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Focus on
Urinary Tract Infection
(Relates to Chapter 46.
S. Buckley, RN, MS
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Urinary Tract Infection (UTI)
• Second most common bacterial
disease
• Most common bacterial infection in
women
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Urinary Tract Infection (UTI) (Cont’d)
• Accounts for more than 8 million
office visits per year
• >100,000 people hospitalized
annually due to UTI
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Urinary Tract Infection (Cont’d)
• >15% patients who develop
gram-negative bacteria infection die
 33% of these caused by infections
originating in urinary tract
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Urinary Tract Infection (Cont’d)
• Bladder and its contents are free of
bacteria in majority of healthy
patients
• Minority of healthy individuals have
colonizing bacteria in bladder
 Called asymptomatic bacteriuria, and
does not justify treatment
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Urinary Tract Infection (Cont’d)
• Escherichia coli most common
pathogen
• Counts of 105 CFU/ml or more
indicate significant UTI
• (p. 1152, normal count: <104)
• Counts as low as 102 CFU/ml in a
person with signs/symptoms are
indicative of UTI
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Urinary Tract Infection (Cont’d)
• Fungal and parasitic infections can
cause UTIs
• Patients at risk
 Immunosuppressed
 Have diabetes
 Undergone multiple antibiotic courses
 Traveled to certain underdeveloped
countries
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Web resources; UTI
• http://video.about.com/womenshea
lth/Urinary-Tract-Infection.htm
• basic images
• http://www.youtube.com/watch?v=
u11DfF6fuCM
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Classification
• Upper versus lower
 Upper tract
•
•
•
Renal parenchyma, pelvis, and ureters
Typically causes fever, chills, flank pain
Example
• Pyelonephritis: Inflammation of renal
parenchyma and collecting system
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Classification
• Upper versus lower (cont’d)
 Lower tract
•
•
•
Lower urinary tract
Usually no systemic manifestations
Example
• Cystitis (inflammation of bladder wall)
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Specific terms (to delineate the location of a
UTI)
• Pyelonephritis=inflammation of renal parenchyma
and collecting system
• Cystitis=inflammation of bladder wall
• Urethritis=inflammation of urethra
• Urosepsis=uti that has spread into the systemic
circulation and is life-threatening
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Sites of Infectious Processes
Fig. 46-1
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Classification (Cont’d)
• Complicated versus uncomplicated
 Uncomplicated
•
•
Occurs in otherwise normal urinary tract
Usually only involves the bladder
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Classification
• Complicated versus uncomplicated
(cont’d)
 Complicated
•
Those with coexisting presence of
•
•
•
•
•
•
Obstruction
Stones
Catheters
Existing diabetes/neurologic disease
Pregnancy-induced changes
Recurrent infection
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Classification (Cont’d)
• According to natural history
 Initial infection
•
•
First or isolated
Uncomplicated UTI in person who never
had one or experiences one remote from a
previous UTI (separated by period of
years)
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Classification
• Natural history (cont’d)
 Recurrent
Caused by second pathogen in a person
who experienced a previous infection that
was eradicated
• If it occurs because original infection was
not eradicated, it is classified as
unresolved bacteriuria or bacterial
persistence
•
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Classification (Cont’d)
• Unresolved bacteriuria
 Occurs when
Bacteria resistant to antibiotic
Drug discontinued before bacteriuria is
completely eradicated
• Antibiotic agent fails to achieve adequate
concentrations in bloodstream or urine to
kill bacteria
•
•
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Classification (Cont’d)
• Bacterial persistence
 Occurs when
Bacteria develop resistance to antibiotic
agent
• Foreign body in urinary system allows
bacteria to survive
•
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Etiology and Pathophysiology
• Urinary tract above urethra normally
sterile
• Defense mechanisms exist to
maintain sterility/prevent UTIs
 Complete emptying of bladder
 Ureterovesical junction competence
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Etiology and Pathophysiology
• Defense mechanisms (cont’d)
 Peristaltic activity
 Acidic pH
 High urea concentration
 Abundant glycoproteins
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Etiology and Pathophysiology (Cont’d)
• 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
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Etiology and Pathophysiology
• Predisposing factors (cont’d)
 Anatomic factors
•
Examples: Obesity, congenital defects,
fistula
 Compromising immune response
factors
•
Examples: Age, HIV, diabetes
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Etiology and Pathophysiology
• Predisposing factors (cont’d)
 Functional disorders
•
Example: Constipation
 Other factors
•
Examples: Pregnancy, multiple sex
partners (women)
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Etiology and Pathophysiology (Cont’d)
• Menopause factor in incidence
of UTI
 Postmenopausal women have lower
estrogen levels, ↓ in vaginal
lactobacilli, ↑ in vaginal pH
•
Overgrowth of other organisms results
