Urinary Tract Infection UTI

What is Urinary Tract Infection UTI ?

A urinary tract infection UTI is caused by the presence of pathogenic microorganisms in the urinary tract with or without signs and symptoms. Lower UTIs may predominate at the bladder (cystitis) or urethra(urethritis).

Bacteriuria refers to the presence of bacteria in the urine (10³ bacteria/mL of urine or greater generally indicates infection).

In asymptomatic bacteriuria, organisms are found in urine, but the patient has no symptoms.

Recurrent UTIs may indicate the following:

• Unresolved- bacteria fails to respond to antimicrobial therapy.
• Recurrent- reinfection after eradication of pathogens.

Causes and Pathophysiology of UTI

1. Ascending infection after entry by way of the urinary meatus.

• Women are more susceptible to developing acute cystitis because of the shorter length of the urethra; anatomical proximity to the vagina, periurethral glands, and rectum (faecal contamination ); and the mechanical effect of coitus.
• Women with recurrent UTIs typically have gram-negative organisms at the vaginal introitus; there may be some defect of the mucosa of the urethra, vagina, or external genitalia of these patients that allows enteric organisms to invade the bladder.
• Poor voiding habits may result in incomplete bladder emptying, increasing the risk of recurrent infection.
• Acute infection in women most commonly arises from organisms of the patients own intestinal flora (Escherichia Coli).

2. Although E. coli causes 86% of UTIs, other pathogens, such as Klebsiella species, Proteus species, and Staphylococcus saprophyticus, may also cause these infections.

3. In men, obstructive abnormalities ( strictures, prostatic hyperplasia) are the most frequent cause.

4. UTI is a considerable source of nosocomial infection and sepsis in older adults.

5. Upper urinary tract disease may occasionally cause a recurrent bladder infection.

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Signs and Symptoms of UTI

• Dysuria, frequency, urgency, nocturia.
• Suprapubic pain and discomfort.
• Microscopic or gross hematuria.
• The only sign of UTI in the older patient may be mental status changes.

Diagnostic Evaluation for UTI

• Urine dipstick may tract positively for blood, white blood cells (WBCs), and nitrates, indicating infection.
• Urine microscopy shows RBCs and many WBCs per field without epithelial cells.
• Urinalysis showing many epithelial cells is likely contaminated by vaginal secretions in women and is therefore inaccurate in indicating infection. Urine culture may be reported as contaminated as well. Obtaining a clean-catch, midstream specimen is essential for accurate results, and catheterization may be necessary for some patients.
• Urine culture is used to detect the presence of bacteria and for antimicrobial sensitivity testing; however, it is not necessary in all cases.
• Patients with indwelling catheters may have asymptomatic bacterial colonization of the urine without UTI. In these patients, UTI is diagnosed and treated only when symptoms are present.

Treatment and Management of UTI

1. Antibiotic therapy according to sensitivity results.

• A wide variety of antimicrobial drugs are available.
• Urinary infections usually respond to drugs that are excreted in urine in high concentrations; a potentially effective drug should rapidly sterilize the urine and thus relieve the patient's symptoms.

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2. For uncomplicated infection:

• First-line therapy for women with uncomplicated cystitis includes a 5-days course of nitrofurantoin or a 3-day course of co-trimoxazole. A 3-day course of a fluoroquinolone such as ciprofloxacin is also effective, but consideration should be given to side effects and reserving this class of drug for other, more serious infections.
• Seven to 10 days of therapy are recommended for women over age 65.
• Men are treated with 7 to 10 days of antibiotic therapy.
• Follow-up culture to prove treatment effectiveness may be indicated.
• Adverse effects include nausea, diarrhoea, drug-related rash, and vaginal candidiasis.
• Pregnant women are usually treated for 7 to 10 days.
• Women with recurrent infections may be treated longer, undergo diagnostic testing to rule out a structural abnormality, or be maintained on a daily dose of antibiotics as prophylaxis.
• For severe discomfort with voiding, phenazopyridine may be ordered three times per day for 2-days.

Complications of UTI

• Pyelonephritis.
• Hematogenous spread resulting in sepsis.

Nursing Care Plan for  UTI

Nursing Assessment

• Determine if the patient has a history of UTIs in childhood, during pregnancy, or has had recurrent infections.
• Question about voiding habits, personal hygiene practices, and methods of contraception (use of diaphragm or spermicides is associated with the development of cystitis).
• Ask if the patient has any associated symptoms of vaginal discharge, itching, or irritation-dysuria may be a prominent symptom of vaginitis or infection from sexually transmitted pathogens, rather than UTI.
• Examine for suprapubic tenderness, as well as abdominal tenderness, guarding, rebound, or masses that may indicate more serious process.

Nursing Diagnosis for UTI

• Acute pain related to inflammation of the bladder mucosa.
• Deficient knowledge related to prevention of recurrent UTI. 

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Nursing Interventions for UTI

Relieving Pain

• Administer or teach self-administration of antibiotic-eradication of infection is usually accompanied by rapid resolution of symptoms.
• Encourage patient to take prescribed analgesics and antispasmodics, if ordered.
• Encourage rest during the acute phase if symptoms are severe.
• Encourage plenty of fluids to promote urinary output and to flush out bacteria from urinary tract.

Understanding and Practice of Preventive Measures

1. For women with recurrent UTIs give the following instructions:

• Reduce vaginal introital concentration of pathogens by hygienic measures.
• Wash genitalia in shower or while standing in bathtub-bacteria in bathwater may gain entrance into urethra.
• Cleanse around the perineum and urethral meatus after each bowel movement, with front-to back cleansing to minimize faecal contamination of periurethral area.

2. Drink liberal amounts of water to lower bacterial concentration in the urine.

3. Avoid bladder irritations-coffee, tea, alcohol, cola drinks, and aspartame.

4. Decrease the entry of microorganisms into the blader during intercourse.

• Void immediately after sexual intercourse.

5. Avoid external irritants such as bubble baths, talcum powders, perfumed vaginal cleansers or deodorants.

6. Patients with persistent bacteria may require long-term antimicrobial therapy to prevent the colonization of the periurethral area and recurrence of UTI.

• Take antibiotic at bedtime after emptying the bladder to ensure adequate concentration of drug overnight because low rates of urine flow and infrequent bladder emptying predispose to the multiplication of bacteria.
• Use self-monitoring tests (dipsticks) at home to monitor for UTI.

Reference: Lippincott Manual of Nursing