Abstract
Background
Urinary tract infections (UTIs) are among the most common bacterial infection during pregnancy, and a leading cause of maternal and neonatal morbidity. In Palestine, limited data exist on the burden, microbial etiology, and antimicrobial resistance. This study aimed to determine the incidence, microbial profiles, antimicrobial resistance patterns, and recurrence of UTIs among pregnant women attending primary healthcare clinics in Nablus, Palestine.
Methodology
A prospective cohort study was conducted between December 2024 and May 2025 across 12 primary healthcare clinics in Nablus, Palestine. Pregnant women aged 18 and older were enrolled. Screening for UTIs was conducted under a combination of study-directed testing and routine clinical practice, where urine culture was more frequently performed in symptomatic women or when clinically indicated. Data were collected using structured questionnaires and laboratory analyses, including urine cultures and antibiotic susceptibility testing. Sociodemographic, obstetric, and clinical data were collected, with a 90-day follow-up to assess recurrence.
Results
Out of 485 women, 279 underwent urine culture, of whom 115 (41.2%) had confirmed UTIs. Escherichia coli (38.3%) and Staphylococcus aureus (22.6%) were the most commonly isolated pathogens. Multidrug resistance (MDR), defined as a non-susceptibility to at least one agent in three or more antimicrobial categories, was observed in 55.7% of isolates with particularly high resistance to ampicillin, cefixime, and fosfomycin. Pregnancy-appropriate options such as nitrofurantoin (81.6%) and fosfomycin (64.7%) retained moderate activity. Symptom severity correlated with MDR status, with women reporting frequent urination, abdominal pain, or higher symptom scores more likely to harbor resistant pathogens (p < 0.001). At 90-day follow-up, 18 women (15%) developed recurrent UTIs, frequently associated with MDR organisms. Most diagnosed women were primarily treated with empirical antibiotics according to routine clinical practice.
Conclusions
Pregnant women in Palestine face a high burden of UTIs, dominated by E. coli and S. aureus, with alarming levels of multidrug resistance. Strengthening culture-based diagnosis, local resistance surveillance, and antimicrobial stewardship in antenatal care is crucial to improving maternal outcomes and mitigating the spread of antimicrobial resistance.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12879-026-13978-0.
Keywords: Antimicrobial resistance, Asymptomatic bacteriuria, Escherichia coli, Multidrug resistance, Palestine, Pregnancy, Primary health care, Urinary tract infection
Background
Urinary tract infections (UTIs) are among the most common bacterial infections affecting women worldwide [1]. Up to 60% of women experience at least one UTI in their lifetime, and the risk increases to 20% during pregnancy, with recurrence occurring in up to 25% of cases [2]. These estimates primarily reflect prevalence data, whereas incidence varies depending on population characteristics and healthcare settings. Physiological changes such as urinary stasis, hormonal shifts, and altered immune responses make pregnant women more susceptible to infections like acute cystitis and pyelonephritis, as well as clinically significant bacterial colonization, such as asymptomatic bacteriuria (ASB) [3]. Although ASB is not a symptomatic infection, it is clinically important during pregnancy due to its association with adverse outcomes if left untreated. These infections, if not promptly treated, can lead to serious complications, including preterm birth, low birth weight, and maternal sepsis [4].
Globally, UTIs among pregnant women are most commonly caused by bacteria from the Enterobacteriaceae family, specifically Escherichia coli [3], followed by Klebsiella pneumoniae and Staphylococcus aureus. However, the bacterial profile of UTIs and associated resistance patterns vary by region, influenced by local antimicrobial prescribing practices, accessibility of healthcare, and the misuse of antibiotics [5]. The increasing prevalence of resistant uropathogens such as extended-spectrum beta-lactamase (ESBL)-producing E. coli and Klebsiella pneumoniae has reduced the effectiveness of first-line treatments and further limited therapeutic options during pregnancy, where safety considerations already restrict the range of available options [6].
Recurrent UTIs during pregnancy add another layer of complexity [7], complicating treatment choices and often resulting in repeated antibiotic use, which may increase the reliance on empiric broad-spectrum antibiotic prescribing, thereby raising the risk of multidrug-resistant infections (MDRs) [8]. Notably, 80% of drug prescriptions during pregnancy are antibiotics, mainly for UTIs [9]. Selecting an antibiotic, therefore, requires a careful balance between the mother’s and fetus’s safety, efficacy, and local resistance rates [10].
In Palestine, data on the epidemiology of UTIs during pregnancy, including microbial etiology, antimicrobial resistance (AMR) patterns, and recurrence, are limited. Antenatal care is primarily delivered through the Ministry of Health primary healthcare clinics, which provide routine maternal services. National policy formally recommends routine screening for ASB using urine culture at the initial booking visit and again at 24 weeks of pregnancy; however, this recommendation is not consistently implemented in practice. Implementation varies across facilities due to differences in access to laboratory screening and diagnostic resources. As a result, urine culture testing is often performed based on clinical judgment, resource availability, or patient acceptance rather than as part of a standardized screening program.
Most available studies focus on general adult populations rather than pregnant women, who represent a high-risk group within antenatal care. Furthermore, prospective cohort data in this population are lacking. Addressing this gap is essential to inform clinical decision-making, optimize the antibiotic stewardship program, and support evidence-based maternal healthcare policies in the local context.
Accordingly, this study aimed to investigate the bacterial profiles, AMR patterns, and recurrence of UTIs as well as associated clinical and sociodemographic factors, among pregnant women attending antenatal care clinics in Nablus, Palestine.
Methods
Study design
A prospective observational cohort study was conducted in primary healthcare clinics in Nablus, West Bank, Palestine, from December 2024 to May 2025. This study incorporated data collected through questionnaires, clinical examination, and laboratory analyses of urine samples.
Study settings and population
The study was conducted in primary health care clinics located in Nablus City, as well as in surrounding villages and refugee camps. These clinics operate under the Palestinian Ministry of Health and include the following sites: Muhammad Al-Maktoum Clinic (Balata), Al-Makhfiya Clinic, Beit Furik Clinic, Aqraba Clinic, Madama Clinic, Jamma’in Clinic, Huwwara Clinic, Qabalan Clinic, Urif Clinic, Duma Clinic, Beit Iba Clinic, and Asira Al-Shamaliya Clinic.
The study included all pregnant women aged 18 years or older who attended these clinics and consented to participate. Exclusion criteria included receipt of antimicrobial therapy within two weeks, provision of an insufficient urine samples (< 10 mL), urine specimens received more than 2 h after collection, samples submitted in leaking or dirty unsterile containers, and cases where cultures indicated growth of more than two types of bacteria.
Cohort and flow
Two analytical cohorts were pre-specified:
Cohort A: all enrolled pregnant women who provided urine samples and underwent culture testing, used for incidence and microbiological analysis.
Cohort B: a subset of cohort A comprising participants who completed the 90-day follow-up period, used for recurrence analysis.
This study was conducted in five sequential phases (Fig. 1).
Fig. 1.
