29 August 2021
WHO recommendation on antibiotic prophylaxis to prevent recurrent urinary tract infections
Antibiotic prophylaxis is only recommended to prevent recurrent urinary tract infections in pregnant women in the context of rigorous research.
(Context-specific recommendation – research)
First published: December 2016
Updated: No update planned
Assessed as up-to-date: December 2016
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.
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.
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)?
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.
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.
Antibiotic prophylaxis to prevent RUTI may lead to increased antimicrobial resistance and there is a lack of evidence on this potential consequence.
Antibiotic costs vary. Trimethoprim is cheaper than nitrofurantoin, which can cost about US$ 5 for 28 × 100 mg tablets (7).
Impact not known.
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).
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:
The GDG identified this priority question related to this recommendation
WHO recommendations on antenatal care for a positive pregnancy experience
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
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