How best to treat UTIs in women who breastfeed?

Abstract

It's unclear, as no studies have specifically evaluated therapies for uncomplicated urinary tract infections (UTIs) in breastfeeding women. However, trimethoprim/sulfamethoxazole (TMP/SMX), b-lactam antibiotics, nitrofurantoin, and fluoroquinolones all produce cure rates of 78% to 95% for uncomplicated UTIs in women who aren't breastfeeding, and all appear to be equivalent (strength of recommendation [SOR]: A, a systematic review). Women who take TMP/SMX develop drug concentrations in breast milk that are below recommended maximum safe levels for infants who don't have glucose-6-phosphate dehydrogenase (G6PD) deficiency (SOR: B, a small observational study and expert opinion); treatment with nitrofurantoin and ciprofloxacin also produces low levels in breast milk (SOR: C, extrapolations from small observational studies and expert opinion). (Though in the case of nitrofurantoin, this does not include patients with G6PD deficiency.) Some antibiotics taken by breastfeeding mothers may occasionally be associated with adverse effects in their infants: TMP/SMX may cause poor feeding; amoxicillin and cephalexin may cause diarrhea; nitrofurantoin may cause diarrhea or, in infants with G6PD deficiency, hemolytic anemia; and ciprofloxacin may cause pseudomembranous colitis in infants and green teeth in neonates (SOR: C, case reports and expert opinion).