Study workflow
Part 1: Baseline data collection
At the time of enrollment, after obtaining informed consent, baseline data were collected using a structured questionnaire administered through face-to-face interviews, and participants’ medical records were reviewed. The questionnaire was adapted from previously published studies [11–14] with certain modifications to fit the study context. These included adding or removing questions to reflect local conditions and study objectives. The questionnaire was originally written in English, as shown in the supplementary file 1, and then translated into Arabic. To validate the adapted version, the questionnaire was reviewed by a panel of specialists in urology, gynecology, and clinical pharmacy. A pilot study involving 10 participants (not included in the final sample) was conducted to assess comprehension and clarity. Based on pilot feedback, minor adjustments were made before final implementation.
Baseline data collected included sociodemographic characteristics (age, place of residence, education level, and monthly income). Socioeconomic status was categorized based on monthly household income into three groups: low (< 2000 NIS), middle (2000–4000 NIS), and high (> 4000 NIS), based on locally relevant income distribution thresholds. In addition, medical and obstetrical information such as gestational age, gravidity, parity, allergies, comorbidities, history of previous UTIs, and history of urinary catheterization (for any medical or obstetric indication). Urinary catheterization was included as a potential risk factor for UTI; however, the specific indication for catheterization (e.g., obstetric, surgical, or diagnostic) was not systematically recorded.
Sociodemographic and clinical characteristics were self-reported by participants, while symptom data were recorded by trained researchers.
Part 2: The follow-up phase, which included
During follow-up, data were collected on clinical characteristics and symptoms of UTIs, including frequency of urination, lower abdominal pain, back pain, dysuria, hematuria, fever, and vaginal discharge accompanied by internal itching. Additional information included the diagnostic method used for confirming UTI (whether urine culture was accepted or declined by the participant), antibiotic prescription status, name of the prescribed antibiotic, route of administration, dosage, and treatment duration. Detailed treatment data were collected for all cases; however, formal evaluation of treatment appropriateness and concordance with antimicrobial susceptibility results was not included in the present analysis. Data were also collected on treatment adherence and symptom improvement following completion of antibiotic therapy.
Urine culture was intended to be performed for all participants as part of the study protocol, in line with recommendations that consider it the gold standard for UTI diagnosis during pregnancy. However, uptake varied, and testing was more frequently performed among symptomatic women, as asymptomatic participants or those with normal urine analysis results were more likely to decline culture testing. This reflects real-world clinical practice in the study setting, where urine culture is often reserved for recurrent or treatment-resistant cases rather than being performed routinely. Urine culture was offered irrespective of urine sediment findings; however, participants with negative urine analysis were more likely to decline testing.
A follow-up period of 90 days was selected to capture early recurrence of UTI following initial diagnosis and treatment, consistent with definitions of short-term recurrence. Recurrent UTI was defined as a new episode of UTI occurring within 90 days after the initial diagnosis, based on clinical assessment with or without culture confirmation, depending on testing availability and patient acceptance.
Part 3: Laboratory sample collection
Participants received standardized verbal instructions for urine collection. A 10-milliliter clean-catch mid-stream urine (MSU) sample was obtained from each study participant using a wide-mouthed sterile container. Each urine sample was labelled and transported to the laboratory. Samples were processed using a calibrated loop (0.001 ml). Urine samples were centrifuged to produce sediment for microscopic analysis, which included counts of red and white blood cells (pyuria), squamous cells, and bacteria.
Urine culture was offered to all enrolled participants as part of the study protocol; however, uptake varied. Some participants did not provide urine samples due to factors including absence of urinary symptoms, negative urine analysis findings, patient refusal, or logistical constraints such as time limitations or inability to provide a sample during the clinic visit.
UTI was defined based solely on urine culture results, with significant bacteriuria defined as ≥ 10⁵ CFU/mL, in accordance with standard microbiological criteria. Urinalysis findings, including pyuria, were recorded as supportive laboratory indicators but were not used to define UTI status.
Part 4: Urine culture and microbiological analysis
To confirm infection and exclude physiological pyuria of pregnancy, a urine culture was done. The urine specimens were inoculated into blood agar and MacConkey agar plates. After overnight incubation at 37 °C for 24–48 h, colony counts were taken to check for significant growth. A colony count of bacterial growth of ≥ 100,000 (105) CFU/mL of a single organism in a voided midstream urine sample was considered significant, in accordance with standard microbiological criteria. Lower colony count thresholds (e.g., 10³ CFU/mL) were not evaluated in this study.
Urine cultures showing growth of more than two organisms (≥ 3) were considered contaminated and excluded from analysis, with repeat sampling recommended. For cultures yielding two organisms, interpretation was based on colony count and relative predominance. When one organism demonstrated significant growth (≥ 10⁵ CFU/mL) and the second organism was present at substantially lower counts, the latter was considered contamination. In rare cases where two organisms were isolated at comparable significant counts (≥ 10⁵ CFU/mL), the culture was classified as a possible polymicrobial infection and interpreted with caution.
Bacterial identification was conducted using colony morphology, Gram staining, and biochemical tests (e.g., indole, citrate, and urease) in accordance with standard microbiological protocols. Specimens that could not be processed immediately were stored at 4 °C until analysis.
Part 5: Antibiotic susceptibility testing
Antibiotic susceptibility testing was performed using the Kirby–Bauer disc diffusion method on Mueller–Hinton agar, and results were interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guidelines, 2022/2023 edition. Quality control, where applicable, included reference strains Escherichia coli ATCC 25,922 and Staphylococcus aureus ATCC 25,923, following CLSI recommendations. Commercial discs (Oxoid, UK) were routinely used, and inhibition zones were measured to the nearest millimeter. The primary antibiotic panel included pregnancy-safe agents (nitrofurantoin, fosfomycin, amoxicillin-clavulanate, cephalosporins, gentamicin, amikacin). Additional agents, including tetracyclines, fluoroquinolones and colistin, were tested as a part of an extended exploratory antimicrobial panel reflecting routine laboratory practices; these were not considered for primary clinical interpretation and are presented the Supplementary Tables. Colistin susceptibility testing was performed using disc diffusion; however, this method is not recommended for colistin according to CLSI/EUCAST guidelines. Therefore, colistin results were excluded from the primary analysis. Extended-spectrum β-lactamase (ESBL) production was screened using cefotaxime and ceftazidime discs with clavulanic acid confirmation. Carbapenemase activity was assessed using meropenem and imipenem discs with inhibitor-based confirmation.
Sub-culturing on Mueller-Hinton media. Bacterial identification involved Gram staining and biochemical characterization. The sterile antibiotic disks were utilized according to CLSI guidelines. The plates were allowed to stand for a few minutes and subsequently incubated at 37 °C for 24 h, within 15 min of application. Antibiotic sensitivity was assessed by measuring the zone of inhibition from the back of the plate to the nearest millimeter using a ruler or caliper. The sterile zone of inhibition was measured to determine the resistance, intermediate susceptibility, or susceptibility of the bacterial isolates.
Bacteria were classified into each of the antibiotics used in the test as sensitive (S), Intermediate (I), or Resistant (R). Multidrug resistance (MDR) was defined according to CDC/ECDC criteria as non-susceptibility to at least one agent in three or more antimicrobial categories [15].
Data analysis
After data collection was done, it was extracted and recorded in an Excel workbook (Microsoft Office, 2024). Before analysis, data cleaning, coding, and grouping were conducted. The data were then summarized using descriptive statistics. All variables collected through the questionnaire and lab data were summarized by calculating the frequency (%) for binary variables.
