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Urinary Tract Infection
CHAPTER 46
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Urinary Tract Infection (UTI)
Most common bacterial infection in women
At least 20% of women will develop a UTI during their lifetime
◦ E. coli is the most common pathogen
Urinary Tract Infection
Bladder and its contents are free of bacteria in majority of healthy
persons
Minority of healthy individuals have colonizing bacteria in bladder
◦ Called asymptomatic bacteriuria and does not justify treatment
Urinary Tract Infection
Strep, staph, E. coli, fungal and parasitic infections can cause
UTIs
Patients at risk
◦ Immunosuppressed
◦ Diabetic
◦ Having undergone multiple antibiotic courses
◦ Have traveled to developing countries
Classification of UTI
Upper versus lower
◦ Upper urinary tract
◦ Renal parenchyma, pelvis, and ureters
◦ Typically causes fever, chills, flank pain
◦ Example
◦ Pyelonephritis: inflammation of kidney and collecting
system
◦ Acute and Chronic
Classification of UTI
Upper versus lower
◦ Lower urinary tract
◦ Usually no systemic manifestations
◦ Examples
◦ Cystitis: inflammation of bladder
◦ Urethritis: inflammation of the urethra
Classification of UTI
Classification of UTI
Complicated versus uncomplicated
◦ Uncomplicated UTI
◦ Occurs in otherwise normal urinary tract
◦ Usually involves only the bladder
◦ Complicated UTI
◦ Coexists with presence of
◦ Obstruction, stones
◦ Catheters
◦ Diabetes/neurologic disease
◦ Pregnancy-induced changes
◦ Recurrent infection
Etiology and Pathophysiology
Urinary tract above urethra normally sterile
Defense mechanisms exist to maintain sterility/prevent UTIs
◦ Complete emptying of bladder
◦ Ureterovesical junction competence
◦ Peristaltic activity
◦ Acidic pH
◦ High urea concentration
◦ Abundant glycoproteins
Etiology and Pathophysiology
Alteration of defense mechanisms increases risk of contracting UTI
Predisposing factors
◦ Factors increasing urinary stasis
◦ Examples: BPH, tumor, neurogenic bladder
◦ Foreign bodies
◦ Examples: catheters, calculi, instrumentation
◦ Anatomic factors
◦ Examples: obesity, congenital defects, fistula
◦ Compromising immune response factors
◦ Examples: age, HIV, diabetes
◦ Functional disorders
◦ Example: constipation
◦ Other factors
◦ Examples: pregnancy, multiple sex partners (women)
Etiology and Pathophysiology
Organisms introduced via the ascending route from urethra and
originate in the perineum
Less common routes
◦ Bloodstream
◦ Lymphatic system
Gram-negative bacilli normally found in GI tract: common cause
Urologic instrumentation allows bacteria to enter urethra and bladder
◦ Catheters
◦ cystoscopy
Etiology and Pathophysiology
Contributing factor: urologic instrumentation
◦ Allows bacteria present in opening of urethra to enter
urethra or bladder
Sexual intercourse promotes “milking” of bacteria from
perineum and vagina
◦ May cause minor urethral trauma
Etiology and Pathophysiology
Rarely results via hematogenous route
Kidney infection occurring from hematogenous transmission
always preceded by injury to urinary tract
◦ Obstruction of ureter
◦ Damage from stones
◦ Renal scars
Etiology and Pathophysiology
Hospital-acquired UTI accounts for 31% of all nosocomial infections
◦ Causes
◦ Often: E. coli
◦ Seldom: Pseudomonas species
◦ Catheter-acquired UTIs
◦ Bacteria biofilms develop on inner surface of catheter
Clinical Manifestations
Symptoms related to either bladder storage or bladder
emptying
◦ Bladder storage
◦ Urinary frequency
◦ Abnormally frequent (more often than every 2 hours)
◦ Urgency
◦ Sudden strong desire to void immediately
◦ Incontinence
◦ Loss or leakage or urine
Clinical Manifestations
◦ Bladder storage
◦ Nocturia
◦ Waking up two or more times at night to void
◦ Nocturnal enuresis
◦ Loss of urine during sleep
◦ Bladder emptying
◦ Weak stream
◦ Hesitancy
◦ Difficulty starting the urine stream
Clinical Manifestations
◦ Bladder emptying
◦ Intermittency
◦ Interruption of urinary stream during voiding
◦ Postvoid dribbling
◦ Urine loss after completion of voiding
◦ Urinary retention
◦ Inability to empty urine from bladder
◦ Dysuria
◦ Difficulty voiding
Clinical Manifestations
Flank pain, chills, and fever indicate infection of upper tract
◦ Pyelonephritis
In older adults
◦
◦
◦
◦
Symptoms often absent
Nonlocalized abdominal discomfort rather than dysuria
