20 TABS. EIPICO 24.00 EGP (1.20/unit) ARKADOLOW 500 MG 30 F.C. TABS. UTOPIA 42.00 EGP (1.40/unit) PARAMOL 500MG 20 TAB. MISR 38.00 EGP (1.90/unit) ADOL 500MG 24 CAPLETS JULPHAR 32.00 EGP AUGICETAMIDE 500 MG 20 SACHETS AUG PHARMA 50.00 EGP FEBRIMOL ORAL DROPS 20 ML PHARCO 4.00 EGP -> ? strength differs, ? different route - not oral solid THERA-LO 3.2G/100ML ORAL SUSP. 100 ML PHAROPHARMA 5.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. 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