To provide a composite measure of UTI symptoms, a symptom score was calculated by summing the number of positive responses for each participant, with possible scores ranging from 0 to 7. Participants with no symptoms received a score of 0, while those experiencing multiple symptoms received higher scores accordingly.
The chi-square test was used to assess associations between categorical variables: clinical/ sociodemographic characteristics and clinical UTI symptoms and urine culture results (positive vs. negative). Significance was considered at a p-value of < 0.05.
In addition, multivariable logistic regression analyses were performed to identify independent predictors of culture-confirmed UTI, MDR, and recurrence while controlling for potential confounding factors. Variables were selected a priori based on clinical relevance and biological plausibility. For the UTI model, variables included age, educational level, occupation, trimester of pregnancy, and prior history of UTI. For the MDR model, analysis was restricted to participants with confirmed UTI and included educational level, prior UTI, prior antibiotic use, Gram stain classification, and trimester. Recurrence analysis was conducted among participants who completed the 90-day follow-up period; due to the limited number of events, the number of variables included was restricted to avoid overfitting. Educational level was recoded into two categories (low vs. secondary or higher education) to improve model stability. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. Complete-case analysis was performed. All analyses were carried out using SPSS version 27.
Ethical consideration
The study protocol received ethical approval from the Ethical Committee at Al-Quds University, with the archive number (461/REC/2024), as well as from the local health authorities. Before participation, informed consent was obtained from each participant, and respondents were informed about the study phases. Participants were also assured that they could withdraw at any stage during the study without any consequences. All information shared and data collected during the study were coded and kept confidential. All methods were performed in accordance with the relevant guidelines and regulations.
Results
Study participants
A total of 485 women were initially recruited into the study. Of these, 279 (57.5%) provided urine culture samples and were included in the microbiological analysis, while 206 (42.5%) did not undergo culture testing. Among the 206 participants who did not complete urine culture testing despite reporting urinary symptoms, the most frequently reported reason was declining the test despite healthcare provider recommendation (n = 58, 28.2%). Other common reasons included perceiving the test as unnecessary due to mild or intermittent symptoms (n = 42, 20.4%), having a negative urine analysis result and electing not to proceed with culture testing (n = 36, 17.5%), and limited access to laboratory services, including transportation difficulties, travel restrictions, and long distances to testing facilities (n = 31, 15.0%). Additional reasons included inability to provide a urine sample during the clinic visit (n = 15, 7.3%), concerns regarding testing costs (n = 10, 4.9%), competing family or work responsibilities (n = 8, 3.9%), failure to return with the requested sample or attend the laboratory appointment (n = 4, 1.9%), and other miscellaneous reasons (n = 2, 1.0%). Comparison of baseline characteristics between participants who provided urine samples and those who did not showed no statistically significant differences in age, gestational age, or history of prior UTI (p > 0.05).
Among them, 120 completed the 90-day follow-up and were included in the final recurrence analysis. A total of 159 participants were lost to follow-up, primarily due to delivery, miscarriage, missed antenatal visits, failure to return for scheduled clinic visits, or inability to establish contact due to incomplete or outdated information despite repeated attempts (Fig. 2).
Fig. 2.
Study participants flow chart
To assess potential attrition bias, baseline characteristics were compared between participants who completed follow-up and those lost to follow-up (Supplementary Table S1). No statistically significant differences were observed regarding age, educational level, or pregnancy trimester (all p > 0.05). However, participants with positive baseline urine cultures were significantly more likely to complete follow-up than those with negative cultures (59.1% vs. 28.7%, p < 0.001).
Sociodemographic, clinical, and obstetrical history of participants
Table 1 presents participants’ characteristics by urine culture results. Most were aged 25–34 years (45.9%), more than half of the participants had completed high school (53.0%), and were housewives (88.9%), and lived in villages (73.5%). Regarding socioeconomic status, nearly two-thirds (64.5%) reported a middle income, followed by 24.0% with low income and 11.5% with high income. The majority were non-smokers (82.4%).
Table 1.
Sociodemographic and clinical characteristics and obstetrical history by urine culture results (Total = 279)
| Variables | Total (n = 279) | Positive (n = 115) | Negative (n = 164) | P-value |
|---|---|---|---|---|
| Age (years) | 0.023* | |||
| 18–24 | 105 (37.6) | 53 (46.1) | 52 (31.7) | |
| 25–34 | 128 (45.9) | 49 (42.6) | 79 (48.2) | |
| 35–44 | 35 (12.5) | 12 (10.4) | 23 (14) | |
| > 45 | 11 (3.9) | 1 (0.9) | 10 (6.1) | |
| Educational Level | 0.001* | |||
| Illiterate | 2 (0.7) | 2 (1.7) | 0 (0) | |
| Primary | 16 (5.7) | 13 (11.3) | 3 (1.8) | |
| Higher school | 148 (53) | 62 (53.9) | 86 (52.4) | |
| Bachelor’s | 110 (39.4) | 38 (33) | 72 (43.9) | |
| Postgraduate degree | 3 (1.1) | 0 (0) | 3 (1.8) | |
| Occupation | < 0.001* | |||
| Housewife | 248 (88.9) | 112 (97.4) | 136 (82.9) | |
| Employee \ Businesswoman | 31 (11.1) | 3 (2.6) | 28 (17.1) | |
| Socioeconomic status | 0.049* | |||
| Low (< 2000 NIS) | 67 (24) | 34 (29.6) | 33 (20.1) | |
| Middle (2000–4000 NIS) | 180 (64.5) | 73 (63.5) | 107 (65.2) | |
| High (> 4000 NIS) | 32 (11.5) | 8 (7) | 24 (14.6) | |
| Smoking status | 0.380 | |||
| Smoker | 14 (5) | 4 (3.5) | 10 (6.1) | |
| Ex-smokers | 35 (12.5) | 12 (10.4) | 23 (14) | |
| Non smoker | 230 (82.4) | 99 (86.1) | 131 (79.9) | |
| Geographic Location of the residence | 0.024* | |||
| City | 64 (22.9) | 22 (19.1) | 42 (25.6) | |
| Village | 205 (73.5) | 85 (73.9) | 120 (73.2) | |
| Camp | 10 (3.6) | 8 (7) | 2 (1.2) | |
| Current Medications | 0.084 | |||
| Yes | 61 (21.9) | 31 (27) | 30 (18.3) | |
| No | 218 (78.1) | 84 (73) | 134 (81.7) | |
| Types of medications | 0.032* | |||
| Anticoagulants | 15 (30.6) | 11 (47.8) | 4 (15.4) | |
| Antibiotics | 12 (24.5) | 7 (30.4) | 5 (19.2) | |
| Pain Relievers / Anti-inflammatory | 8 (16.3) | 1 (4.3) | 7 (26.9) | |
| Thyroid Medications | 11 (22.4) | 3 (13) | 8 (30.8) | |
| Miscellaneous | 3 (6.1) | 1 (4.3) | 2 (7.7) | |
| History of urinary catheterization (for any reason) | 0.171 | |||
| Yes | 19 (6.8) | 5 (4.3) | 14 (8.5) | |
| No | 260 (93.2) | 110 (95.7) | 150 (91.5) | |
| Pregnancy trimester currently in | < 0.001* | |||
| First Trimester (1–12 weeks) | 60 (21.5) | 44 (38.3) | 16 (9.8) | |
| Second Trimester (13-26weeks) | 111 (39.8) | 47 (40.9) | 64 (39) | |
| Third Trimester (27–40 weeks) | 108 (38.7) | 24 (20.9) | 84 (51.2) | |
| Gravidity | 0.382 | |||
| 1 | 79 (28.3) | 30 (26.1) | 49 (29.9) | |
| 2–5 | 172 (61.6) | 76 (66.1) | 96 (58.5) | |
| ≥ 6 | 28 (10) | 9 (7.8) | 19 (11.6) | |
| Parity | 0.385 | |||
| 0 | 70 (25.1) | 32 (27.8) | 38 (23.2) | |
| 1 | 58 (20.8) | 19 (16.5) | 39 (23.8) | |
| 2–5 | 144 (51.6) | 60 (52.2) | 84 (51.2) | |
| ≥ 6 | 7 (2.5) | 4 (3.5) | 3 (1.8) | |
| Abortion | 0.002* | |||
| Yes | 94 (33.7) | 51 (44.3) | 43 (26.2) | |
| No | 185 (66.3) | 64 (55.7) | 121 (73.8) |
* Indicates a statistically significant difference at P<0.05; N: number of the subject
Obstetrical history showed that 39.8% were in the second trimester of pregnancy, followed by the third trimester (38.7%), while a smaller proportion were in the first trimester (21.5%). Nearly two-thirds of the women (61.6%) reported two to five previous pregnancies. A notable proportion of participants (33.7%) reported a history of abortion.