Cognitive impairment possible
Fever less likely
Diagnostic Studies
Urine for culture and sensitivity
(if indicated)
◦ Clean-catch sample preferred
◦ Specimen by catheterization or suprapubic needle aspiration more
accurate
◦ Determine bacteria susceptibility to antibiotics
◦ Imaging studies
◦ CT urography or ultrasonography when obstruction
suspected
◦ KUB
Collaborative Care
Drug Therapy
Antibiotics
◦ Selected on therapy or results of sensitivity testing
◦ Uncomplicated cystitis
◦ Short-term course (1 to 3 days)
◦ Complicated UTIs
◦ Long-term treatment (7 to 14 days)
Collaborative Care
Drug Therapy
Antibiotics
◦ Trimethoprim/sulfamethoxazole (TMP/SMX)
◦ Used to treat uncomplicated or initial UTI
◦ Inexpensive, Taken twice a day
◦ Nitrofurantoin (Macrodantin)
◦ Given three or four times a day
◦ Long-acting preparation (Macrobid) is taken twice daily
◦ Ampicillin, amoxicillin, cephalosporins
◦ Treat uncomplicated UTI
Collaborative Care
Drug Therapy
◦ Fluoroquinolones
◦ Treat complicated UTIs
◦ Example: ciprofloxacin (Cipro, Levaquin)
Antifungals
◦ Amphotericin or fluconazole
◦ UTIs secondary to fungi
Collaborative Care
Drug Therapy
Urinary analgesic
◦ Methenamine/phenyl salicylate (Urised, Methylene Blue)
◦ Used in combination with antibiotics
◦ Used to relieve UTI symptoms
◦ Preparations with methylene blue tints urine blue or green
Urinary analgesic
◦ Phenazopyridine (Pyridium)
◦ Used in combination with antibiotics
◦ Provides soothing effect on urinary tract mucosa
◦ Stains urine reddish orange
◦ Can be mistaken for blood and may stain underclothing
Nursing Management
Nursing Assessment
Health history
◦ Previous UTIs, calculi, stasis, retention, pregnancy, STIs,
bladder cancer
◦ Antibiotics, anticholinergics, antispasmodics
◦ Urologic instrumentation
◦ Urinary hygiene
◦ Nausea, vomiting, anorexia, chills, nocturia, frequency,
urgency
◦ Suprapubic/lower back pain, bladder spasms, dysuria,
burning sensation on urination
Nursing Management
Nursing Assessment
Objective data
◦ Fever
◦ Hematuria, foul-smelling urine, tender, enlarged kidney
◦ Leukocytosis, positive findings for bacteria, WBCs, RBCs,
pyuria, ultrasound, CT scan, IVP
Nursing Management
Nursing Implementation
Health promotion
◦ Recognize individuals at risk
◦ Debilitated persons, Older adults
◦ Underlying diseases (HIV, diabetes)
◦ Taking immunosuppressive drug or corticosteroids
◦ Emptying bladder regularly and completely
◦ Evacuating bowel regularly
◦ Wiping perineal area front to back
◦ Drinking adequate fluids (person’s weight in pounds/2)
◦ Twenty percent of fluid comes from food
Nursing Management
Nursing Implementation
Health promotion
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◦
Cranberry juice or cranberry tablets may reduce the number of UTIs
Avoid unnecessary catheterization and early removal of indwelling catheters
Aseptic technique must be followed during instrumentation procedures
Wash hands before and after contact
Wear gloves for care of urinary system
Routine and thorough perineal care for all hospitalized patients
Avoid incontinent episodes by answering call light and offering bedpan at
frequent intervals
Nursing Management
Nursing Implementation
Health promotion
Acute intervention
◦ Adequate fluid intake
◦ Patient may think condition will worsen because of discomfort
◦ Dilutes urine, making bladder less irritable
◦ Flushes out bacteria before they can colonize
◦ Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods
◦ Potential bladder irritants
◦ Emphasize taking full course of antibiotics despite disappearance of
symptoms
◦ Second or reduced dosage of a drug may be ordered after initial course in
susceptible patients
Nursing Management
Nursing Implementation
Acute intervention
◦ Instruct patient to monitor for signs of improvement and decrease in or
cessation of symptoms
◦ Counsel on persistence of lower tract symptoms beyond treatment or onset
of flank pain or fever: should be reported immediately
Ambulatory and home care
◦ Emphasize importance of compliance with drug regimen
◦ Take as ordered
◦ Maintain adequate fluids
◦ Regular voiding (every 3 to 4 hours)
◦ Void after intercourse
Case Study
Jupiterimages/Photos.com/Thinkstock
E.L. is a 27-year-old woman who complains of urgency to urinate,
frequent urination, and urethral burning sensation during urination.