 Low-dose intravaginal estrogen
replacement may be effective in
treating recurrent UTIs
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Etiology and Pathophysiology (Cont’d)
• Organisms introduced via the
ascending route from the urethra
and originate in the perineum
• Less common routes
 Bloodstream
 Lymphatic system
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Etiology and Pathophysiology (Cont’d)
• Gram-negative bacilli normally
found in GI tract common cause
• Urologic instrumentation allows
bacteria to enter urethra and
bladder
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Etiology and Pathophysiology (Cont’d)
• 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
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Etiology and Pathophysiology (Cont’d)
• Rarely result from hematogenous
route
• For kidney infection to occur from
hematogenous transmission, must
have prior injury to urinary tract
 Obstruction of ureter
 Damage from stones
 Renal scars
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Etiology and Pathophysiology (Cont’d)
• Hospital-acquired UTI accounts for
31% of all nosocomial infections
 Causes
•
•
Often: E. coli
Seldom: Pseudomonas
 Catheter-acquired UTIs
•
Bacteria biofilms develop on inner surface
of catheter
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Clinical Manifestations (lower urinary
tract)
• Symptoms related to either bladder
storage or bladder emptying
 Bladder storage
•
Urinary frequency
• Abnormally frequent (> every 2 hours)
•
Urgency
• Sudden strong desire to void immediately
•
Incontinence
• Loss or leakage or urine
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Clinical Manifestations
 Bladder storage (cont’d)
•
Nocturia
• Waking up ≥2 times at night to void
•
Nocturnal enuresis
• Complaint of loss of urine during sleep
 Bladder emptying
•
•
Weak stream
Hesitancy
• Difficulty starting the urine stream
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Clinical Manifestations
 Bladder emptying (cont’d)
•
Intermittency
• Interruption of urinary stream while voiding
•
Postvoid dribbling
• Urine loss after completion of voiding
•
Urinary retention
• Inability to empty urine from bladder
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Clinical Manifestations
 Bladder emptying (cont’d)
•
Dysuria
• Difficulty voiding
•
Pain on urination
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Clinical Manifestations (Cont’d)
• Urine may contain visible blood or
sediment (hematuria), giving cloudy
appearance
• (Flank pain, chills, and fever indicate
infection of upper tract
 Pyelonephritis)
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Clinical Manifestations (Cont’d)
• In older adults
 Symptoms often absent
 Experience nonlocalized abdominal
discomfort rather than dysuria
 May have cognitive impairment
 Less likely to have a fever
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Clinical Manifestations (Cont’d)
• Patients with significant bacteriuria
 May have no symptoms
 Nonspecific symptoms such as fatigue
or anorexia
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Diagnostic Studies
• History and physical examination
• Dipstick urinalysis
 Identify presence of nitrates, WBCs,
and leukocyte esterase
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Diagnostic Studies (Cont’d)
• 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
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Diagnostic Studies (Cont’d)
• Imaging studies
 IVP or abdominal CT when obstruction
suspected
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Collaborative Care
Drug Therapy
• Antibiotics
 Selected on empiric therapy or results
of sensitivity testing
 Uncomplicated cystitis
•
Short-term course (1 to 3 days)
 Complicated UTIs
•
Requires long-term treatment (7 to 14
days)
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Collaborative Care
Drug Therapy
• Antibiotics (cont’d)
 Trimethoprim/sulfamethoxazole
(TMP/SMX)
Used to treat uncomplicated or initial
Inexpensive
Taken BID
• E. coli resistance to TMP-SMX ↑
•
•
•
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Collaborative Care
Drug Therapy
• Antibiotics (cont’d)
 Nitrofurantoin (Macrodantin)
•
•
Given three or four times a day
Long-term use
• Pulmonary fibrosis
• Neuropathies
 Fluoroquinolones
•
•
Treat complicated UTIs
Example: Ciprofloxacin (Cipro)
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Collaborative Care
Drug Therapy (Cont’d)
• Urinary analgesic
 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
•
OTC
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Collaborative Care
Drug Therapy
• Urinary analgesic (cont’d)
 Urised
•
•
•
Used in combination with antibiotics
Used to relieve UTI symptoms
Preparations with methylene blue tint
urine blue or green
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Collaborative Care
Drug Therapy (Cont’d)
• Prophylactic or suppressive
antibiotics sometimes administered
to patients with repeated UTIs
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Collaborative Care
Drug Therapy (Cont’d)
• Suppressive therapy often effective
on short-term basis
 Limited because of antibiotic
resistance ultimately leading to
breakthrough infections
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Nursing Management
Nursing Assessment
• Health history
 Previous UTIs, calculi, stasis,
retention, pregnancy, STDs, bladder
cancer
 Antibiotics, anticholinergics,
antispasmodics
 Urologic instrumentation
 Urinary hygiene
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Nursing Management
Nursing Assessment
• Health history (cont’d)
 N/V, anorexia, chills, nocturia,
frequency, urgency
 Suprapubic/lower back pain, bladder
spasms, dysuria, burning on urination
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Nursing Management
Nursing Assessment (Cont’d)
• Objective Data
 Fever
 Hematuria, foul-smelling urine,
tender, enlarged kidney
 Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria,
ultrasound, CT scan, IVP
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Nursing Management
Nursing Diagnoses
• Impaired urinary elimination
• Ineffective therapeutic regimen
management
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Nursing Management
Planning
• Patient will have
 Relief from lower urinary tract
symptoms
 Prevention of upper urinary tract
involvement
 Prevention of recurrence
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Nursing Management
Nursing Implementation
• Health Promotion
 Recognize individuals at risk
•
•
•
•
Debilitated persons
Older adults
Underlying diseases (HIV, diabetes)
Taking immunosuppressive drug or
corticosteroids
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Nursing Management
Nursing Implementation
• Health Promotion (cont’d)
 Emptying bladder regularly and
completely
 Evacuating bowel regularly
 Wiping perineal area front to back
 Drinking adequate fluids (15 ml/lb)
•
20% fluid comes from food
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cystitis
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Nursing Management
Nursing Implementation
• Health Promotion (cont’d)
 Cranberry juice or cranberry essence
may help decrease risk
 Avoid unnecessary catheterization and
early removal of indwelling catheters
 Aseptic technique must be followed
during instrumentation procedures
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Web resources
• http://www.livestrong.com/video/17
94-urinary-tract-infection-healthbyte/
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Nursing Management
Nursing Implementation
• Health Promotion (cont’d)
 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
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Nursing Management
Nursing Implementation (Cont’d)
• Acute Intervention
 Adequate fluid intake
Patient may think will worsen condition
due to discomfort
• Dilutes urine, making bladder less
irritable
• Flushes out bacteria before they can
colonize
•
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Avoid caffeine, alcohol, citrus juices,
chocolate, and highly spiced foods
•
Potential bladder irritants
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Application of local heat to suprapubic
or lower back may relieve discomfort
 Instruct patient about drug therapy
and side effects
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Emphasize taking full course despite
disappearance of symptoms
 Second or reduced drug may be
ordered after initial course in
susceptible patients
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Instruct patient to watch urine for
changes in color and consistency and
decrease in cessation of symptoms
 Counsel that persistence of lower tract
symptoms beyond treatment, onset of
flank pain, or fever should be reported
immediately
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Nursing Management
Nursing Implementation (Cont’d)
• Ambulatory and Home Care
 Emphasize compliance with drug
regimen
•
Take as ordered
 Maintain adequate fluids
 Regular voiding (every 3 to 4 hours)
 Void after intercourse
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Nursing Management
Nursing Implementation
• Ambulatory and Home Care (cont’d)
 Temporarily discontinue use of
diaphragm
 Instruct on follow-up care
 Recurrent symptoms typically occur
1 to 2 weeks after therapy
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Nursing Management
Evaluation
•
•
•
•
•
Use of nonanalgesic relief measures
Appropriate use of analgesics
Pass urine without urgency
Urine free of blood
Adequate intake of fluids
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Acute Pyelonephritis
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pyelonephritis
• http://ehealthforum.com/videos/2211/kidney-infectionpyelonephritis
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Etiology and Pathophysiology
• Inflammation of renal parenchyma
and collecting system
• (infection of kidneys and ureters)
• Caused most commonly by bacteria
• Fungi, protozoa, or viruses infecting
kidneys can also cause
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Etiology and Pathophysiology (Cont’d)
• Urosepsis
 Systemic infection from urologic
source
 Prompt diagnosis/treatment critical
•
Can lead to septic shock and death
• Septic shock: Outcome of unresolved
bacteremia involving gram-negative
organism
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Etiology and Pathophysiology (Cont’d)
• Usually begins with colonization and
infection of lower tract via ascending
urethral route
• Frequent causes
 Escherichia coli
 Proteus
 Klebsiella
 Enterobacter
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Etiology and Pathophysiology (Cont’d)
• 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
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Etiology and Pathophysiology (Cont’d)
• Commonly starts in renal medulla
and spreads to adjacent cortex
• Recurring episodes lead to scarred,
poorly functioning kidney and
chronic pyelonephritis
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Etiology and Pathophysiology (Cont’d)
• One of most important risk factors
 Pregnancy-induced physiologic
changes in urinary system
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Clinical Manifestations
•
•
•
•
•
Mild fatigue
Chills
Fever
Vomiting
Malaise
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Clinical Manifestations (Cont’d)
