Bacterial infections in pregnancy (MSF Essential obstetric and newborn care) — MSF Essential obstetric and newborn care — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Essential obstetric and newborn care › Chapter 4: Pathologies during pregnancy and pregnancy-related disorders · Médecins Sans Frontières, Current online edition, 2026

Clinical guidance on managing syphilis, gonorrhoea and urinary tract infections during pregnancy for clinicians in resource-limited settings.

In one sentenceTreat pregnancy syphilis with benzathine benzylpenicillin 2.4 MIU IM; gonorrhoea with ceftriaxone 250 mg plus azithromycin 1 g; screen and treat asymptomatic bacteriuria; admit pyelonephritis for parenteral ceftriaxone.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians managing pregnant women in resource-limited settings, midwives, obstetricians
Evidence: Evidence-based protocols with CDC references
Reviewed: 23 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 23 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This section of the MSF Essential Obstetric and Newborn Care guideline provides evidence-based protocols for managing bacterial infections during pregnancy, specifically syphilis, gonorrhoea and urinary tract infections. These infections pose significant risks including spontaneous abortion, intrauterine death, preterm labour and congenital infection if left untreated.

The guideline emphasises antimicrobial therapy tailored to infection type and severity. For syphilis, benzathine benzylpenicillin remains first-line treatment, with dosing dependent on disease duration. Gonorrhoea requires dual therapy with ceftriaxone and azithromycin to cover co-infection with chlamydia. Urinary tract infections are stratified by severity, from single-dose treatment for asymptomatic bacteriuria to prolonged parenteral therapy for complicated pyelonephritis.

The protocols include practical guidance on route of administration, partner treatment, monitoring for complications such as Jarisch-Herxheimer reaction, and clear criteria for escalation to inpatient care. Temperature management with paracetamol is recommended when axillary temperature reaches 38.5°C or above.

Key points

For clinicians — doses and thresholds as stated in the guideline

Administer paracetamol 1 g orally 3 times daily when axillary temperature ≥38.5°C in all bacterial infections during pregnancy
For early syphilis: benzathine benzylpenicillin 2.4 MIU IM single dose (half-dose in each buttock); for late latent syphilis: one injection weekly for 3 weeks
Treat gonorrhoea with dual therapy: ceftriaxone 250 mg IM single dose plus azithromycin 1 g oral single dose to cover chlamydial co-infection
Asymptomatic bacteriuria diagnosed by leukocytes and nitrites on urine dipstick requires treatment as acute cystitis to prevent pyelonephritis and preterm labour
Acute cystitis: fosfomycin-tromethamine 3 g oral single dose or cefixime 200 mg orally twice daily for 5 days
Uncomplicated pyelonephritis: ceftriaxone 1 g IM or IV daily, then switch to oral amoxicillin/clavulanic acid or cefixime after 24–48 hours apyrexia to complete 10–14 days
Severe or complicated pyelonephritis: add gentamicin 5 mg/kg IM or IV once daily for the first 3 days alongside ceftriaxone
Treat sexual partners simultaneously for syphilis and gonorrhoea to prevent reinfection

Antibiotic regimens for urinary tract infections in pregnancy

Table extracted from the guideline

Condition	First-line treatment	Duration	Notes
Asymptomatic bacteriuria	Fosfomycin-tromethamine 3 g PO single dose OR cefixime 200 mg PO twice daily	Single dose OR 5 days	Leukocytes and nitrites on dipstick without symptoms
Acute cystitis	Fosfomycin-tromethamine 3 g PO single dose OR cefixime 200 mg PO twice daily	Single dose OR 5 days	Advise 1.5 litres water daily; symptoms should resolve in 2–3 days
Uncomplicated pyelonephritis	Ceftriaxone 1 g IM/IV daily → switch to amoxicillin/clavulanic acid PO or cefixime 200 mg PO twice daily	10–14 days total	Switch after 24–48 hours apyrexia; admit for inpatient care
Severe/complicated pyelonephritis	Ceftriaxone 1 g IV daily + gentamicin 5 mg/kg IM/IV daily	Gentamicin for 3 days; total 10–14 days	Add gentamicin if no improvement after 24 hours

Source: Médecins Sans Frontières, Bacterial infections in pregnancy (MSF Essential obstetric and newborn care) — MSF Essential obstetric and newborn care. Reproduced in summary form.

