Urinary Tract Infection

Diagnostic Studies Imaging studies (selected cases) What is it used for?

(CT) urogram or ultrasound suspect: obstruction of the urinary system or UTIs recur.

CLASSIFICATION OF UTI Upper urinary tract infections:

(involving the renal parenchyma, pelvis, and ureters) typically causes fever, chills, and flank pain)

Other Facts: Assessment and Symptoms

1. Frequency and urgency 2. Burning on urination 3. Voiding in small amounts 4. Inability to void 5. Incomplete emptying of the bladder 6. Lower abdominal discomfort or back discomfort 7. Cloudy, dark, foul-smelling urine 8. Hematuria 9. Bladder spasms 10. Malaise, chills, fever 11. Nausea and vomiting 12. WBC count greater than 100,000 cells/mm3 on urinalysis 13. An elevated specific gravity and pH may be noted on urinalysis.

Extra Stuff: Note regarding elders and UTI

Altered mentation is a sign of a urinary tract infection in older adults; frequency and urgency may not be specific symptoms of UTI because of urinary elimination changes that occur with aging.

FACTS: What is the most common cause of UTI?

Bacterial infection

CLINICAL MANIFESTATION Multiple factors may produce LUTS similar to the symptoms of a UTI:

Bladder tumors Intravesical chemotherapy Pelvic radiation

Etiology and Pathophysiology What is the most common HAI?

Catheter-acquiredurinary tract infections (CAUTIs) are the most common HAIs Caused by development of bacterial biofilms that are found on the catheter's inner surface. (often underrecognized and undertreated)

CLASSIFICATION OF UTI Classification: Complicated or Uncomplicated What is complicated UTI? What is uncomplicated UTI?

Classifying a UTI as complicated or uncomplicated: Uncomplicated UTIs: occur in normal urinary tract and usually involve only the bladder. Complicated UTIs: infections with coexisting obstruction, stones, or catheters; diabetes or neurologic diseases; or pregnancy-induced changes. (also applies to a recurrent infection) Note: complicated infection: increase risk for pyelonephritis, urosepsis, and renal damage.

Etiology and Pathophysiology What can CAUTIs lead to?

Complications such as renal abscesses, epididymitis, periurethral gland infections, and bacteremia.

NURSING IMPLEMENTATION HEALTH PROMOTION. Cranberry products

Daily cranberry juice/tablets/capsules reduce # of UTIs (enzymes found in cranberries inhibit attachment of urinary pathogens on bladder wall exp. E coli.

FACTS: Do people with asymptomatic bacteriuria need treatment?

Does not justify screening or treatment except in pregnant women.

CLASSIFICATION OF UTI Lower urinary tract

Does not usually have systemic manifestations.

FACTS: What is the most common pathogen causing a UTI?

Escherichia coli

COLLABORATIVE CARE What drugs are used for complicated UTIs?

Fluoroquinolones ciprofloxacin (Cipro) levofloxacin (Levaquin) norfloxacin (Noroxin) ofloxacin (Floxin), gatifloxacin(Tequin)

FACTS: What are the ucommon cause of UTI?

Fungal and parasitic infections (Immunicompromised, DM, patients who gone under multiple antibiotic therapy, traveled to developing countries)

COLLABORATIVE CARE When is prophylactic or suppressive antibiotics used? How popular is this method?

Given to patients who have repeated UTIs. -Low dose of TMP/SMX,nitrofurantoin, or another antibiotic taken daily to prevent recurring UTIs -Single dose may be taken before an event likely to provoke a UTI, such as sexual intercourse. Note: Although suppressive therapy is often effective on a short-term basis, this strategy is limited because of the risk of antibiotic resistance, which ultimately leads to breakthrough infections with increasingly virulent pathogens.

Etiology and Pathophysiology What organisms usually cause an UTI?