Symptoms began 48 hours ago.
She has a history of recurring urinary tract infections since age 22, when
she got married.
E.L. is allergic to penicillin.
Vital signs are as follows:
◦ Temperature 98.6° F orally
◦ Blood pressure 114/64
Dipstick urinalysis indicates WBCs and bacteria.
Case Study
Jupiterimages/Photos.com/Thinkstock
Urinalysis results:
◦ Color: dark yellow
◦ pH: 6.5
◦ Nitrates: positive
◦ WBCs: large amount
◦ Occult blood: trace
◦ Urine culture: positive for E. coli
◦ Sensitivity to ampicillin, nitrofurantoin, ciprofloxacin,
cephalexin, TMP-SMX
◦ Given her history, what would be
Case Study
Jupiterimages/Photos.com/Thinkstock
E.L. states that because of her penicillin allergy, she has taken Cipro for 7day courses in the past.
She asks about what could be causing the recurring infections.
Given her history, what is the likely course of treatment?
Acute
Pyelonephritis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Etiology and Pathophysiology
Inflammation of renal parenchyma and collecting system
Most commonly caused by bacteria
Fungi, protozoa, or viruses can also infect kidneys
Acute Pyelonephritis
Etiology and Pathophysiology
Urosepsis
◦ Systemic blood infection from urologic source (instrumentation)
◦ Prompt diagnosis/treatment critical
◦ Can lead to septic shock and death
◦ Septic shock: outcome of unresolved bacteremia involving gramnegative organism
◦ Usually begins with colonization and infection of lower
tract via ascending urethral route
Frequent causes
◦
◦
◦
◦
Escherichia coli
Proteus
Klebsiella
Enterobacter
Etiology and Pathophysiology
◦ Preexisting factor usually present
◦ Vesicoureteral reflux
◦ Backward movement of urine from lower to
upper urinary tract
◦ Dysfunction of lower urinary tract
◦ Obstruction from BPH
◦ Stricture
◦ Urinary stone
◦ Recurring episodes lead to scarred, poorly
functioning kidney and chronic pyelonephritis
Clinical Manifestations
Mild fatigue
Chills, Fever
Nausea, Vomiting
Flank pain
Lower urinary tract symptoms characteristic of cystitis
Costovertebral tenderness usually present on affected side
Manifestations usually subside in a few days, even without
therapy
◦ Bacteriuria and pyuria still persist
Diagnostic Studies
History & Physical examination
◦ Palpation for CVA pain
Laboratory tests
◦ Urinalysis
◦ Urine for culture and sensitivity
◦ CBC with differential
◦ Blood culture (if bacteremia is suspected)
Ultrasonography
CT urography
Diagnostic Studies
If bacteremia is a possibility, close observation and vital sign monitoring
are essential
Prompt recognition and treatment of septic shock may prevent
irreversible damage or death
Hospitalization for patients with
severe infections and complications
◦ Such as nausea and vomiting with dehydration
Signs/symptoms typically improve within 48 to 72 hours after therapy
starts
Reinfections treated as individual episodes or managed with long-term
therapy
◦ Prophylaxis may be used for recurrent infection
Audience Response Question
The nurse identifies that the patient with the greatest risk for a
urinary tract infection is
a. A 37-year-old man with renal colic associated with kidney
stones.
b. A 26-year-old pregnant woman who has a history of urinary
tract infections.
c. A 69-year-old man who has urinary retention caused by benign
prostatic hyperplasia.
d. A 72-year-old woman hospitalized with a stroke who has a
urinary catheter because of urinary incontinence.
