1. LOWER URINARY TRACT INFECTIONS (UTI)
Fadi Jehad Zaben RN MSN
IMET 2000

2. Overview Definition Mechanism of Disease – common pathogens
Classification – Lower v.s Upper infection
Signs and Symptoms
Physical Exam
Urine analysis and culture
Treatment
Nursing care

3. Definition:
A 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 (105 bacteria/mL of urine or greater generally indicates infection).

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In asymptomatic bacteriuria, organisms are found in urine, but the patient has no symptoms.
Recurrent UTIs may indicate the following:
Relapse recurrent infection with an organism that has been isolated during a prior infection
Reinfection recurrent infection with an organism distinct from previous infecting organism

5. Pathophysiology and Etiology:
Ascending infection after entry by way of the urinary meatus:
Women are more susceptible to developing acute cystitis because of shorter length of urethra, anatomical proximity to vagina, periurethral glands, and rectum (fecal 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 patient's own intestinal flora (Escherichia coli).

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E. coli causes 86% of UTIs, other pathogens, such as Klebsiella species, Proteus species, and Staphylococcus saprophyticus, may also cause infections.
In men, obstructive abnormalities (strictures, prostatic hyperplasia) are the most frequent cause.
UTI is a considerable source of nosocomial infection and sepsis in older adults.
Upper urinary tract disease may occasionally cause recurrent bladder infection.

7. Classifications of infections:
Lower urinary tract infections: urethritis, prostatitis, cystitis.
Upper urinary tract infection: pyelonephritis (inflammation of kidney and renal pelvis).

8. Risk Factors:
Aging:
Increased incidence of diabetes mellitus
Increased risk of urinary stasis
Impaired immune response
Females: short urethra, having sexual intercourse, use of contraceptives that alter normal bacteria flora of vagina and perineal tissues; with age increased incidence of cystocele, rectocele (incomplete emptying).
Males: prostatic hypertrophy, bacterial prostatitis, anal intercourse.
Urinary tract obstruction: tumor or calculi, strictures.
Impaired bladder innervation.
Pregnant women are at increased risk for UTI's starting in week 6 through week 24.

9. Clinical Manifestations:
Dysuria, frequency, urgency, nocturia
Suprapubic pain and discomfort
Blood or mucus in the urine
Cramps or pain in the lower abdomen
Pain during sexual intercourse
Microscopic or gross hematuria
Manifestations in older adults:
Change in behavior
Acute confusion
Incontinence

10. Diagnostic Evaluation:
Urine dipstick may react positively for blood, white blood cells (WBCs), and nitrates indicating infection.
Urine microscopy shows RBCs and many WBCs per field without epithelial cells.
Urine culture is used to detect presence of bacteria and for antimicrobial sensitivity testing.
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.

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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 in some patients.

12. Management: Antibiotic therapy according to sensitivity results:
A wide variety of antimicrobial drugs are available.

13. For uncomplicated infection:
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For uncomplicated infection:
Women with uncomplicated cystitis may be treated with a 3-day course of a fluoroquinolone such as ciprofloxacin (Cipro), a 7-day course of nitrofurantoin (Macrodantin), or a 3-day course of co-trimoxazole (Bactrim, Septra). 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, diarrhea, drug- related rash, and vaginal candidiasis.

14. Pregnant women are usually treated for 7 to 10 days.
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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 antibiotic as prophylaxis.

15. Complications:
Pyelonephritis
Hematogenous spread resulting in sepsis

16. Nursing Diagnoses:
Acute Pain related to inflammation of the bladder mucosa
Deficient Knowledge related to prevention of recurrent UTI

17. 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.

18. Increasing Understanding and Practice of Preventive Measures:
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 bath water may gain entrance into urethra.
Cleanse around the perineum and urethral meatus after each bowel movement, with front-to-back cleansing to minimize fecal contamination of periurethral area.
Drink liberal amounts of water to lower bacterial concentrations in the urine.
Avoid bladder irritants coffee, tea, alcohol, cola drinks, and aspartame.

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Decrease the entry of microorganisms into the bladder during intercourse.
Void immediately after sexual intercourse.
A single dose of an oral antimicrobial agent may be prescribed after sexual intercourse.
Avoid external irritants such as bubble baths, talcum powders, perfumed vaginal cleansers or deodorants.
Patients with persistent bacteria may require long-term antimicrobial therapy to prevent colonization of periurethral area and recurrence of UTI.
Take antibiotic at bedtime after emptying bladder to ensure adequate concentration of drug overnight because low rates of urine flow and infrequent bladder emptying predispose to multiplication of bacteria.
Use self-monitoring tests (dipsticks) at home to monitor for UTI.

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