Gram-negative bacilli found in (GI) tract (most common) Gram-positive organisms streptococci, enterococci, and Staphylococcus saprophyticus

NURSING IMPLEMENTATION ACUTE CARE Application of local heat

Heat suprapubic area or lower back may relieve the discomfort Advise the patient to apply a heating pad (turned to its lowest setting) against the back or suprapubic area. A warm shower or sitting in a tub of warm water filled above the waist can also provide temporary relief.

Etiology and Pathophysiology Rare, but how can UTI result hematogenously?

Hematogenous route blood-borne bacteria secondarily invade the kidneys, ureters,or bladder from elsewhere in the body. There must be prior injury to the urinary tract (obstruction of the ureter,damage caused by stones, or renal scars, for a kidney infection to occur from hematogenous transmission)

NURSING IMPLEMENTATION HEALTH PROMOTION. How to estimate the amount of fluid intake a person should have in 24 hours.

How to estimate the amount of fluid intake a person should have in 24 hours 1) Take the person's weight in pounds and divide that number in half. Result # of ounces of fluid aperson should have per day Ex 150-pound person75 oz/day. 20% of this fluid from food leaves 60 oz (1775 mL) obtained by drinking

NURSING IMPLEMENTATION Ambulatory Care What emphasis should the nurse focus for home care of patients?

Importance of adhering to the drug regimen.

COLLABORATIVE CARE For patients in LTC facility and have chronic asymptomatic bacteriuria, what is done?

In general, only symptomatic UTIs are treated.

NURSING IMPLEMENTATION Ambulatory CARE What should the patient do if the treatment is complete and the symptoms are still present?

Instruct the patient to get follow-up care. Occur within 1-2 weeks after completion of therapy. (Recurrent symptomsbacterial persistence or inadequate treatment) If the patient has followed the treatment regimen, a relapse indicates the need for further evaluation.

CLINICAL MANIFESTATION What is LUTS?

Lower urinary tract symptoms (LUTS) are experienced in patients who have UTIs of the upper urinary tract, as well as those confined to the lower tract.

Diagnostic Studies Instruction for clean catch urine sample: Men

Men instruct them to wipe the glans penis around the urethra and collect the specimen 1 to 2seconds after voiding begins. Refrigerate urine immediately on collection.

DEFINITION: What is urinary tract infection?

Most common bacterial infection in women.

Nursing Management Nursing Diagnosis

NURSING DIAGNOSES • Impaired urinary elimination related to the effects of UTI • Readiness for enhanced self-health management

NURSING IMPLEMENTATION Ambulatory CARE What should be taught to go home:

Need for ongoing care Taking antimicrobial drugs as ordered Maintaining adequate daily fluid intake Voiding regularly (approximately every 3 to 4 hours) Urinating before and after intercourse Temporarily discontinuing the use of a diaphragm.

COLLABORATIVE CARE How many times are Nitrofurantoin taken? How many times are Macrobid taken?

Nitrofurantoin is normally given three or four times daily, but a long-acting preparation (Macrobid) is available that is taken twice daily.

CLINICAL MANIFESTATION Symptoms for older adults: (might be different)

Non localized abdominal discomfort VS dysuria and suprapubic pain. Cognitive impairment Generalized clinical deterioration. Less likely to experience a fever with a UTI

Nursing Management Planning

PLANNING The overall goals are that the patient with a UTI will have (1) relief from bothersome LUTS (2) prevention of upper urinarytract involvement (3) prevention of recurrence.

COLLABORATIVE CARE Urinary Analgesic What urinary analgesics are used for severe dysuria?

Phenazopyridine (Azo-Standard, Pyridium) (oral) Phenazopyridine is an azo dye excreted in urine exerts a topical analgesic effect on the urinary tract mucosa.

NURSING IMPLEMENTATION HEALTH PROMOTION Hygiene

Routine and thorough perineal hygiene is important forall hospitalized patients, especially when a bedpan is used, after a bowel movement, or if fecal incontinence is present.

Diagnostic Studies What is urine culture accompanied with? Why is it necessary?

Sensitivity testing to determine the bacteria's susceptibility to a variety of antibiotic drugs. *Results of this test allow MD to decide antibiotic known to be capable of destroying the bacteria causing a UTI

Diagnostic Studies What is done for suspected UTI?

Suspected UTI: Initially obtain a dipstick urinalysis: -identify the presence of nitrites (indicating bacteriuria) -white blood cells (WBCs)--> 100,000> -leukocyte esterase (anenzyme present in WBCs indicating pyuria) These findings can be confirmed by microscopic urinalysis.

NURSING IMPLEMENTATION HEALTH PROMOTION. What are the preventive measures that can be taught for UTI?

Teaching preventive measures such as (1) emptying the bladder regularly and completely, (2) evacuating the bowel regularly, (3) wiping the perineal area from front to back after urination and defecation, (4) drinking an adequate amount of liquid each day.

Etiology and Pathophysiology How sterile is the urinary tract?

The urinary tract above the urethra is normally sterile.

Diagnostic Studies Instruction for clean catch urine sample: When should refigerated urine be cultured?

The urine should be cultured within 24 hours of refrigeration.

COLLABORATIVE CARE What is the first choice drugs to treat uncomplicated or unitial UTI?

Trimethoprim/sulfamethoxazole (TMP/SMX) (Bactrim, Septra) nitrofurantoin (Macrodantin) fosfomycin(Monurol).

COLLABORATIVE CARE Length of treatment Uncomplicated Cystitis Complicated Cystitis

Uncomplicated cystitis can be treated by a short-term course of antibiotics, typically for 1 to 3 days. Complicated UTIs (longer-term treatment): lasting 7 to 14 days or longer.

Diagnostic Studies What is the preferred method of obtaining urine culture

Voided midstream technique (clean-catch urine sample)

COLLABORATIVE CARE What drugs are used for UTIs secondary to fungi?

amphotericinor fluconazole (Diflucan) is the preferred therapy

Diagnostic Studies Which is actually a better specimen? Cath or clean catch?

A specimen obtained by catheterization provides more accurate results than a clean-catch specimen.

NURSING IMPLEMENTATION ACUTE CARE Adequate fluid intake Increasing fluid and irritabitlity Type of food and juice to avoid:

Adequate fluid intake Ensure adequate fluid intake (if not contraindicated) Maintaining adequate fluid intake may be difficult ( patient's perception: intake will worsen discomfort and urinary frequency) Tell patients that fluids will increase frequency of urination at first but will also dilute the urine, making the bladder less irritable. Fluids will help flush out bacteria before they have a chance to colonize in the bladder. Caffeine, alcohol, citrus juices, chocolate, and highly spiced foods or beverages should be avoided because they are potential bladder irritants.

Diagnostic Studies After confirmation of bacteriuria and pyuria a urine, what may be obtained?

After confirmation of bacteriuria and pyuria a urine culture may be obtained.

COLLABORATIVE CARE What other antibiotics are used to treat uncomplicated UTI?

Ampicillin Amoxicillin Cephalosporins.

NURSING IMPLEMENTATION HEALTH PROMOTION. How to avoid UTIs from instrumentation

Avoidance of unnecessary catheterization and early removal of indwelling catheters are the most effective means for reducing HAI UTIs. Always follow aseptic technique during these procedures. Wash your hands before and after contact with each patient. Wear gloves for care involving the urinary system. When a catheter has been inserted,use special measures

FACTS: Bacteria count result that indicate clinically significant UTI?

Bacterial countsof 105 colony forming units per milliliter (CFU/mL) or higher typically indicate a clinically significant UTI. However, counts as low as 102 to 103 CFU/mL in a person with signs and symptoms are indicative of UTI.

NURSING IMPLEMENTATION ACUTE CARE Type of food and juice to avoid:

Caffeine, alcohol, citrus juices, chocolate, and highly spiced foods or beverages should be avoided because they are potential bladder irritants.

