Recommendation

Antibiotic prophylaxis is only recommended to prevent recurrent urinary tract infections in pregnant women in the context of rigorous research.

(Context-specific recommendation – research)

 

Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016

 

Remarks

• Further research is needed to determine the best strategies for preventing RUTI in pregnancy, including the effects of antibiotic prophylaxis on pregnancy-related outcomes and changes in antimicrobial resistance.

 

Background

A recurrent urinary tract infection (RUTI) is a symptomatic infection of the urinary tract (bladder and kidneys) that follows the resolution of a previous urinary tract infection (UTI), generally after treatment. Definitions of RUTI vary and include two UTIs within the previous six months, or a history of one or more UTIs before or during pregnancy (1). RUTIs are common in women who are pregnant and have been associated with adverse pregnancy outcomes including preterm birth and small-forgestational-age newborns (1). Pyelonephritis (infection of the kidneys) is estimated to occur in 2% of pregnancies, with a recurrence rate of up to 23% within the same pregnancy or soon after the birth (2). Little is known about the best way to prevent RUTI in pregnancy.

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (3). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (4) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (5) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (6) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women susceptible to RUTIs (P), do prophylactic antibiotics to prevent RUTIs (I) compared with no intervention (C) improve maternal and perinatal outcomes (O)?

 

Evidence summary

The evidence on the effects of prophylactic antibiotics to prevent RUTI was derived from a Cochrane review in which only one trial in the USA involving 200 pregnant women contributed data (1). Women admitted to hospital with pyelonephritis were randomized, after the acute phase, to prophylactic antibiotics (nitrofurantoin 50 mg three times daily) for the remainder of the pregnancy plus close surveillance (regular clinic visits and urine culture, with antibiotics on positive culture), or to close surveillance only.

Maternal outcomes

Evidence from this single study on the risk of recurrent pyelonephritis and RUTI with prophylactic antibiotics is very uncertain. No other maternal ANC guideline outcomes were reported in the study.

Fetal and neonatal outcomes

Evidence on the risk of low birth weight and preterm birth with prophylactic antibiotics is very uncertain. No other fetal and neonatal ANC guideline outcomes were reported in the study.

 

Additional considerations

Antibiotic prophylaxis to prevent RUTI may lead to increased antimicrobial resistance and there is a lack of evidence on this potential consequence.

Resources

Antibiotic costs vary. Trimethoprim is cheaper than nitrofurantoin, which can cost about US$ 5 for 28 × 100 mg tablets (7).

Equity

Impact not known.

Acceptability

In LMICs, some women hold the belief that pregnancy is a healthy condition and may not accept the use of antibiotics in this context (particularly if they have no symptoms) unless they have experienced a previous pregnancy complication (high confidence in the evidence) (8). Others view ANC as a source of knowledge, information and medical safety and generally appreciate the interventions and advice they are offered (high confidence in the evidence). However, engagement may be limited if this type of intervention is not explained properly. In addition, where there are likely to be additional costs associated with treatment, women are less likely to engage (high confidence in the evidence).

Feasibility

A lack of resources in LMICs, both in terms of the availability of the medicines and testing, and the lack of suitably trained staff to provide relevant information and perform tests, may limit implementation (high confidence in the evidence) (9).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

 

 

Implementation considerations

• The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
• The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
• An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
• Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
• Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation

• What are the effects of prophylactic antibiotics to prevent RUTI in pregnancy, compared to monitoring with use of antibiotics only when indicated, on maternal infections, perinatal morbidity and antimicrobial drug resistance?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

1. Schneeberger C, Geerlings SE, Middleton P, Crowther CA. Interventions for preventing recurrent urinary tract infection during pregnancy. Cochrane Database Syst Rev. 2012;(11):CD009279.
2. Gilstrap LC 3rd, Cunningham FG, Whalley PJ. Acute pyelonephritis in pregnancy: an anterospective study. Obstet Gynecol. 1981;57(4):409–13.
3. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
4. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
5. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
6. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
7. Joint Formulary Committee. Urinary tract infections. Chapter 5: Infection. In: British National Formulary (BNF) 72. London: BMJ Publishing Group Ltd and Royal Pharmaceutical Society; 2016.
8. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
9. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on antibiotic prophylaxis to prevent recurrent urinary tract infections. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization