Urinary Tract Infection Chapter 46 9 th edition

Urinary Tract Infection (UTI) § Most common bacterial infection in women § May be

Urinary Tract Infection § Bladder and its contents are free of bacteria in majority

Urinary Tract Infection § Escherichia coli (E. coli) most common pathogen § Counts of

Urinary Tract Infection § Fungal and parasitic infections may cause UTIs § Patients at

Classification of UTI § Upper versus lower § Upper urinary tract § Renal parenchyma,

Classification of UTI § Upper versus lower § Lower urinary tract § Usually no

Classification of UTI § Urosepsis § UTI that has spread systemically § Life-threatening condition

Classification of UTI Copyright © 2017, Elsevier Inc. All Rights Reserved.

Classification of UTI § Complicated versus uncomplicated § Uncomplicated UTI § Occurs in otherwise

Classification of UTI § Complicated versus uncomplicated § Complicated UTI § Coexists with presence

Etiology and Pathophysiology § Urinary tract above urethra normally sterile § Defense mechanisms exist

Etiology and Pathophysiology § Defense mechanisms § Acidic p. H (less than 6. 0)

Etiology and Pathophysiology § Alteration of defense mechanisms increases risk of contracting UTI §

Etiology and Pathophysiology § Predisposing factors § Anatomic factors § Examples: obesity, congenital defects,

Etiology and Pathophysiology § Predisposing factors § Functional disorders § Example: constipation § Other

Etiology and Pathophysiology § Organisms introduced via ascending route from urethra and originate in

Etiology and Pathophysiology § Gram-negative bacilli normally found in GI tract: common cause §

Etiology and Pathophysiology § Contributing factor: urologic instrumentation § Allows bacteria present in opening

Etiology and Pathophysiology § Rarely results via hematogenous route § Kidney infection occurring from

Etiology and Pathophysiology § Catheter-associated urinary tract infections (CAUTI) are the most common HAI

Clinical manifestations § Range from painful urination in uncomplicated urethritis or cystitis § To

Clinical Manifestations § Symptoms related to either bladder storage or bladder emptying § Bladder

Clinical Manifestations § Bladder storage § Nocturia § Waking up two or more times

Clinical Manifestations § Bladder emptying § Intermittency § Interruption of urinary stream during voiding

Clinical Manifestations § Flank pain, chills, and fever indicate infection of upper tract §

Clinical Manifestations § In older adults § Symptoms often absent § Nonlocalized abdominal discomfort

Diagnostic Studies § History and physical examination § Dipstick urinalysis § Identify presence of

Diagnostic Studies § Urine for culture and sensitivity (if indicated) § Clean-catch sample preferred

Diagnostic Studies § Imaging studies § Ultrasound § CT scan (CT urogram) Copyright ©

Interprofessional Care Drug Therapy § Antibiotics § Selected on empiric therapy or results of

Interprofessional Care Drug Therapy § Antibiotics § Trimethoprim/sulfamethoxazole § Used to treat uncomplicated or

Interprofessional Care Drug Therapy § Antibiotics § Nitrofurantoin (Macrodantin) § Given three or four

Interprofessional Care Drug Therapy § Antibiotics § Fluoroquinolones § Treat complicated UTIs § Example:

Interprofessional Care Drug Therapy § Urinary analgesic § Phenazopyridine § Used in combination with

Interprofessional Care Drug Therapy § Prophylactic or suppressive antibiotics sometimes administered to patients with

Nursing Management Nursing Assessment § Health history § Previous UTIs, calculi, stasis, retention, pregnancy,

Nursing Management Nursing Assessment § Health History § Nausea, vomiting, anorexia, chills, nocturia, frequency,

Nursing Management Nursing Assessment § Objective Data § Fever § Hematuria, foul-smelling urine, tender,

Nursing Management Nursing Diagnoses § Impaired urinary elimination § Readiness for enhanced health management

Nursing Management Planning § Patient will have § Relief from lower urinary tract symptoms

Nursing Management Nursing Implementation § Health Promotion § Recognize individuals at risk § Debilitated

Nursing Management Nursing Implementation § Health Promotion § Emptying bladder regularly and completely §

Nursing Management Nursing Implementation § Health Promotion § Cranberry juice or cranberry tablets may