Urinary Tract
Calculi
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nephrolithiasis
Highest in the southeast, southwest
Affects 500,000 people per year many of whom are
hospitalized
20-55 y/o, more common in men
Affects Caucasians more than African Americans
Occurs more often in the summer months
50% patients experience a recurrence
Etiology
Multi-factorial process
◦ Metabolic
◦ Dietary (inc protein)
◦ Genetic
◦ Climatic (heat)
◦ Lifestyle
◦ Occupational
Pathophysiology
Crystals when in supersaturated concentration can
precipitate and form a stone
Urinary pH, solute load, and inhibitors affect the formation
of stones
◦ Keep urine free-flowing
◦ Higher pH: calcium and phosphate are less soluble
◦ Lower the pH: uric acid and cystine are less soluble
Types of stones
Calcium phosphate, Calcium oxalate
◦ most common
Uric acid, Cystine, Struvite
◦ caused from magnesium and ammonia phosphate
◦ Can be anywhere in urinary tract
◦ Kidney stone dance
Clinical Manifestations
Symptoms
◦ Severe abdominal pain depends on location of
stone (Renal colic)
◦ CVA tenderness (flank pain)
◦ Hematuria
◦ Nausea and vomiting
Diagnostics
UA
Urine culture (C&S)
IVP
Ultrasound
Measurement of serum calcium, phosphate, oxalate, uric
acid
Renal function tests
KUB
Collaborative Care
Management of acute attack
◦ Narcotic pain relief
◦ Treat infections proximal to obstruction
◦ Immediate drainage with Percutaneous Nephrostomy
tube or ureteral stent
◦ Removal by endo-urologic procedures
◦ Ureteroscopy
◦ Nephrolithotomy
◦ Lithotripsy (ESWL extracorporeal shock wave laser)
Collaborative Care
Prevent further stone formation
◦ Adequate hydration (3L/day to produce urine
output of 2L/day)
◦ Dietary sodium restrictions
◦ Dietary changes
◦ Medications to minimize formation
◦ Control infection
Nutrition therapy
Calcium oxalate: reduce dietary oxalate
◦
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◦
◦
◦
◦
◦
◦
spinach,
rhubarb,
asparagus,
cabbage,
tomatoes,
beets,
nuts,
celery,
chocolate, cocoa,
caffeine
Nutrition therapy
Uric acid stones: reduce dietary purine
◦ High: sardines, herring, mussels, liver, kidney, goose,
venison, meat soups, sweetbreads
◦ Moderate: chicken, salmon, crab, veal, mutton, bacon,
pork, beef, ham
Nursing management
Preventive measures
◦ Immobility
◦ Urinary stasis
Acute phase
◦ Stone retrieval-strain all urine
◦ Forcing fluids if not contraindicated
◦ Ambulation
◦ Narcotics for pain relief
Interstitial Cystitis
Chronic painful inflammation of bladder characterized by
urgency, frequency, pain in bladder or pelvic region.
Odorous urine, hematuria.
Neurosensitivity of lower UTS. Bladder wall is constantly
irritated, becomes inflamed and scarred. Pain-mod to
severe.
