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Urinary Tract Infections NURS 541 – Women’s Healthcare: Diagnosis & Management Objectives Definitions Etiology and pathophysiology of UTIs Risk factors for UTIs Clinical presentation Approach to assessment Approach to patient management Definitions Asymptomatic bacteriuria Presence of bacteria in an uncontaminated urine specimen without signs or symptoms of UTI Acute cystitis (bladder infection) Uncomplicated Infection in an otherwise healthy premenopausal woman Complicated Recurrent infections, resistant infections, post-menopausal infections, infections in men, co-existing conditions Pyelonephritis (kidney infection) Uncomplicated Complicated Etiology In reproductive ages Most often seen in women 15-29 years of age Infections in younger men (<50 years of age) uncommon Not common with children Pathophysiology Urinary tract mechanisms for infection prevention Mucus lining in urethra to trap ascending bacteria Length of urethra (protective for men) Sphincters at bladder/ureter junction to prevent retrograde flow to kidneys Urine with high acidity/high osmolality – ‘hostile’ environment Urine containing multiple bacteria-fighting proteins Sensitive immunosupport system in epithelial lining of urinary tract Pathophysiology Most UTIs caused by uropathogenic E. coli (~50-90%) Other potential pathogens Staph saprophyticus Proteus mirabilis Enterobacter species Pseudomonas species Risk factors For premenopausal women Sexual intercourse New sexual partners Use of spermicide (diaphragms) Close family history of frequent UTIs Pregnancy Previous UTI (or maternal family hx UTI) Diabetes mellitus Sickle cell trait/disease Urinary calculi (stones) For postmenopausal women Others, PLUS hormonal changes to epithelial cells/mucus lining Vaginal atrophy Urinary incontinence Genital organ prolapse (cystocele, rectocele) Others Bladder catheterization Prostate issues Clinical presentation Symptoms may include the following: Dysuria Most commonly at the end of the urine stream Frequency/urgency Pelvic pain/cramping Suprapubic With the absence of any vaginal symptoms For older adults: Above symptoms may be subtle or may include irritability, confusion, change in mental status, or lethargy Clinical presentation Signs of a UTI may include: Pyuria Cloudy appearance to urine usually due to WBCs (+ leukocytes) Hematuria Presence of blood in urine (+ blood) Foul odor to urine (with some bacteria) Presence of nitrites in urine Bacteria converting urinary nitrates to nitrites (+ nitrites) S/Sx of pyelonephritis also include: Fever Flank pain/CVA tenderness Scenario #1 Susanna , 22 y.o woman, comes into your office with the concern of dysuria, frequency, and urgency x 2 days. What do you want to know? Approach to Assessment Focused history: Physical exam: HPI/presenting symptoms Overall appearance Thorough medical history Temperature Co-existing medical Abdominal palpation conditions Structural abnormalities of bladder, ureters, kidneys CVA tenderness Family history of relevant conditions Menstrual and sexual history Pelvic exam (if indicated) Scenario #1 You gather Susanna’s focused medical history: Medical history uncomplicated New sexual partner (male), using condoms with spermicide Also on oral contraception x 6 months No history of prior UTIs Denies any vaginal symptoms What type of exam would be appropriate? Temperature 97.9F No CVA tenderness Some suprapubic tenderness upon palpation Approach to Assessment Do you need to do a pelvic exam? NOT NECESSARILY! Do a pelvic exam IF: There are vaginal symptoms needing investigation You choose to do STI screening and need a vaginal specimen Scenario #1 What labwork would you want for Susanna today? Urine specimen (clean-catch) Urine dipstick and urinalysis Types of urine specimens Random (contaminated) Clean-catch (uncontaminated) Wipe front to back with antiseptic wipes x 2 or 3 Start urination, collect sample midstream, complete urination in toilet Catheter derived sample (uncontaminated) Laboratory Assessment Urine dipstick Leukocyte esterase, blood, nitrites, high specific gravity Urinalysis Determine presence of: Epithelials cells (indicator of contamination) WBCs RBCs Urine culture Isolation and culture of bacteria in urine Sensitivities to antibiotics Laboratory Assessment When is a urine culture necessary? In pregnancy Signs of an upper UTI (pyelonephritis) Recent or recurrent UTI Recent antibiotic treatment (for anything) Chronic disease affecting the immune system Any complicated UTI presentation! Scenario #1 You examine Susanna’s urine specimen in the lab: Urine dipstick + nitrites, + leukocytes, specific gravity 1.030 Urinalysis (per HPF) Epithelial cells – 3 (>5 = contaminated) WBCs – TMTC (too many to count) RBCs – 2-3 Mucus seen Scenario #1 What is Susanna’s diagnosis? Uncomplicated UTI/cystitis For non-pregnant women Should include: Hallmark symptoms of UTI (dysuria, frequency, urgency) Positive finding in urine dipstick, urinalysis or urine culture Differential diagnosis STI Vaginal infection Pyelonephritis Kidney stones/urinary calculi Diagnosis Criteria Why is Susanna’s diagnosis “uncomplicated” UTI? No co-existing medical issues that would affect treatment No history of UTIs or failed treatment for UTIs She is female and premenopausal Typical presentation for UTI Management of uncomplicated UTI ACOG recommended antibiotic regimens (2010) Trimethoprim-sulfamethoxazole (Bactrim) one tab PO BID x 3 days Trimethoprim 100mg PO BID x 3 days Ciprofloxacin 250mg PO BID x 3 days Levofloxacin 250mg PO BID x 3 days Norfloxacin 400mg PO BID x 3 days Gatifloxacin 200mg PO BID x 3 days Nitrofurantoin monohydrate (Macrobid) 100mg PO BID x 7 days Fosfomycin tromethamine 3g single dose Management of associated discomfort Phenazopyridine (Pyridium) OTC medication for pain relief of bladder symptoms Turns urine bright orange For short-term use ONLY Associated with many side effects Headaches Rash GI upset G6PD deficiency – hemolysis Nephrotoxicity if chronic use Back to Susanna… Rx You prescribe nitrofurantoin 100mg orally BID x 7 days Encourage using pyridium if needed for 2-3 days Education Review preventive measures Review medication taking, finish entire course of antibiotics Follow-up To call if symptoms do not resolve within 3 days Management of complicated UTI Urine culture and sensitivities to guide antibiotic treatment Longer course of antibiotics (3 7 days, 7 10 days) Test of cure may be indicated Management of uncomplicated pyelonephritis For non-pregnant, otherwise healthy individuals who can tolerate oral medications Fluoroquinolones orally, 7-10 day course Urine culture Follow up in 2-3 days to assure treatment effectiveness Reduction in symptoms Management of complicated pyelonephritis Often requires inpatient parenteral antibiotic treatment Indications for hospitalization Severe illness Pregnancy (in most cases) Immunocompromise Inability to tolerate oral treatment Inability to adequately follow up Prevention of UTI Little evidence to support prevention recommendations Adequate hydration Wiping front to back after using bathroom Urination after intercourse Avoidance of delayed urination Solid evidence to support: Use of cranberry products – decrease recurrence, ability of bacteria to colonize Post-coital antibiotics For those with UTI associated with sexual activity Bactrim, macrobid, and fluoroquinolones all effective as single-dose post-coital treatment Questions?