• 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
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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)
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Diagnostic Studies (Cont’d)
• Ultrasound
• CT scan
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Diagnostic Studies (Cont’d)
• Urinalysis shows pyuria, bacteriuria,
and varying degrees of hematuria
• WBC casts indicate involvement of
renal parenchyma
• CBC will show leukocytosis with
increase in immature bands
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Diagnostic Studies (Cont’d)
• Imaging studies (IVP or CT) requiring
intravenous injection of contrast
metals
 Usually not obtained in early stages to
prevent possible spread of infection
• Ultrasonography of urinary system
to identify anatomic abnormalities
or presence of obstructing stone
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Diagnostic Studies (Cont’d)
• Imaging studies also used to assess
complications of pyelonephritis
 Impaired renal function
 Scarring
 Chronic pyelonephritis
 Abscesses
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Diagnostic Studies (Cont’d)
• If bacteremia is a possibility, close
observation and vitals monitoring
are essential
• Prompt recognition and treatment
of septic shock may prevent
irreversible damage or death
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Collaborative Care
• 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 starting
therapy
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Collaborative Care (Cont’d)
• Drug therapy
 Antibiotics
•
Parenteral in hospital to rapidly establish
high drug levels
 NSAIDs or antipyretic drugs
•
•
Fever
Discomfort
 Urinary analgesics
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Collaborative Care (Cont’d)
• Relapses may be treated with 6week course of antibiotics
• Follow-up urine culture and imaging
studies
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Collaborative Care (Cont’d)
• Reinfections treated as individual
episodes or managed with long-term
therapy
 Prophylaxis may be used for recurrent
infection
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Nursing Management
Nursing Assessment
• Health history
 Previous UTIs, calculi, stasis,
retention, pregnancy, STDs, bladder
cancer
 Antibiotics, anticholinergics,
antispasmodics
 Urologic instrumentation
 Urinary hygiene
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Nursing Management
Nursing Assessment
• Health history (cont’d)
 Nausea, vomiting, anorexia, chills,
nocturia, frequency, urgency
 Suprapubic or lower back pain, bladder
spasms, dysuria, burning on urination
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Nursing Management
Nursing Assessment (Cont’d)
• Objective Data
 Fever
 Hematuria, foul-smelling urine,
tender, enlarged kidney
 Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria,
ultrasound, CT scan, IVP
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Nursing Management
Nursing Diagnoses
• Acute pain
• Impaired urinary elimination
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Nursing Management
Planning
• Patient will have
 Relief of pain
 Normal body temperature
 No complications
 Normal renal function
 No recurrence of symptoms
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Nursing Management
Nursing Implementation
• Health Promotion
 Early treatment for cystitis to prevent
ascending infections
Patient with structural abnormalities is at
high risk
• Stress for regular medical care
•
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Nursing Management
Nursing Implementation (Cont’d)
• Ambulatory and Home Care
 Need to continue drugs as prescribed
 Need for follow-up urine culture
 Identification of risk for recurrence or
relapse
 Encourage adequate fluids
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Nursing Management
Nursing Implementation
• Ambulatory and Home Care (cont’d)
 Rest to increase comfort
 Low-dose, long-term antibiotics to
prevent relapses or reinfections
 Explain rationale to enhance
compliance
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Nursing Management
Evaluation
•
•
•
•
•
Use of nonanalgesic relief measures
Appropriate use of analgesics
Pass urine without urgency
Urine free of blood
Adequate intake of fluids
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Case Study
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Case Study
• 27-year-old female with urgency to
urinate, frequent urination, and
urethral burning during urination
• Symptoms began 48 hours ago
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Case Study (Cont’d)
• Urine has strong odor and cloudy
appearance
• History of recurring urinary tract
infections since 22 years of age when
she got married
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Case Study (Cont’d)
• Allergic to penicillin
• Temperature 98.6° F orally
• Blood pressure 114/64 mm Hg
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Case Study (Cont’d)
• Urinalysis results
 Color: dark yellow
 pH: 6.5
 Nitrates: positive
 Leukocytes: large amount
 Trace occult blood
 Urine culture: E. coli >106 CFU/ml
•
Sensitivity to ampicillin, nitrofurantoin,
ciprofloxacin, cephalexin, TMP-SMX
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Discussion Questions
1. What type of urinary tract infection
does she probably have?
2. Why might she be having recurring
infections?
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Discussion Questions (Cont’d)
3. What is the priority of care for her?
4. What teaching should be done
with her?
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