URINARY TRACT INFECTION P 1122 1127 Second most common bacterial disease and the most common bacterial infection in women Pregnant women and hospitalized patients are at increased risk for UTI The bladder is usually free from bacteria however colonization can occur asymptomatic bacteriuria E Coli is the most common UTI pathogen o Immunosuppressed patients DM and patients undergoing extreme antibiotic therapy can sometimes have UTIs caused by fungi or parasites ETIOLOGY AND PATHOPHYSIOLOGY Normal defense to keep urinary tract sterile o Normal voiding with complete emptying of the bladder o Ureterovesical junction competence o Peristaltic activity that propels urine towards the bladder o Urine has natural antibacterial properties Acidic pH 6 0 high urea glycoproteins interfere with bacteria growth Predisposing factors to UTI o Anything that causes an alteration in the above defenses o Factors increasing urinary stasis Intrinsic obstruction stone tumor stricture BPH Extrinsic obstruction tumor fibrosis compressing urinary tract Renal impairment o Foreign Bodies Urinary tract calculi o Anatomic Factors Catheters indwelling intermittent external condom catheter stent nephrostomy tube Medical instruments cystoscopy urodynamics Congenital defects obstruction or stasis Fistula exposing urinary stream to skin vagina or fecal stream Short female urethra and normal vagina flora colonization Obesity o Factors compromising immune response Aging HIV and DM o Functional disorders Constipation and voiding dysfunction o Other Hypoestrogenic state menopausal women higher pH and E coli colonization Multiple sex partners and use of spermicidal agents or diaphragms women Poor personal hygiene Pregnancy Hematogenous route infections rare hemat blood o Blood borne bacteria invade the kidneys ureters or body from another body location o Urinary tract injury must be present obstruction stone damage renal scars Nosocomial UTI infections 31 of all HAI most caused by catheters o Can lead to renal abscess arthritis epididymitis periurethral gland infections and bacteremia CLASSIFICATION Upper UTI renal parenchyma pelvis and ureters o Fever chills and flank pain Lower UTI Pyelonephritis o No common systemic manifestations o Inflammation of the parenchyma and collecting system Cystitis Urethritis Urosepsis o Inflammation of the bladder wall o Inflammation of the urethra o UTI that has spread into systemic circulation life threatening Uncomplicated Complicated o Infections that occur in an otherwise normal urinary tract o Usually only involves the bladder o Infections with coexisting presence of obstruction stones or catheters o Existing diabetes neurologic disease pregnancy changes or reoccurring infection o Uncomplicated UTI of a person who has never had a UTI before or a UTI that is remote o Occurs as a reinfection caused by secondary pathology in a person who had a previous Initial Infection first isolated infection from past infections years apart Recurrent UTI infection that WAS eradicated Unresolved Bacteriuria Bacterial Perdidtence o Occurs when the initial infection was NOT eradicated antibiotic D C d too soon antibiotic never reaches therapeutic levels in the patient bacteria is already antibiotic resistant o Bacteria becomes resistant to the antibiotic used to treat or a foreign body is in the urinary system like a catheter that serves a harbor for the bacteri despite appropriate treatment CLINICAL MANIFESTATIONS Lower Urinary Tract Symptoms LUTS o LUTS are symptoms for both upper and lower infections o Emptying symptoms Hesitancy intermittency postvoid dribbling urinary retention incomplete emptying dysuria and pain on urination o Storage symptoms Urinary frequency 8 times 24hrs usually 200 ml urgency incontinence nocturia and nocturnal enuresis Urine may contain sediment blood hematuria and have a cloudy appearance Older adults may only experience a distended abdomen or decrease in temperature not fever Flank pain chills and fever indicate upper UTI pyelonephritis Can have no symptoms or general such as fatigue or anorexia o Sudden cognitive impairment may also occur Dipstick urinalysis always done initially step 1 o Identify nitrates bacteriuria WBC and leukocyte esterase WBC enzyme pyuria DIAGNOSTIC STUDIES Microscopic urinalysis step 2 o Confirm dipstick results Urine culture step 3 o Determines classification confirms questionable dx and when the infection is unresponsive to empiric therapy sensitivity testing what antibiotics will work o Ideally a clean catch mid stream specimen otherwise unreliable Wipe void 1 2 seconds collect finish voiding in toilet Can be done via catheterization better results but risk of infection o Refrigerate immediately after collection Must be cultured within 24 hours Intravenous pyelogram IVP and CT scans o When obstruction is suspected Renal ultrasound o Preferred for recurrent UTIs noninvasive easy to preform inexpensive COLLABORATIVE THERAPY AND DRUG THERAPY Studies show to only treat symptomatic UTIs and not asymptomatic bacteriuria Uncomplicated UTI o Antibiotics Trimethoprim sulfamethoxazole Bactrim septra Trimethoprim alone sulfa allergy Nitrofurantoin Macrodantin Macrobid Long term use can cause pulmonary fibrosis and neuropathies o Patient teaching o Adequate fluid intake 6 8oz glasses a day Recurrent uncomplicated UTI o Repeat urinalysis o Urine culture and sensitivity testing o Imagine study of urinary tract o Antibiotics same as above o Sensitivity guided antibiotic therapy Ampicillin amoxicillin first generation cephalosporin fluroquinolones o Possible 3 6 month trial of suppressive or prophylactic antibiotic regimen Not preferable due to resistance and break through infection risk o Consider postcoital antibiotic prophylaxis Trimethoprim sulfamethoxazole nitrofurantoin cephalexin o Repeat patient teaching o Adequate fluid intake 6 8oz glasses a day Fungi cause amphotericin or fluconazole Uncomplicated cystitis may be short term 1 3 days of antibiotics Complicated need 7 14 days or longer NURSING IMPLEMENTATION Health promotion o Identify individuals at risk Debilitated persons elderly immune compromised due to co morbid diseases cancer HIV DM patients being treated with immunosupressives or corticosteroids o Teaching preventative measures Empty bladder regularly and completely at least every 3 4 hours Before and after intercourse use of diaphragm and bathing Evacuating bowel regularly Wiping the perineal area from front to back Drinking adequate