Glomerulations form. (ulcerations in mucosa with pinpoint
bleeds)
Relieved by urination. Often misdiagnosed as UTI
Incontinence
Involuntary leakage of urine, more common in older women
Stress and urge incontinence
Bladder pressure exceeds urethral closure pressure
Therapy- Kegel exercises
Drugs- Atropine, dries bladder mucosa, inhibits secretions, relaxes GU
tract (parasympathetic)
Surgery- (abdominal) sling for bladder neck
Benign Prostatic Hypertrophy
Most common reason for UI in men, enlarged prostate gland
Frequency, urgency, dysuria, difficulty voiding
Bladder calculi can develop
TURP- transurethral resection of prostate is a possible treatment
Removes prostate cystoscopically
After surgery 3 way indwelling catheter is constantly irrigated to prevent
mucus or blood clots from clogging urethra
Pediatric
Epispadias- urethra is dorsal, on top of glans. Rare and
associated with bladder extrophy
Hypospadias- incomplete development of urethra in utero.
Congenital anomaly. Opening of urethra in on the bottom
of the glans. Commonly associated with undescended
testes and increased risk for inguinal hernia.
Enuresis- nighttime bedwetting. Dec bladder capacity, neuro
abnormalities , constipation, diabetes, emotional factors or
abuse are some causes. Most kids outgrow this.
Pediatric
Vesicoureteral reflux◦ junction of bladder and ureter causes reflux of urine
back up into ureters. Can be grade of I-V.
◦ I is reflux into lower ureter and V is gross dilation of
ureter, possible UTI if backs up into the kidney.
◦ Grades I-III are treated with antbx.
◦ Grades IV-V have surgery to re-implant ureter into
bladder
Diuretics
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Diuretics
Purposes of diuretics
◦Lowered blood pressure
◦Decreased edema
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Kidney Function
Diuretics
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Act on Different Segments of the Renal Tube.
Types of Diuretics
Thiazide and thiazide-like
Loop or high-ceiling
Osmotic
Carbonic anhydrase inhibitor
Potassium-sparing
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Thiazide and Thiazide-Like Diuretics
Chlorothiazide (Diuril)
Hydrochlorothiazide (HCTZ)
Bendroflumethiazide with nadolol (Corzide)
Methyclothiazide (Enduron)
Chlorthalidone (Thalitone)
Indapamide (Lozol)
Metolazone (Zaroxolyn)
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Thiazide and Thiazide-Like Diuretics
Serum chemistry abnormalities with
thiazides
◦Hypokalemia
◦Hypomagnesemia
◦Hypercalcemia
◦Hypochloremia
◦Hyperuricemia
◦Hyperglycemia
◦Hyperlipidemia
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Thiazide and Thiazide-Like Diuretics
Side effects and adverse reactions
◦Electrolyte imbalances
◦Hyperglycemia
◦Hyperuricemia
◦Others–dizziness, headache, nausea, vomiting,
constipation, urticaria, and blood dyscrasias
 Contraindications
◦Renal failure
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Nursing Process: Thiazides
Assessment
Nursing diagnoses
Planning
Nursing interventions
◦Patient teaching
◦Cultural considerations
Evaluation
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Loop Diuretics
Loop diuretics: furosemide (Lasix), bumetanide
(Bumex)
◦ Laboratory changes:
◦ Hypokalemia, hyponatremia, hypocalcemia,
hypomagnesemia, hypochloremia
◦ Hyperglycemia possible in diabetic pts
◦ Hyperuricemia
◦ Elevated BUN and creatinine
◦ Elevated lipids
◦ Thrombocytopenia, leukopenia
Loop Diuretics
Side effects and adverse reactions
◦Fluid and electrolyte imbalances
◦Hypochloremic metabolic alkalosis
◦Orthostatic hypotension
◦Thrombocytopenia
◦Skin disturbances
◦Transient deafness
◦Thiamine deficiency
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Nursing Process: Loop Diuretics
Assessment
Nursing diagnoses
Planning
Nursing interventions
◦Patient teaching
◦Cultural considerations
Evaluation
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Osmotic Diuretics
Osmotic diuretics: mannitol
◦Use: Prevent kidney failure, decrease ICP,
and decrease IOP
◦Side effects/adverse reactions: fluid and
electrolyte imbalance, pulmonary edema,
N&V, tachycardia, and acidosis
◦Crystallization of mannitol
◦Contraindications: Heart failure, renal
failure