UTI diagnostic approaches and laboratory findings
Table 2 summarizes the microbiological and clinical diagnostic findings among the 279 pregnant women who underwent urine culture. Of these, 115 (41.2%) had culture-positive UTIs, while 164 (58.8%) showed negative growth. Among the culture-positive cases, the majority (62.6%) were caused by Gram-negative bacteria, whereas 37.4% were caused by Gram-positive bacteria. The majority of the isolates were bacterial (95.1%), while Candida species were infrequently isolated (4.9%). Clinically, 91.3% of culture-positive cases presented with symptomatic infections, whereas only 8.7% were asymptomatic bacteriuria.
Table 2.
Urine culture growth, Gram staining, and classification of bacteriuria among participants
| Variables | Categories | N (%) |
|---|---|---|
| Culture growth (n = 279) | Bacteria | 115 (41.2) |
| Candida | 9 (3.2) | |
| Negative | 155 (55.6) | |
| Gram stain (n = 115) | Gram positive | 43 (37.4) |
| Gram negative | 72 (62.6) | |
| Clinical classification (n = 115) | Asymptomatic Bacteriuria | 10 (8.7%) |
| Symptomatic Bacteriuria | 105 (91.3%) |
Clinical UTI symptoms among the study participants and risk factors
The most frequently reported symptoms were frequent urination (65.6%), back pain (45.2%), lower abdominal pain (45.2%), Vaginal discharge and internal itching (38.0%), and painful urination (26.9%). Fever and blood in the urine were uncommon, 5.7% and 5.4%, respectively. All reported symptoms were statistically significant with culture positivity (all P < 0.001). Higher symptom scores correlated with a greater likelihood of urine culture positivity (P < 0.001, Table 3).
Table 3.
Clinical UTI symptoms by culture results among the study participants
| Total (n = 279) | Positive UTI (n = 115) | Negative UTI (n = 164) | P-value | ||
|---|---|---|---|---|---|
| Frequent urination | < 0.001 * | ||||
| Yes | 173 (62.0%) | 105 (91.3) | 68 (41.5) | ||
| No | 106 (38.0%) | 10 (8.7) | 96 (58.5) | ||
| Lower abdominal pain | < 0.001 * | ||||
| Yes | 126 (45.2%) | 89 (77.4) | 37 (22.6) | ||
| No | 153 (54.8%) | 26 (22.6) | 127 (77.4) | ||
| Back pain | < 0.001 * | ||||
| Yes | 126 (45.2%) | 91 (79.1) | 35 (21.3) | ||
| No | 153 (54.8%) | 24 (20.9) | 129 (78.7) | ||
| Painful urination | < 0.001* | ||||
| Yes | 75 (26.9) | 72 (62.6) | 3 (1.8) | ||
| No | 204 (73.1) | 43 (37.4) | 161 (98.2) | ||
| Blood in urine | < 0.001* | ||||
| Yes | 15 (5.4) | 15 (13.0) | 0 (0) | ||
| No | 264 (94.6) | 100 (87.0) | 164 (100) | ||
| Fever | < 0.001* | ||||
| Yes | 16 (5.7) | 16 (13.9) | 0 (0) | ||
| No | 263 (94.3) | 99 (86.1) | 164 (100) | ||
| Vaginal discharge and internal itching | < 0.001* | ||||
| Yes | 106 (38.0) | 73 (63.5) | 33 (20.1) | ||
| No | 173 (62.0) | 42 (36.5) | 131 (79.9) | ||
|
Scoring 0 1 2 3 4 5 6 |
< 0.001* | ||||
| 98 (35.3%) | 2 (1.8%) | 96 (58.5%) | |||
| 38 (13.7%) | 13 (11.4%) | 25 (15.2%) | |||
| 30 (10.8%) | 18 (15.8%) | 12 (7.3%) | |||
| 50 (18.0%) | 19 (16.7%) | 31 (18.9%) | |||
| 47 (16.9%) | 47 (41.2%) | 0 (0) | |||
| 2 (0.7%) | 2 (1.8%) | 0 (0) | |||
| 13 (4.7%) | 13 (11.4%) | 0 (0) | |||
* Indicates a statistically significant difference at P<0.05; N: number of the subject & X2: chi-square test
Microbial profile of confirmed UTI cases
Figure 3 presents bacterial species isolated from participants during the study period. Two cultures (n = 2) met criteria for possible polymicrobial infection and were included with cautious interpretation. E. coli was the most prevalent (44(38.3%)), followed by S. aureus (26 (22.6%)) and K. pneumoniae (23 (20%)). Table 4 demonstrates the distribution of microbial isolates by Gram stain classification. The majority of isolates were identified as Gram-negative (72 (62.6%)). Among the Gram-negative bacteria, E. coli was the most prevalent isolate (61.1%), followed by K. pneumoniae (31.9%), P. aeruginosa (4.2%), E. cloacae (1.4%), and Proteus species (1.4%). Among the Gram-positive bacteria (n = 43), S. aureus was the most dominant species, representing 60.5%. Other notable Gram-positive organisms included S. coagulase-negative (16.3%), Enterococcus species (14.0%), S. saprophyticus (4.7%), S. agalactiae (2.3%), and S. epidermidis (2.2%).
Fig. 3.
Distribution of types of Bacteria among the study participants
Table 4.
Urinary tract bacterial isolates
| Bacteria isolates total (n = 115) | n (%) |
|---|---|
| Gram-negative (n = 72) | |
| E. coli | 44 (38.3) |
| Klebsiella pneumoniae | 23 (20) |
| Pseudomonas aeruginosa | 3 (2.6) |
| Enterobacter cloacae | 1 (0.9) |
| Proteus | 1 (0.9) |
| Gram positive (n = 43) | |
| S. aureus | 26 (22.6) |
| Staph CNS | 7 (6.1) |
| Enterococcus | 6 (5.2) |
| S. agalactiae | 1 (0.9) |
| S. Saprophyticus | 2 (1.7) |
| Staph epidermidis | 1 (0.9) |
n: number of the subject
Antimicrobial susceptibility pattern of uropathogens isolated from urine specimens
Table 5 presents antibiotic susceptibility patterns for the most clinically relevant uropathogens and commonly used antibiotics during pregnancy. Extended susceptibility data for additional antibiotics and less frequent organisms are provided in the Supplementary Table 1a and b. The results reveal varied responses across different pathogens. E. coli, the most common isolate, showed good sensitivity to nitrofurantoin (81.6%) and fosfomycin (64.7%), making them appropriate treatment options. However, resistance was notable to commonly used antibiotics such as amoxicillin clavulanate and cefuroxime, both with resistance rates above 30%. K. pneumoniae and S. aureus also showed mixed susceptibility, with lower sensitivity to several first-line agents but better response to drugs like amikacin and ceftriaxone. Other organisms, such as Enterococcus and coagulase-negative staphylococci, displayed inconsistent patterns.
Table 5.
Antimicrobial susceptibility pattern of uropathogens isolated from urine specimens
| Organism | Antibiotic | Tested (N) | Sensitive n (%) | Intermediate n (%) | Resistant n (%) |
|---|---|---|---|---|---|
| E. coli (n = 44) | Nitrofurantoin | 43 | 36 (83.7% | 2 (4.7%) | 5 (11.6% |
| Fosfomycin | 17 | 11 (64.7) | 0(0) | 6 (35.3) | |
| Amoxicillin-clavulanate | 40 | 22 (55.0) | 5 (12.5) | 13 (32.5) | |
| Cefuroxime | 40 | 24 (60) | 3 (7.5) | 13 (32.5) | |
| Cefixime | 25 | 14 (56.0) | 1 (4) | 10 (40.0) | |
| K. pneumoniae (n = 23) | Nitrofurantoin | 22 | 18 (81.8%)) | 0(0) | 4 (18.2) |
| Fosfomycin | 13 | 11 (84.6) | 0(0) | 2 (15.4) | |
| Amoxicillin-clavulanate | 15 | 1(6.7) | 0(0) | 14(93.3%)) | |
| Cefuroxime | 17 | 3 (17.6) | 0(0) | 14(82.4%) | |
| Cefixime | 14 | 3 (21.4) | 2 (14.3) | 9 (64.3) | |
| S. aureus (n = 26) | Nitrofurantoin | 21 | 20 (95.2%)) | 0(0) | 1 (4.8) |
| Fosfomycin | 18 | 5 (27.8) | 2 (11.1) | 11 (61.1) | |
| Amoxicillin-clavulanate | 15 | 11 (73.3) | 0(0) | 4 (26.7%) | |
| Cefuroxime | 17 | 14 (82.4%) | 1 (5.9) | 2 (11.8) | |
| Cefixime | 13 | 3 (23.1) | 0(0) | 10 (76.9) |
Note: n represents the absolute number of bacterial isolates presenting the specific susceptibility pattern, while the percentage (%) indicates the proportion relative to the total number of isolates explicitly tested for that individual agent (N)Prevalence of MDR Among Isolates
Table 6 presents the distribution of uropathogens by number of antibiotic resistances among positive cultures (n = 115). Overall, 55.7% of the isolates were classified as MDR, showing non-susceptibility to at least one agent in three or more antimicrobial classes, while 44.3% were non-MDR. When stratified by Gram stain, resistance was more pronounced among Gram-negative uropathogens. E. coli remained the leading resistant species, with nearly half of isolates (46.4%) resistant to ≥ 5 antibiotics, followed by K. pneumoniae (25%). Gram-positive bacteria showed comparatively lower resistance, although S. aureus accounted for 10.7% of isolates resistant to five or more agents. The more than 5 antibiotics resistance category highlights a particularly concerning issue with E. coli, where 46.4% of isolates exhibit resistance to five or more antibiotics. Similarly, other pathogens such as K. pneumoniae and S. aureus also demonstrate moderate resistance, with 25% and 10.7% of isolates, respectively, showing resistance to five or more antibiotics. Gram-negative isolates overall were significantly more likely to be MDR than Gram-positive (p = 0.048; Table 6).
Table 6.
Distribution of Uropathogens by Number of Antibiotic Resistances Among Confirmed UTI Cases (n = 115)
| Number of antibiotic resistance n (%) | ||||||
|---|---|---|---|---|---|---|
| No resistance | 1 | 2 | 3 | 4 | 5 or more | |
| Gram-negative bacteria | ||||||
| E. coli | 6 (42.9) | 8 (44.4) | 4 (21.1) | 4 (19) | 9 (60) | 13 (46.4) |
| K. pneumoniae | 3 (21.4) | 1 (5.6) | 6 (31.6) | 5 (23.8) | 1 (6.7) | 7 (25) |
| P. aeruginosa | 1 (7.1) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 2 (7.1) |
| E. cloacae | 0 (0) | 1 (5.6) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Proteus | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (3.6) |
| Gram-positive bacteria | ||||||
| S. aureus | 2 (14.3) | 5 (27.8) | 5 (26.3) | 8 (38.1) | 3 (20) | 3 (10.7) |
| Coagulase negative | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Staph CNS | 0 (0) | 0 (0) | 2 (10.5) | 3 (14.3) | 1 (6.7) | 1 (3.6) |
| Enterococcus | 1 (7.1) | 2 (11.1) | 1 (5.2) | 1 (4.8) | 1 (6.6) | 0 (0) |
| S. agalactiae | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (3.6) |
| S. Saprophyticus | 1 (7.2) | 1 (5.5) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Staph Epidermidis | 0 (0) | 0 (0) | 1 (5.3) | 0 (0) | 0 (0) | 0 (0) |
| Variables | Categories | Total (n = 115) | Gram-Negative (n = 72) | Gram-Positive (n = 43) | P-value | |
| MDR | No resistance | 14 (12.2) | 10 (13.9) | 4 (9.3) | 0.048* | |
| 1 | 18 (15.7) | 10 (13.9) | 8 (18.6) | |||
| 2 | 19 (16.5) | 10 (13.9) | 9 (20.9) | |||
| 3 | 21 (18.3) | 9 (12.5) | 12 (27.9) | |||
| 4 | 15 (13) | 10 (13.9) | 5 (11.6) | |||
| ≥ 5 | 28 (24.3) | 23 (31.9) | 5 (11.6) | |||
* Indicates a statistically significant difference at P<0.05; n: number of the subject & c2: chi-square test
Recurrence of UTI among participants
At 90-day follow-up, 18 women (15%) developed recurrent UTI. The chi-square test revealed no statistically significant association between recurrent UTI and clinical-sociodemographic or obstetric variables (p > 0.05; Table 7).
Table 7.
