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Symptomatic lower urinary tract infection at term in pregnancy — MSRA MCQ

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HardUrinary Tract InfectionsSymptomatic lower urinary tract infection at term in pregnancyMSRA

A 29-year-old primigravida at 39+6 weeks’ gestation contacts her GP with 18 hours of dysuria, urinary frequency and suprapubic discomfort. She is afebrile, haemodynamically stable and has no loin pain, uterine tenderness, contractions, vomiting or systemic upset. She is booked for elective caesarean birth tomorrow morning. Her eGFR is 82 mL/minute/1.73 m² and she has no drug allergies. A midstream urine sample can be obtained immediately. Her most recent urine culture, 4 months ago, grew Escherichia coli resistant to amoxicillin and susceptible to nitrofurantoin and cefalexin. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Send a midstream urine sample for culture, then start cefalexin 500 mg twice daily for 7 days

Explanation lettering: B = shown as A · E = shown as B · D = shown as C · A = shown as D · C = shown as E

This is symptomatic lower UTI in a pregnant woman, so a midstream urine sample should be obtained before treatment and she should receive an immediate antibiotic prescription rather than await culture. Although nitrofurantoin is ordinarily NICE’s first-choice agent in pregnancy when renal function is adequate, it should be avoided at term because of the risk of neonatal haemolysis. At 39+6 weeks with delivery planned the following day, cefalexin is the appropriate oral alternative. Her prior culture also supports its likely activity. B is initially attractive because nitrofurantoin is usually first-line for lower UTI in pregnancy and her eGFR is adequate; however, her gestational timing is the decisive exception. C is inappropriate because amoxicillin should be used only when current culture confirms susceptibility, and her previous isolate was resistant. D fails because pregnancy requires immediate treatment of symptomatic lower UTI while culture is pending. E would be appropriate if she had features suggesting pyelonephritis, sepsis, inability to take oral treatment or another obstetric indication for admission, none of which are present.

Reference: NICE NG109: Urinary tract infection (lower): antimicrobial prescribing — Recommendations (2018; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng109/chapter/recommendations Nitrofurantoin 100 mg capsules — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/101006/smpc