Collaborative Therapy Uncomplicated UTI (Textbook)

Collaborative Therapy Uncomplicated UTI • Antibiotics •trimethoprim/sulfamethoxazole (Bactrim, Septra) • trimethoprim alone in patients with sulfa allergy • nitrofurantoin (Macrodantin, Macrobid) • fosfomycin (Monurol) • Patient teaching • Adequate fluid intake (six 8-oz glasses/day)

Etiology and Pathophysiology Statistic: HAI and UTI

HAI (nosocomial infection) associated infection (UTI) 31% of all HAI Organisms associated with HAI UTIs E. coli and, less frequently, Pseudomonas organisms.

NURSING IMPLEMENTATION ACUTE CARE Instruction on taking antibiotics.

Instruction about prescribed drug therapy: Emphasize: importance of taking the full course of antibiotics. (Patients may stop antibiotic therapy once symptoms disappear lead to inadequate tx. and recurrence of infection or resistance to antibiotics) If second drug or reduced dosage of drug is ordered (after initial course)

Diagnostic Studies Instruction for clean catch urine sample: Women

Instruction for clean catch urine sample: Women: teach them to spread the labia and wipe the periurethral area from front to back using a moistened, clean gauze sponge (no antiseptic is used because it could contaminate the specimen and cause false positives). Then tell them to keep the labia spread, start voiding, and collect the specimen 1 to 2seconds after voiding starts.

Extra Stuff: List of interventions

Interventions 1. Before administering prescribed antibiotics, obtain a urine specimen for culture and sensitivity, if prescribed, to identify bacterial growth. 2. Encourage the client to increase fluids up to 3000 mL/day, especially if the client is taking a sulfonamide; sulfonamides can form crystals in concentrated urine. 3. Administer prescribed medications, which may include analgesics, antiseptics, antispasmodics, antibiotics, and antimicrobials. 4. Maintain an acid urine pH (5.5); instruct the client about foods to consume to maintain acidic urine. 5. Provide heat to the abdomen or sitz baths for complaints of discomfort. 6. Note that if the client is prescribed an aminoglycoside, sulfonamide, or nitrofurantoin (Macrodantin), the actions of these medications are decreased by acidic urine. 7. Use sterile technique when inserting a urinary catheter. 8. Maintain closed urinary drainage systems for the client with an indwelling catheter and avoid elevating the urinary drainage bag above the level of the bladder. 9. Provide meticulous perineal care for the client with an indwelling catheter. 10. Discourage caffeine products such as coffee, tea, and cola. 11. Client education a. Avoid alcohol. b. Take medications as prescribed. c. Take antibiotics on schedule and complete the entire course of medications as prescribed, which may be 10 to 14 days. d. Repeat the urine culture following treatment. e. Prevent recurrence of cystitis

Etiology and Pathophysiology Where are the organisms that cause UTI introduced?

Introduced via the ascending route from the urethra and originate in the perineum.

NURSING IMPLEMENTATION HEALTH PROMOTION. Who are the people who are at risk for UTI?

It is important to recognize individuals who are at risk for a UTI. debilitated persons older adults patients who are immunocompromised(e.g., cancer, human immunodeficiency virus [HIV], diabetes mellitus, Patients treated with immunosuppressive drugs or corticosteroids. Can help decrease the frequency of infections and provide for early detection of infection.

Etiology and Pathophysiology What are the mechanical and physiologic defense mechanisms that assist in maintaining sterility and preventing UTIs? (Note: An alteration in any of these defense mechanisms increases the risk for a UTI)

Normal voiding with complete emptying of the bladder Ureterovesical junction competence Ureteral peristaltic activity (propels urine toward the bladder) Antibacterial characteristicsof urine Acidic pH (less than 6.0) High urea concentration abundant glycoproteins interfere with the growth of bacteria Note: An alteration in any of these defense mechanisms increases the risk for a UTI

COLLABORATIVE CARE Once UTI has been diagnosed, what is initiated?