Nursing Management Nursing Implementation § Health Promotion § Routine and thorough perineal care for

Prevention of CAUTI § Avoidance of unnecessary catheterization § Early removal of indwelling catheters

Prevention of CAUTI § Follow aseptic technique for procedures § Handwashing before and after

Nursing Management Nursing Implementation § Acute Care § Adequate fluid intake § Patient may

Nursing Management Nursing Implementation § Acute Care § Avoid caffeine, alcohol, citrus juices, chocolate,

Nursing Management Nursing Implementation § Acute Care § Application of local heat to suprapubic

Nursing Management Nursing Implementation § Acute Care § Emphasize taking full course of antibiotics

Nursing Management Nursing Implementation § Acute Care § Instruct patient to monitor for signs

Nursing Management Nursing Implementation § Ambulatory Care § Emphasize importance of compliance with drug

Nursing Management Nursing Implementation § Ambulatory Care § Temporarily discontinue use of contraceptive diaphragm

Nursing Management Evaluation § The patient with a UTI will § Experience normal urinary

Acute Pyelonephritis Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Inflammation of renal parenchyma and collecting system (including the renal

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Urosepsis § Systemic infection from urologic source § Prompt diagnosis/treatment

Etiology and Pathophysiology § Usually begins with colonization and infection of lower tract via

Etiology and Pathophysiology § Preexisting factor usually present § Vesicoureteral reflux § Retrograde (backward)

Etiology and Pathophysiology § Commonly starts in renal medulla and spreads to adjacent cortex

Clinical Manifestations § Mild fatigue § Chills § Fever § Vomiting § Malaise §

Clinical Manifestations § LUTS characteristic of cystitis § Dysuria, urgency, frequency § Costovertebral tenderness

Diagnostic Studies § History § Physical examination § Palpation for CVA pain § Laboratory

Diagnostic Studies § Ultrasound § CT urogram Copyright © 2017, Elsevier Inc. All Rights

Interprofessional Care § Hospitalization for patients with severe infections and complications § Such as

Interprofessional Care § Drug therapy § Antibiotics § Parenteral administration in hospital to rapidly

Interprofessional Care § Relapses may be treated with 6 week course of antibiotics Antibiotic

Interprofessional Care § Urosepsis is characterized by bacteriuria and bacteremia § Close observation and

Nursing Management Nursing Diagnoses § Acute pain § Impaired urinary elimination Copyright © 2017,

Nursing Management Planning § Patient will have § Normal renal function § Normal body

Nursing Management Nursing Implementation § Health Promotion § Early treatment for cystitis to prevent

Nursing Management Nursing Implementation § Ambulatory Care § Continue medications as prescribed § Follow-up

Nursing Management Nursing Implementation § Ambulatory Care § Rest to increase comfort § Long-term,

Nursing Management Evaluation § Use of nonanalgesic relief measures § Appropriate use of analgesics

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Urinary Tract Infection (UTI) § Most common bacterial infection in women § May be caused by a variety of disorders § Bacterial infection most common Copyright © 2017, Elsevier Inc. All Rights Reserved.

Urinary Tract Infection § Bladder and its contents are free of bacteria in majority of healthy people § Minority of healthy individuals have some bacteria colonizing in bladder § Called asymptomatic bacteriuria and does not justify treatment Copyright © 2017, Elsevier Inc. All Rights Reserved.

Urinary Tract Infection § Escherichia coli (E. coli) most common pathogen § Counts of 105 CFU/m. L or more indicate significant UTI § Counts as low as 102 CFU/m. L in a person with signs/symptoms are indicative of UTI Copyright © 2017, Elsevier Inc. All Rights Reserved.

Urinary Tract Infection § Fungal and parasitic infections may cause UTIs § Patients at risk § Immunosuppressed § Diabetic § Have kidney problems § Have undergone multiple antibiotic courses § Have traveled to developing countries Copyright © 2017, Elsevier Inc. All Rights Reserved.

Classification of UTI § Upper versus lower § Upper urinary tract § Renal parenchyma, pelvis, and ureters § Typically causes fever, chills, flank pain § Example § Pyelonephritis: inflammation of renal parenchyma and collecting system Copyright © 2017, Elsevier Inc. All Rights Reserved.