Clinical-sociodemographic and obstetric variables by recurrent UTI status among participants
| Variables | Total (N = 120) | Non-Recurrent (N = 102) | Recurrent (N = 18) | P-value |
|---|---|---|---|---|
| Age (years) | 0.946 | |||
| 18–24 | 52 (43.3) | 45 (44.1) | 7 (38.9) | |
| 25–34 | 47 (39.2) | 40 (39.2) | 7 (38.9) | |
| 35–44 | 16 (13.3) | 13 (12.7) | 3 (16.7) | |
| > 45 | 5 (4.2) | 4 (3.9) | 1 (5.6) | |
| Educational Level | 0.365 | |||
| Illiterate | 2 (1.7) | 2 (2) | 0 (0) | |
| Primary | 10 (8.3) | 10 (9.8) | 0 (0) | |
| Higher school | 62 (51.7) | 50 (49) | 12 (66.7) | |
| Bachelor’s | 46 (38.3) | 40 (39.2) | 6 (33.3) | |
| Master/ PhD | 0 (0) | 0 (0) | 0 (0) | |
| Occupation | 1.000 | |||
| Housewife | 100 (83.3) | 85 (83.3) | 15 (83.3) | |
| Employee Businesswoman | 20 (16.7) | 17 (16.7) | 3 (16.7) | |
| Socioeconomic status (income in shekels) | 0.894 | |||
| Low (< 2000) | 33 (27.5) | 28 (27.5) | 5 (27.8) | |
| Middle (2000–4000) | 71 (59.2) | 61 (59.8) | 10 (55.6) | |
| High (> 4000) | 16 (13.3) | 13 (12.7) | 3 (16.7) | |
| Smoking status | 0.209 | |||
| Smoker | 5 (4.2) | 3 (2.9) | 2 (11.1) | |
| Ex-smokers | 14 (11.7) | 13 (12.7) | 1 (5.6) | |
| Non smoker | 101 (84.2) | 86 (84.3) | 15 (83.3) | |
| Geographic Location of the residence | 0.692 | |||
| City | 25 (20.8) | 21 (20.6) | 4 (22.2) | |
| Village | 91 (75.8) | 77 (75.5) | 14 (77.8) | |
| Camp | 4 (3.3) | 4 (3.9) | 0 (0) | |
| Current pregnancy trimester | 0.345 | |||
| First Trimester (1–12 weeks) | 34 (28.3) | 27 (26.5) | 7 (38.9) | |
| Second Trimester (13–26 weeks) | 50 (41.7) | 42 (41.2) | 8 (44.4) | |
| Third Trimester (27–40 weeks) | 36 (30) | 33 (32.4) | 3 (16.7) | |
| Gravidity | 0.136 | |||
| 1 | 29 (24.2) | 24 (23.5) | 5 (27.8) | |
| 2–5 | 72 (60) | 59 (57.8) | 13 (72.2) | |
| ≥ 6 | 19 (15.8) | 19 (18.6) | 0 (0) | |
| Parity | 0.619 | |||
| 0 | 51 (42.5) | 44 (43.1) | 7 (38.9) | |
| 1 | 0 (0) | 0 (0) | 0 (0) | |
| 2–5 | 65 (54.2) | 54 (52.9) | 11 (61.1) | |
| ≥ 6 | 4 (3.3) | 4 (3.9) | 0 (0) | |
| Abortion | 0.317 | |||
| Yes | 46 (38.3) | 41 (40.2) | 5 (27.8) | |
| No | 74 (61.7) | 61 (59.8) | 13 (72.2) | |
Predictors of culture-positive UTI
Statistical analysis revealed that age group, educational level, occupation, income level, and place of residence were significantly associated with UTI culture positivity (p < 0.05) (Table 1). Among obstetrical variables, trimester of pregnancy (p < 0.001) and abortion history (p = 0.002) were significantly associated, while no associations were found with gravidity or parity (p-values > 0.05) (Table 1).
UTI symptoms and resistance burden
Table 8 presents the relationship between UTI symptoms and the drug susceptibility pattern of UTI in pregnant women (N = 115). Participants who experienced frequent urination, lower abdominal pain, back pain, dysuria, hematuria, fever, or vaginal discharge/ internal itching, as well as higher scores (p < 0.001), were more likely to harbor antibiotic resistance.
Table 8.
Correlation between Clinical UTI Symptoms and Number of Antibiotic Resistances Among Confirmed Cases (N = 115)
| Variables | Total positive (115) |
Number of antibiotic resistance n (%) | ||||||
|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | 4 | 5 or more | P-value | ||
| Frequent urination | < 0.001* | |||||||
| Yes | 105 (91.3) | 6 (42.9) | 16 (88.9) | 19 (100) | 21 (100) | 15 (100) | 28 (100) | |
| No | 10 (8.7) | 8 (57.1) | 2 (11.1) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
| Lower abdominal pain | 0.001* | |||||||
| Yes | 78 (67.8) | 2 (14.3) | 14 (77.8) | 15 (78.9) | 15 (71.4) | 11 (73.3) | 21 (75) | |
| No | 37 (32.2) | 12 (85.7) | 4 (22.2) | 4 (21.1) | 6 (28.6) | 4 (26.7) | 7 (25) | |
| Back pain | 0.009* | |||||||
| Yes | 79 (68.7) | 4 (28.6) | 11 (61.1) | 15 (78.9) | 14 (66.7) | 13 (86.7) | 22 (78.6) | |
| No | 36 (31.3) | 10 (71.4) | 7 (38.9) | 4 (21.1) | 7 (33.3) | 2 (13.3) | 6 (21.4) | |
| Painful urination | 0.031* | |||||||
| Yes | 58 (50.4) | 2 (14.3) | 10 (55.6) | 13 (68.4) | 8 (38.1) | 9 (60) | 16 (57.1) | |
| No | 57 (49.6) | 12 (85.7) | 8 (44.4) | 6 (31.6) | 13 (61.9) | 6 (40) | 12 (42.9) | |
| Blood in urine | 0.023* | |||||||
| Yes | 7 (6.1) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 3 (20) | 4 (14.3) | |
| No | 108 (93.9) | 14 (100) | 18 (100) | 19 (100) | 21 (100) | 12 (80) | 24 (85.7) | |
| Fever | 0.003* | |||||||
| Yes | 12 (10.4) | 0 (0) | 0 (0) | 0 (0) | 1 (4.8) | 3 (20) | 8 (28.6) | |
| No | 103 (89.6) | 14 (100) | 18 (100) | 19 (100) | 20 (95.2) | 12 (80) | 20 (71.4) | |
| Vaginal discharge and internal itching | < 0.001* | |||||||
| Yes | 73 (63.5) | 0 (0) | 11 (61.1) | 8 (42.1) | 17 (81) | 9 (60) | 28 (100) | |
| No | 42 (36.5) | 14 (100) | 7 (38.9) | 11 (57.9) | 4 (19) | 6 (40) | 0 (0) | |
|
Scoring 0 1 2 3 4 5 6 7 |
8 (7) 6 (5.2) 16 (13.9) 20 (17.4) 25 (21.7) 25 (21.7) 8 (7) 7 (6.1) |
8 (57.1) 2 (14.3) 2 (14.3) 0 (0) 2 (14.3) 0 (0) 0 (0) 0 (0) |
0 (0) 1 (5.6) 5 (27.8) 2 (11.1) 5 (27.8) 5 (27.8) 0 (0) 0 (0) |
0 (0) 2 (10.5) 2 (10.5) 2 (10.5) 7 (36.8) 6 (31.6) 0 (0) 0 (0) |
0 (0) 0 (0) 4 (19) 5 (23.8) 6 (28.6) 5 (23.8) 1 (4.8) 0 (0) |
0 (0) 1 (6.7) 0 (0) 4 (26.7) 3 (20) 3 (20) 3 (20) 1 (6.7) |
0 (0) 0 (0) 3 (10.7) 7 (25) 2 (7.1) 6 (21.4) 4 (14.3) 6 (21.4) |
< 0.001* |
* Indicates a statistically significant difference at P<0.05; n: number of the subject
Resistance according to a specific antibiotic
Among the 115 confirmed UTI cases, a high prevalence of MDR was observed, particularly for doxycycline (42.8%), tetracycline (42.8%), ceftazidime (43%), cefaclor (44.5%), moxifloxacin (43%), and piperacillin (60%), where more than two-fifths of isolates were resistant to five or more antibiotics. Commonly used agents such as cefuroxime, amoxicillin–clavulanic acid, nitrofurantoin, and ceftriaxone also showed considerable resistance, with nearly one-quarter of isolates resistant to at least five antibiotics, as shown in Supplementary Table 1. Comparison by Gram stain described in Supplementary Table 2 revealed significant associations for cefuroxime, amoxicillin–clavulanic acid, nitrofurantoin, cefixime, doxycycline, cefaclor, and piperacillin, with Gram-positive isolates generally showing higher susceptibility, while no significant differences were noted for most other agents, including fluoroquinolones, aminoglycosides, and carbapenems.