Once a UTI has been diagnosed, appropriate antimicrobial therapy is initiated. An antibiotic may be selected based on the health care provider's best judgment (empiric therapy) or the results of sensitivity testing.

Etiology and Pathophysiology Why does sexual intercourse promote UTI?

Promotes "milking" of bacteria from the vagina and perineum and may cause minor urethral trauma

CLASSIFICATION OF UTI Terms used to further delineate location for UTI: Define: Pyelonephritis Cystitis Urethritis Urosepsis

Pyelonephritis: implies inflammation (usually caused by infection) of the renal parenchyma and collecting system Cystitis: indicates inflammation of the bladder Urethritis: means inflammation of the urethra. Urosepsis: is a UTI that has spread systemically (life-threatening condition requiring emergency treatment)

Collaborative Therapy Recurrent, Uncomplicated UTI (Textbook)

Recurrent, Uncomplicated UTI • Repeat urinalysis • Urine culture and sensitivity testing • Imaging study of urinary tract (if indicated) • Antibiotic: trimethoprim/sulfamethoxazole, nitrofurantoin • Sensitivity-guided antibiotic therapy: ampicillin, amoxicillin, first-generation cephalosporin, fluoroquinolones • Consider 3- to 6-mo trial of suppressive or prophylactic antibiotic regimen • Consider postcoital antibiotic prophylaxis: trimethoprim/ sulfamethoxazole, nitrofurantoin, cephalexin • Adequate fluid intake (six 8-oz glasses/day) • Repeat patient teaching

FACTS: What is asymptomatic bacteriuria?

Someone healthy that have some bacteria colonizing the bladder Note: bladder and its contents are usually free from bacteria in normal people

Statistic: Women develop: Number hospitalized Death

Statistic: 20% of women develop at least one UTI (life time) >100,000 people are hospitalized annually >15% of patients who develop gram-negative bacteremia die: 1/3 of cases: bacteria from urinary tract

CLINICAL MANIFESTATION LUTS SYmptoms (From Chart. Read over)

Symptoms Description Emptying Symptoms Hesitancy • Difficulty starting urine stream • Delay between initiation of urination (because of urethral sphincter relaxation) and beginning of flow of urine • Diminished urinary stream Intermittency • Interruption of urinary stream while voiding Postvoid dribbling • Urine loss after completion of voiding Urinary retention or incomplete emptying • Inability to empty urine from bladder • Caused by atonic bladder or obstruction of urethra • Can be acute or chronic Dysuria • Painful or difficult urination Storage Symptoms Urinary frequency • >8 times in 24-hr period • Often <200 mL each voiding Urgency • Sudden, strong, or intense desire to void immediately • Commonly accompanied by frequency Incontinence • Involuntary or accidental urine loss or leakage Nocturia • Awakened by urge to void 2 or more times during sleep • May be diurnal or nocturnal depending on sleep schedule Nocturnal enuresis • Adults: loss of urine during sleep

CLINICAL MANIFESTATION What are lower urinary tract symptoms ) LUTS?

Symptoms are related to either bladder storage or Bladder emptying. Dysuria Frequent urination (more than every 2 hours) Urgency Suprapubic discomfort or pressure Urine: may contain grossly visible blood (hematuria) or sediment, giving it a cloudy appearance. Flank pain, chills, and fever indicate an infection involving the :upper urinary tract (pyelonephritis). People with significant bacteriuria: may have no symptoms or may have nonspecific symptoms such as fatigue or anorexia.

COLLABORATIVE CARE What are the advantage and the disadvantage of TMP/SMX?

TMP/SMX has the advantages of being relatively inexpensive and being taken twice daily. A disadvantage is E.coli resistance to TMP/SMX, which is an increasing problem inthe United States.

NURSING IMPLEMENTATION ACUTE CARE What signs and symptoms should the patient report to health care provider?

Teach patientsto promptly report any of the following to their health careprovider: (1) persistence of bothersome LUTS beyond the antibiotictreatment course, (2) onset of flank pain (3) fever. Instruct the patient to monitor for signs of improvement (e.g., cloudy urine becomes clear) and a decrease in or cessation of symptoms.