Classification of UTI § Upper versus lower § Lower urinary tract § Usually no systemic manifestations § Examples § Cystitis: inflammation of bladder § Urethritis: inflammation of urethra Copyright © 2017, Elsevier Inc. All Rights Reserved.

Classification of UTI § Complicated versus uncomplicated § Uncomplicated UTI § Occurs in otherwise normal urinary tract § Usually only involves bladder Copyright © 2017, Elsevier Inc. All Rights Reserved.

Classification of UTI § Complicated versus uncomplicated § Complicated UTI § Coexists with presence of § Obstruction or stones § Catheters § Abnormal GU tract § Diabetes/neurologic disease § Resistance to antibiotics § immunocompromised § Pregnancy-induced changes § Recurrent infection Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Urinary tract above urethra normally sterile § Defense mechanisms exist to maintain sterility/prevent UTIs § Complete emptying of bladder § Ureterovesical junction competence § Ureteral peristaltic activity Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Predisposing factors § Anatomic factors § Examples: obesity, congenital defects, fistula § Compromising immune response factors § Examples: age, HIV, diabetes Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Predisposing factors § Functional disorders § Example: constipation § Other factors § Examples: pregnancy, multiple sex partners (women) Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Organisms introduced via ascending route from urethra and originate in the perineum § Less common routes § Bloodstream § Lymphatic system Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Gram-negative bacilli normally found in GI tract: common cause § Urologic instrumentation allows bacteria to enter urethra and bladder Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Catheter-associated urinary tract infections (CAUTI) are the most common HAI § Causes § Often: E. coli § Less frequently: Pseudomonas species § Most are underrecognized and undertreated Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical manifestations § Range from painful urination in uncomplicated urethritis or cystitis § To severe systemic illness associated with abdominal or back pain, fever, sepsis, and decreased kidney function in some cases of pyelonephritis Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations § In older adults § Symptoms often absent § Nonlocalized abdominal discomfort rather than dysuria § Cognitive impairment possible § Fever less likely Copyright © 2017, Elsevier Inc. All Rights Reserved.

Diagnostic Studies § History and physical examination § Dipstick urinalysis § Identify presence of nitrites, WBCs, and leukocyte esterase § Urine culture Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § Antibiotics § Selected on empiric therapy or results of sensitivity testing § Uncomplicated cystitis § Short-term course (typically 3 days) § Complicated UTIs § Long-term treatment (7 to 14 days or more) Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § Antibiotics § Trimethoprim/sulfamethoxazole § Used to treat uncomplicated or initial UTI § Inexpensive § Taken twice a day Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § Antibiotics § Nitrofurantoin (Macrodantin) § Given three or four times a day § Long-acting preparation (Macrobid) is taken twice daily § Ampicillin, amoxicillin, cephalosporins § Treat uncomplicated UTI Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § Antibiotics § Fluoroquinolones § Treat complicated UTIs § Example: ciprofloxacin (Cipro) § Antifungals § Amphotericin or fluconazole § UTIs secondary to fungi Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care Drug Therapy § Urinary analgesic § Phenazopyridine § 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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Assessment § Health history § Previous UTIs, calculi, stasis, retention, pregnancy, STIs, bladder cancer § Antibiotics, anticholinergics, antispasmodics § Urologic instrumentation § Urinary hygiene Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Assessment § Health History § Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency § Suprapubic/lower back pain, bladder spasms, dysuria, burning sensation on urination Copyright © 2017, Elsevier Inc. All Rights Reserved.

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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Planning § Patient will have § Relief from lower urinary tract symptoms (LUTS) § No upper urinary tract involvement § No recurrence Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Health Promotion § Recognize individuals at risk § Debilitated persons § Older adults § Underlying diseases (HIV, diabetes) § Taking immunosuppressive drug or corticosteroids Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Health Promotion § Emptying bladder regularly and completely § Evacuating bowel regularly § Wiping perineal area front to back § Drinking adequate fluids (person’s weight in pounds/2) § 20% of fluid comes from food Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Health Promotion § Cranberry juice or cranberry tablets may reduce number of UTIs § Avoid unnecessary catheterization and early removal of indwelling catheters § Aseptic technique must be followed during instrumentation procedures Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Health Promotion § Routine and thorough perineal care for all hospitalized patients § Answer call lights and offer bedpan or urinal at frequent intervals Copyright © 2017, Elsevier Inc. All Rights Reserved.