Most women diagnosed with UTIs were treated with empirical antibiotic therapy according to routine clinical practice.
Factors associated with UTI among pregnant females
On multivariable analysis, a higher educational level was associated with a lower likelihood of UTI (aOR 0.06, 95% CI 0.01–0.23, P < 0.001). In contrast, being a housewife was associated with increased odds of infection (aOR 6.54, 95% CI 2.19–28.79, P = 0.003). Pregnancy trimester was significantly associated with UTI risk, with reduced odds observed in the second trimester (aOR 0.39, 95% CI 0.22–0.69, P = 0.001) and third trimester (aOR 0.23, 95% CI 0.12–0.43, P < 0.001) compared with the first trimester. A prior history of UTI was also independently associated with increased risk (aOR 2.97, 95% CI 1.79–5.07, P < 0.001). No significant associations were observed for age or catheterization (Table 9).
Table 9.
Multivariable logistic regression analysis of sociodemographic and clinical factors associated with UTI during pregnancy
| Variable | Category | Adjusted OR | 95% CI | p-value |
|---|---|---|---|---|
| Age (years) | ≥ 45 (Reference) | 1.00 | ||
| 18–24 | 1.75 | 0.28–34.49 | 0.615 | |
| 25–34 | 1.15 | 0.18–22.57 | 0.900 | |
| 35–44 | 0.82 | 0.12–16.78 | 0.865 | |
| Education | Low education (Reference) | 1.00 | ||
| Secondary or higher | 0.06 | 0.01–0.23 | < 0.001 | |
| Occupation | Non-housewife (Reference) | 1.00 | ||
| Housewife | 6.54 | 2.19–28.79 | 0.003 | |
| Trimester | First trimester (Reference) | 1.00 | ||
| Second trimester | 0.39 | 0.22–0.69 | 0.001 | |
| Third trimester | 0.23 | 0.12–0.43 | < 0.001 | |
| Prior UTI | No (Reference) | 1.00 | ||
| Yes | 2.97 | 1.79–5.07 | < 0.001 | |
| Catheterization | No (Reference) | 1.00 | ||
| Yes | 0.79 | 0.24–2.16 | 0.666 |
Factors associated with MDR among UTI-positive cases
On multivariable analysis, a prior history of UTI was associated with lower odds of MDR (aOR 0.36, 95% CI 0.13–0.91, P = 0.037). No statistically significant associations were observed between MDR and educational level, antibiotic use, Gram stain, or pregnancy trimester (Table 10).
Table 10.
Multivariable logistic regression analysis of associated factors with MDR among UTI-positive cases
| Variable | Category | Adjusted OR (aOR) | 95% CI | p-value |
|---|---|---|---|---|
| Education | Low education (Reference) | 1.00 | ||
| Secondary or higher | 2.05 | 0.62–7.11 | 0.240 | |
| Prior UTI | No (Reference) | 1.00 | ||
| Yes | 0.36 | 0.13–0.91 | 0.037 | |
| Antibiotic use | No (Reference) | 1.00 | ||
| Yes | 1.02 | 0.39–2.64 | 0.962 | |
| Gram stain | Reference group | 1.00 | ||
| Gram-negative | 0.66 | 0.29–1.46 | 0.304 | |
| Trimester | First trimester (Reference) | 1.00 | ||
| Second trimester | 0.50 | 0.20–1.20 | 0.124 | |
| Third trimester | 0.59 | 0.21–1.69 | 0.329 |
Predictors of recurrence of UTI
On multivariable analysis, no statistically significant predictors of recurrence were identified (Table 11).
Table 11.
Multivariable logistic regression analysis of associated factors with recurrence of UTI
| Variable | Category | Adjusted OR (aOR) | 95% CI | p-value |
|---|---|---|---|---|
| Prior UTI | No (Reference) | 1.00 | ||
| Yes | 0.56 | 0.19–1.71 | 0.296 | |
| Education | Low education (Reference) | 1.00 | ||
| Secondary or higher | 2.00 | 0.32–39.44 | 0.535 | |
| Trimester | First trimester (Reference) | 1.00 | ||
| Second trimester | 0.99 | 0.28–3.69 | 0.984 | |
| Third trimester | 0.82 | 0.20–3.34 | 0.778 |
Discussion
This study provides evidence on the burden and AMR of UTIs among pregnant women in Palestine. The incidence of culture-positive UTI was 41.2%, considerably higher than the 2–10% typically reported in high-income countries [16]. This incidence also exceeded figures from other regional and low- and middle-income countries, where reported rates generally range from 15% to 25%. For example, studies from Jordan (21.5%) [17], and from Ethiopia, Ghana, and Latin America (17–23%) [11, 18–23] reported lower but still elevated rates compared with high-income settings. These differences likely reflect a combination of epidemiological, structural, and health system factors unique to Palestine, including limited access to culture-based diagnostics, delayed initiation of antenatal care, and environmental challenges in rural and refugee settings. Additionally, the high observed prevalence may be partially influenced by selection bias, as urine culture testing was more frequently performed among symptomatic women or those with clinical indications, potentially leading to overestimation of UTI burden in this cohort. The clinic-based setting may have further contributed to this, as it may overrepresent women seeking care for symptoms or complications.
Frequent urination, although commonly reported among participants, may represent both a normal physiological change during pregnancy and a symptom of UTI. Therefore, its presence should be interpreted with caution and in conjunction with laboratory findings. Notably, a higher cumulative symptom score was associated with culture-confirmed UTI, suggesting that symptom clustering may improve clinical relevance compared to individual symptoms alone. After adjustment for confounding factors using multivariate logistic regression, primary education, occupation, and first trimester remained significantly associated with UTI.