NURSING IMPLEMENTATION ACUTE CARE Why second drug or reduce dosage of drug is ordered?

To suppress bacterial growth inpatients susceptible to recurrent UTI.

Diagnostic Studies Urine culture is indicated for people who are?

Urine culture is indicated: complicated or HAI UTIs, persistent bacteriuria, frequently recurring UTIs (more than two or three episodes per year). **Urine may also be cultured when the infection is unresponsive to empiric therapy or the diagnosis is questionable.

Etiology and Pathophysiology What is the most common factor contributing to ascending infection?

Urologic instrumentation (e.g., catheterization, cystoscopic examinations). Instrumentation allows bacteria normally present at opening of the urethra to enter urethra or bladder

Develop and implement a teaching plan:

Use good perineal care, wiping front to back. Avoid bubble baths, tub baths, and vaginal deodorants or sprays. Void every 2 to 3 hours. Wear cotton pants and avoid wearing tight clothes or pantyhose with slacks. Avoid sitting in a wet bathing suit for prolonged periods of time. If pregnant, void every 2 hours. If menopausal, use estrogen vaginal creams to restore pH. Use water-soluble lubricants for intercourse, especially after menopause. Void and drink a glass of water after intercourse. 1. Take entire prescription as directed. 2. Consume oral fluids up to 3 L/day (water, juices); should not consume CITRUS juices. 3. Shower rather than bathe as a preventive measure. If bathing is necessary, never take a bubble or oil bath and avoid feminine hygiene sprays. 4. Cleanse from front to back after toileting (women and girls). 5. Avoid urinary tract irritants: alcohol, sodas, citrus juices, spices. 6. Void immediately after intercourse (women). 7. Void every 2 to 3 hours during the day. 8. Wear cotton undergarments and loose clothing to help decrease perineal moisture. 9. Practice good handwashing technique. 10. Obtain follow-up care.

Diagnostic Studies What should be done when clean-catch specimen cannot be obtained?

When an adequate clean-catch specimen cannot be readily obtained, a catheterization may be necessary.

NURSING IMPLEMENTATION Ambulatory CARE Teaching Table

When teaching a patient and caregiver measures to prevent a recurrence of a urinary tract infection (UTI), include the following. 1. Take all antibiotics as prescribed. Symptoms may improve after 1-2 days of therapy, but organisms may still be present. 2. Practice appropriate hygiene, including the following: • Carefully clean the perineal region by separating the labia when cleansing. • Wipe from front to back after urinating. • Cleanse with warm soapy water after each bowel movement. 3. Empty the bladder before and after sexual intercourse. 4. Urinate regularly, approximately every 3-4 hr during the day. 5. Maintain adequate fluid intake. 6. Avoid vaginal douches and harsh soaps, bubble baths, powders, and sprays in the perineal area. 7. Report to the health care provider symptoms or signs of recurrent UTI (e.g., fever, cloudy urine, pain on urination, urgency, frequency). 8. Consider drinking unsweetened cranberry juice (8 oz three times a day) or taking cranberry extract tablets 300-400 mg/day for UTI prevention.

CLASSIFICATION OF UTI What are the two main classification of UTI?

upper or lower UTI according to location

COLLABORATIVE CARE DRUG ALERT: Nitrofurantoin (Furadantin, Macrodantin)

• Avoid sunlight. Use sunscreen, and wear protective clothing. • Notify health care provider immediately if fever, chills, cough,chest pain, dyspnea, rash, or numbness or tingling of fingers or toesdevelops.

Diagnostic (Testbook) What are the diagnostic done for UTI?

• History and physical examination • Urinalysis (obtain midstream, "clean-catch" voided specimen) • Urine for culture and sensitivity (if indicated) • Imaging studies of urinary tract (if indicated) • CT urogram • Intravenous pyelogram (IVP) • CT/IVP • Cystoscopy • Ultrasound