Prevention of CAUTI § Follow aseptic technique for procedures § Handwashing before and after patient contact § Wear gloves for care of urinary catheters Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § 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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods § Potential bladder irritants Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § Application of local heat to suprapubic or lower back may relieve discomfort § Instruct patient about drug therapy and side effects Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § 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 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Acute Care § Instruct patient to monitor for signs of improvement and decrease in or cessation of symptoms § Teach patient to promptly report to HCP § Persistence of LUTS beyond antibiotic treatment course § Onset of flank pain § Fever Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Ambulatory Care § Emphasize importance of compliance with drug regimen § Take as ordered § Maintain adequate fluids § Regular voiding (every 3 to 4 hours) § Void after intercourse Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Ambulatory Care § Temporarily discontinue use of contraceptive diaphragm § Instruct on follow-up care § Recurrence of symptoms: typically 1 to 2 weeks after therapy Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Evaluation § The patient with a UTI will § Experience normal urinary elimination patterns § Report relief of bothersome urinary tract symptoms § Verbalize knowledge of treatment regimen Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Inflammation of renal parenchyma and collecting system (including the renal pelvis) § Most common cause is bacterial infection § Fungi, protozoa, or viruses can also infect kidneys Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Urosepsis § Systemic infection from urologic source § Prompt diagnosis/treatment critical § Can lead to septic shock and death unless promptly treated Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Usually begins with colonization and infection of lower tract via ascending urethral route § Frequent causes § Escherichia coli § Proteus § Klebsiella § Enterobacter Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Preexisting factor usually present § Vesicoureteral reflux § Retrograde (backward) movement of urine from lower to upper urinary tract § Dysfunction of lower urinary tract § Obstruction from BPH § Stricture § Urinary stone § CAUTI Copyright © 2017, Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology § Commonly starts in renal medulla and spreads to adjacent cortex § Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis Copyright © 2017, Elsevier Inc. All Rights Reserved.

Clinical Manifestations § LUTS characteristic of cystitis § Dysuria, urgency, frequency § Costovertebral tenderness to percussion typically present on affected side § Manifestations may subside in a few days, even without therapy § Bacteriuria and pyuria still persist Copyright © 2017, Elsevier Inc. All Rights Reserved.

Diagnostic Studies § History § Physical examination § Palpation for CVA pain § Laboratory tests § Urinalysis § Urine for culture and sensitivity § CBC with WBC differential § Blood culture (if bacteremia is suspected) Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional 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 therapy starts Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care § Drug therapy § Antibiotics § Parenteral administration in hospital to rapidly establish high drug levels § NSAIDs or antipyretic drugs § Fever § Discomfort § Urinary analgesics Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care § Relapses may be treated with 6 week course of antibiotics Antibiotic prophylaxis may be used for recurrent infection § Follow-up urine culture and imaging studies § Copyright © 2017, Elsevier Inc. All Rights Reserved.

Interprofessional Care § Urosepsis is characterized by bacteriuria and bacteremia § Close observation and vital sign monitoring are essential § Prompt recognition and treatment of septic shock may prevent irreversible damage or death Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Assessment § Health History § Previous UTIs, calculi, stasis, retention, pregnancy, STIs, bladder cancer § Antibiotics, anticholinergics, antispasmodics § Urologic instrumentation § Urinary hygiene Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Assessment § Health History § Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency § Suprapubic or lower back pain, bladder spasms, dysuria, burning sensation on urination Copyright © 2017, Elsevier Inc. All Rights Reserved.

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, and IVP abnormalities Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Planning § Patient will have § Normal renal function § Normal body temperature § No complications § Relief of pain § No recurrence of symptoms Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Health Promotion § Early treatment for cystitis to prevent ascending infections § Patients with structural abnormalities are at high risk § Stress need for regular medical care Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Ambulatory Care § Continue medications as prescribed § Follow-up urine culture § Recognize manifestations of recurrence or relapse § Encourage adequate fluids Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation § Ambulatory Care § Rest to increase comfort § Long-term, low-dose antibiotics to prevent relapses or reinfections § Explain rationale to increase adherence Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Management Evaluation § Use of nonanalgesic relief measures § Appropriate use of analgesics § Pass urine without urgency § Urine free of blood § Adequate intake of fluids Copyright © 2017, Elsevier Inc. All Rights Reserved.