In this study, E. coli was the predominant pathogen (61.1% of Gram-negative), consistent with global and regional reports indicating that E. coli is responsible for 60–82% of pregnancy-associated UTIs [24–26]. Interestingly, S. aureus was the most frequent Gram-positive organism, representing 60.5% of Gram-positive isolates (22.6% overall). While S. aureus has been reported in other studies, its frequency is typically lower, often ranging between 5% and 15%, with Group B Streptococcus more commonly described as the predominant Gram-positive uropathogen in pregnancy [1]. Regional studies similarly report lower proportions: 7–12% in Jordan [17], below 15% in Lebanon [27]. This may represent true epidemiological variation, but contamination during sample collection cannot be excluded, particularly given the use of clean-catch urine samples, which are susceptible to periurethral or skin flora contamination if the collection technique is suboptimal. Although standardized instructions were provided, variations in adherence may have influenced results. In addition, laboratory-related factors, including specimen handling and processing conditions, may contribute to variability in organism detection. Therefore, the relatively high proportion of S. aureus should be interpreted with caution, as it may reflect both true infection and methodological influences. These findings emphasize the need for ongoing surveillance and targeted antibiotic stewardship to manage UTIs in pregnancy effectively. Future research should investigate resistance patterns and explore new therapeutic options to enhance maternal and neonatal health outcomes.
This study also highlighted a high prevalence of MDR uropathogens (55.7%), particularly against first-line agents such as ampicillin, cefixime, and fosfomycin. These findings are consistent with reports from Lebanon, East Africa, and other low- and middle-income settings, where MDR rates in pregnancy range from 18% to 50% [19, 20, 22, 23].
The high prevalence of MDR raises concerns regarding the continued reliance on empirical antibiotic therapy, particularly in settings where culture-based diagnostics are not consistently implemented. This may contribute to inappropriate antibiotic selection and further accelerate resistance. Updated local antibiograms, strengthened culture-based diagnostics, and antimicrobial stewardship programs are essential to improve maternal and neonatal outcomes.
A previous study demonstrated that MDR status is independently associated with notable maternal and neonatal complications, such as preterm birth, premature rupture of membranes, neonatal respiratory distress syndrome, and NICU admission [28]. In this cohort, cases involving MDR organisms frequently exhibited persistent symptoms post-treatment, indicating insufficient infection clearance and a potential increase in obstetric risk. These findings highlight the importance of ongoing antimicrobial surveillance and localized antibiograms for guiding empiric therapy.
Typical UTI symptoms—including frequent urination, lower abdominal pain, and back pain—were strongly associated with culture positivity, in line with global evidence that these features are key predictors of UTI in pregnancy [14, 29–31]. It is also strongly associated with MDR infections, and higher symptom scores correlated with resistance to five or more antibiotics, suggesting that symptom severity may reflect the underlying resistance profile. This aligns with observations from a study that reported high resistance rates among isolates from patients presenting with more pronounced symptoms. These findings suggest a possible link between symptom severity and the burden of antibiotic resistance [32]. Multivariate logistic regression analysis was conducted among culture-positive cases to identify predictors of MDR, and no independent predictors were identified after adjustment. This finding may be related to the limited number of MDR events, which reduced the model’s statistical power.
The recurrence rate of 15% over three months was lower than global estimates (20–40%) [33], possibly due to high loss to follow-up or the short follow-up period. Unlike previous studies that identified behavioral and clinical predictors, no significant associations were observed, probably reflecting the small number of recurrent cases or unmeasured confounders, such as genetic predisposition or biofilm formation, which can sustain subclinical infections [34]. Notably, recurrence appeared linked to treatment failure, as infections with MDR pathogens showed persistent symptoms despite therapy [35]. No independent predictors of UTI recurrence were identified in the multivariate analysis. This may be due to limited statistical power and sparse data within categorical subgroups. Unmeasured clinical and microbiological factors may play a more important role in recurrence, highlighting the need for larger studies.
Strengths and limitations
Strengths of this study include its prospective cohort design, relatively large sample size, integration of clinical symptom assessment with microbiological confirmation, and use of standardized laboratory procedures. The inclusion of follow-up enabled assessment of recurrence, an underexplored aspect in similar regional studies.
Key limitations should be considered. First, the high loss to follow-up may have affected the accuracy of recurrence estimates and limited the ability to identify predictors of recurrence. The incomplete uptake of urine culture introduces potential selection bias, particularly as testing may have been more likely among symptomatic participants. Furthermore, urine culture uptake was influenced by several patient- and system-level barriers, including patient refusal, perceptions that testing was unnecessary, and limited access to laboratory services. These findings highlight challenges in implementing culture-based diagnosis within routine antenatal care and may have contributed to incomplete microbiological ascertainment. Second, the study was conducted in a single geographic setting which may limit generalizability.
Third, urine culture testing was not uniformly implemented, and clinic-based sampling may have overrepresented symptomatic or high-risk women, introducing potential selection bias and possibly overestimating UTI prevalence. Fourth, the follow-up period was limited to 90-days, which may underestimate recurrence, particularly among women enrolled early in pregnancy, as late pregnancy recurrences were not captured. In addition, the absence of molecular characterization of resistance mechanisms restricted deeper exploration of AMR drivers, highlighting the need for future studies to include molecular analyses across multiple centres. Data management was conducted using Microsoft Excel, which lacks audit trail functionality and may increase the risk of data handling errors. However, data were double-checked and cross-verified against original data collection forms to minimize potential errors.
Fifth, sociodemographic and clinical characteristics were self-reported by participants, which may be subject to social desirability bias, particularly for sensitive variables such as smoking, potentially leading to underreporting. In contrast, symptom data were recorded by trained researchers, reducing the likelihood of reporting bias for clinical variables. Although baseline demographic and obstetric characteristics were comparable between participants who completed follow-up and those lost to follow-up, women with culture-confirmed UTIs were more likely to remain in the study. This differential retention may have influenced recurrence estimates and should be considered when interpreting follow-up findings. Finally, colistin susceptibility testing was performed using disc diffusion, which is not recommended according to CLSI/EUCAST guidelines. Therefore, colistin results were excluded from the primary analysis and should be interpreted with caution.
Conclusion
Urinary tract infections among pregnant women in Nablus, Palestine, are frequently caused by multidrug-resistant Escherichia coli and Staphylococcus aureus. Resistance exceeded 60% for commonly prescribed antibiotics, including ampicillin and cefaclor, whereas meropenem and cefepime remained highly effective. Recurrent infections were observed but were not linked to sociodemographic or obstetric factors. These findings support the use of culture-based diagnostics and continued local AMR surveillance to inform empirical antibiotic selection and guide the management of UTI during pregnancy.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors are deeply grateful to the healthcare staff at the participating clinics in Nablus for their support, as well as to the women who kindly agreed to participate.
Author contributions
Lara Z. Khatatba and Dala N. Daraghmeh contributed to the conceptualization and study design. Lara Z. Khatatba collected the data, performed the analysis, and drafted the manuscript. Dala N. Daraghmeh provided supervision, contributed to data interpretation, and critically revised the text. Both authors read and approved the final manuscript.
Funding
This research did not receive any specific funding.
Data availability
The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethical Committee at Al-Quds University (approval number: 461/REC/2024) and the Palestinian Ministry of Health. Written informed consent was obtained from all participants before enrollment. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request.