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Potassium-Sparing Diuretics
Potassium-sparing diuretics:
spironolactone (Aldactone), amiloride
(Midamor), triamterene (Dyrenium), and
eplerenone (Inspra)
◦Action
◦Hyperkalemia
◦Effects when given with ACE inhibitors
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Drugs for Urinary Tract Disorders
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Urinary Tract Infections (UTIs)
Upper UTI
◦Acute pyelonephritis
◦Usually female patients
◦Symptoms
◦Chills, fever, flank pain
◦Painful urination, frequency,
urgency, pyuria
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Urinary Tract Infections
Lower UTI
◦Acute cystitis
◦Frequently in females
◦E. coli, Staph, Klebsiella, Pseudomonas
◦Symptoms
◦Pain and burning on urination, frequency,
urgency
◦Urethritis, prostatitis
◦Same symptoms
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Treatment of UTIs
Nitrofurantoin (Macrodantin)
Trimethoprim-sulfamethoxazole (Bactrim,
Septra)
Fluoroquinolones such as nalidixic acid
(NegGram)
Norfloxacin (Noroxin)
Ciprofloxacin (Cipro)
Fosfomycin tromethamine (Monurol): single
dose
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Treatment of UTIs
Other agents:
◦Oral amoxicillin/clavulanic acid
(Augmentin)
◦Oral third-generation cephalosporins
(cefixime, cefpodoxime proxetil, or
ceftibuten)
◦For severe UTIs, IV drug therapy followed
by oral drug therapy is usually
recommended.
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Urinary Antiseptics/Antiinfectives and
Antibiotics
Nitrofurantoin (Macrodantin)
◦Bacteriostatic or bactericidal
depending on the drug dosage
◦Effective against many gram-positive
and gram-negative organisms,
especially E. coli.
◦Side effects/adverse reactions
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Urinary Antiseptics/Antiinfectives and
Antibiotics
Methenamine hippurate (Hiprex)
◦Treats chronic UTIs
◦Effective for E. coli and P. aeruginosa
◦Bactericidal when urine is acidic
◦Caution
◦Not to be taken with sulfonamides (may cause
crystalluria)
◦Patient teaching
◦Consume acidic foods and fluids
◦Side effects/adverse reactions
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Urinary Antiseptics/Antiinfectives and
Antibiotics
Trimethoprim and trimethoprim
sulfamethoxazole
◦Trimethoprim (Proloprim): can be used alone
for the treatment of UTIs; usually used in
combination with a sulfonamide,
sulfamethoxazole (Bactrim, Septra)
◦Used in the treatment and prevention of
acute and chronic UTIs
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Urinary Antiseptics/Antiinfectives and
Antibiotics
Fluoroquinolones
◦Nalidixic acid (NegGram), norfloxacin
(Noroxin), ciprofloxacin hydrochloride
(Cipro), ofloxacin (Floxin), and
lomefloxacin (Maxaquin)
◦Treats lower UTIs
◦Side effects/adverse reactions
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Urinary Analgesics
Phenazopyridine (Pyridium)
◦Action
◦Relieves pain, burning sensation,
frequency, urgency
◦Side effects/adverse reactions
◦GI upset
◦Red-orange urine
◦Blood dyscrasia
◦Nephrotoxicity, hepatotoxicity
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Urinary
Stimulants
Urinary stimulants
◦Bethanechol (Urecholine)
◦Treat hypotonic bladder: neurogenic, spinal cord
injury, or severe head injury
◦Action
◦Increases bladder tone
◦Contraindication
◦Peptic ulcer
◦Side effects/adverse reactions
◦GI distress, dizziness, fainting
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Urinary Antispasmodics/
Antimuscarinics
Oxybutynin (Ditropan) and flavoxate (Urispas)
◦ Action
◦ Direct action on smooth muscles to relieve spasms
◦ Side effects/adverse reactions
◦ Drowsiness, tachycardia, dizziness, fainting, blurred
vision, dry mouth, constipation
◦ Patient assessment
◦ Avoid in glaucoma, GI or urinary obstruction
◦ Use cautiously with history of cardiac, renal, hepatic,
prostate problems
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Urinary Antispasmodics/
Antimuscarinics
Tolterodine tartrate (Detrol)
◦Used to control an overactive bladder,
which causes frequency in urination
◦Decreases urge and urinary
incontinence
◦Same side effects as
antispasmodics/anticholinergics
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