From the guideline

Verbatim

“Asymptomatic bacteriuria and cystitis, if left untreated, can lead to pyelonephritis and preterm labour.”

— Médecins Sans Frontières, Bacterial infections in pregnancy (MSF Essential obstetric and newborn care) — MSF Essential obstetric and newborn care, Section 4.2.3 (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise that bacterial infections in pregnancy remain a preventable cause of maternal and neonatal morbidity across the South Caucasus. The MSF protocols are particularly valuable for resource-limited settings in our region, where point-of-care urine dipstick testing can identify asymptomatic bacteriuria before complications develop. I would emphasise to Georgian clinicians the critical importance of dual therapy for gonorrhoea—the combination of ceftriaxone and azithromycin addresses both co-infection and antimicrobial resistance that we are increasingly documenting in regional surveillance. The primary implementation challenge will be ensuring uninterrupted supply of benzathine benzylpenicillin for syphilis treatment, as this long-acting formulation has experienced global shortages, and the alternative erythromycin regimen is associated with substantial treatment failure rates that jeopardise both maternal and congenital outcomes.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026

Applicability

Georgia and the South Caucasus

These protocols are highly relevant for Georgia and the South Caucasus, where sexually transmitted infections remain a public health concern and antenatal screening programmes vary in coverage. National maternal health programmes should ensure availability of benzathine benzylpenicillin for syphilis treatment, as erythromycin alternatives are associated with treatment failure. The guideline’s emphasis on urine dipstick screening for asymptomatic bacteriuria aligns with cost-effective prevention of pyelonephritis and preterm birth. Georgian clinicians should note that dual therapy for gonorrhoea addresses emerging antimicrobial resistance patterns documented globally. Implementation requires reliable supply chains for ceftriaxone, azithromycin and fosfomycin, and training in recognition of severe infection requiring inpatient management. Integration with existing antenatal care protocols and partner notification systems is essential for programme effectiveness.

Questions this guideline answers

Quick answers

Why treat asymptomatic bacteriuria in pregnancy when the woman has no symptoms?

Asymptomatic bacteriuria, if left untreated, can progress to pyelonephritis and trigger preterm labour. Early treatment with a short course prevents these serious complications. Detection by urine dipstick showing leukocytes and nitrites allows simple screening at antenatal visits.

What is Jarisch-Herxheimer reaction and how should it be managed?

Jarisch-Herxheimer reaction may occur 2–5 hours after the first dose of penicillin for syphilis, especially in early disease. Patients develop fever, chills, muscle pain, tachycardia, flushing or mild hypotension. Treatment is symptomatic with paracetamol 1 g every 6 hours. Most reactions are moderate but severe reactions can occur.

Why is dual therapy required for gonorrhoea in pregnancy?

Gonorrhoea is frequently associated with chlamydial co-infection. The combination of ceftriaxone 250 mg IM plus azithromycin 1 g orally as a single dose treats both infections simultaneously and addresses antimicrobial resistance patterns, ensuring effective cure and preventing neonatal complications.

When should a pregnant woman with pyelonephritis be admitted to hospital?

All pregnant women with acute pyelonephritis should be admitted for inpatient care and bed rest, as the condition can progress to maternal sepsis and preterm labour. Admission allows parenteral antibiotic administration, monitoring for complications, and ensures adequate hydration (1.5 litres daily).

Related on GMJ

Interconnected resources

Dictionary of Public Health

Drugs A–Z

GMJ News coverage

Quality & accreditation

Same guideline

Iron deficiency anaemia — MSF Essential obstetric and newborn careChapter 4: Pathologies during pregnancy and pregnancy-related disorders
Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Uterine rupture — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Abruptio placentae — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Placenta praevia — Essential obstetric and newborn care — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Molar pregnancy (hydatidiform mole) — MSF Essential obstetric and newborn careChapter 2: Bleeding during the first half of pregnancy

Bacterial infections in pregnancy (MSF Essential obstetric and newborn care) — MSF Essential obstetric and newborn care

What this guideline says

Key points

Antibiotic regimens for urinary tract infections in pregnancy

From the guideline