I.

Urinary Tract Infections Overview

A urinary tract infection (UTI) is an infection involving the kidneys, ureters, bladder, or urethra.
These are the structures that urine passes through before being eliminated from the body. The urine is
normally sterile. An infection occurs when bacteria get into the urine and begin to grow. The infection
usually starts at the opening of the urethra where the urine leaves the body and moves upward into the
urinary tract.

II. General Characteristics

The initial evaluation of a patient with a urinary tract infection should focus on dividing
complicated from uncomplicated infection. The term “complicated UTI” indicates that a functionally,
metabolically, or anatomically abnormal urinary tract is present, or that a UTI is caused by an organism
known to be resistant. Common complicating factors include urinary tract instrumentation or
catheterization, diabetes mellitus, pregnancy, immunosuppression, uretero-vesical reflux or other
urologic abnormalities, obstructive uropathy and azotemia.

A. Acute uncomplicated UTI in women:

The clinical presentation of cystitis in women usually consists of the classic triad of
dysuria, urgency and frequency, and the organisms causing acute uncomplicated cystitis in women are
highly predictable. This permits presumptive diagnosis and empiric treatment. In women with typical
symptoms and pyuria by dipstick testing, no urine culture is necessary. A short course of antibiotics
should be prescribed, and no follow-up appointment is needed unless symptoms persist or recur.

Uncomplicated cystitis may be effectively treated with a wide variety of antibiotics. Most
guidelines recommend the use of TMP/SMX, based on urinary drug excretion rates, safety, cost and
effects on vaginal flora. Recent surveys, however, indicate increasing rates of resistance among urinary
pathogens. A large study of uncomplicated UTI among women at an HMO showed that resistance to
TMP/SMX among E. coli isolates rose from 9 percent in 1992 to 18 percent in 1996. [iv] Rates of
resistance to ampicillin and cephalothin were also rising. This study, of course, could not include women
in whom no urine cultures were sent. Another recent study of antibiotic resistance among patients in
the emergency department of a tertiary care center demonstrated TMP/SMX resistance in 15 percent of
all coliform isolates; diabetes, recent hospitalization and use of antibiotics were independent risk factors
for antimicrobial resistance.

Based on these data, it may be reasonable to reconsider our management of acute

uncomplicated UTI in women, balancing concerns about creation of fluoroquinolone resistance and
efficacy of TMP/SMX. In the past, fluoroquinolones were reserved for patients with recurrent infections,
treatment failures, known resistant organisms or allergies to alternate antibiotics. We recommend
modifying this approach; fluoroquinolones should also be used as first-line agents in women with a
history of recent antibiotic use.

There have been numerous studies comparing seven-day, three-day and single- dose regimens.
For most antibiotics, three-day regimens are optimal, with similar cure rates, lower cost and fewer side
effects when compared to seven-day regimens. Single dose therapy is effective with some agents, but
cure rates are lower and recurrence more frequent. When using beta-lactams, seven-day regimens are
required to produce optimal cure rates.

In summary, most women presenting with the typical symptoms of cystitis, pyuria by dipstick,
no complicating features and no sulfa allergies should be treated empirically with three days of
TMP/SMX (Bactrim DS bid x three days). Trimethoprim alone can be used in sulfa-allergic patients. Non-
pregnant women with recent antibiotic use or history of resistant organisms should be treated with
ciprofloxacin (250 mg bid x 3 days). Patients with unresolved symptoms after appropriate treatment
should return to clinic for urine cultures. Those who were initially treated with TMP/SMX may be
switched to a fluoroquinolone while culture results are pending.

B. UTI in men:
Cystitis is far more common in women than in men, and most of the research on UTIs
has focused on women. In the past, UTIs in men were considered “complicated” by definition, as they
were felt to occur only in the presence of an anatomic abnormality. However, several studies have
shown that anal intercourse, lack of circumcision and intercourse with a female partner whose vaginal
flora is colonized with uropathogens can predispose to cystitis in young men. Symptoms of cystitis in
men can be irritative (frequency, urgency, dysuria) or obstructive (hesitancy, dribbling, poor stream).
The presence of urethral discharge points to urethritis rather than cystitis.

In a man with suspected cystitis, pretreatment urine cultures should be obtained. In

symptomatic men, 103 CFU/ml is considered significant bacteriuria. A seven day course of antibiotics is
recommended - it is reasonable to start with empiric treatment such as TMP/SMX (Bactrim DS bid x
seven days) and to adjust based on culture results if necessary. Urologic evaluation can be reserved for
men with recurrent infection.

C. Recurrent infection:
Recurrences are defined as two or more infections in a six-month period, or at least
three infections in a 12-month period. It is estimated that 20 percent of young women with an initial
bout of cystitis have recurrences, and that 90 percent of these are due to repeat exogenous infections.
These patients rarely have anatomic or functional abnormalities of the urinary tract, making imaging
studies and cystoscopy of little help. Colonization of the vaginal introitus and peri-urethral areas with
uropathogenic strains of bacteria has been implicated in recurrent infection in women. [x] The
responsible organisms can be treated with the same regimens used for uncomplicated cystitis.

Women with recurrent cystitis should have urine cultures performed, and attention should be
paid to the frequency and setting of cystitis. If cystitis is temporally linked to sexual intercourse and is
very frequent, post-coital prophylaxis with single strength TMP/SMX or nitrofurantoin is recommended.
Post-coital urinary voiding may also be helpful. Patients with frequent recurrent infection not temporally
associated with intercourse may require continuous prophylaxis. Regimens include single strength
TMP/SMX, nitrofurantoin 50 mg or cephalexin 250 mg given daily or three times a week for six to 12
months.

Alternatives to prophylaxis include intermittent patient-initiated therapy, where medication is

kept at home and a single dose or three-day regimen is started when the patient recognizes typical
symptoms of cystitis. In post-menopausal women, atrophic vaginitis and the alteration of vaginal flora
may contribute to recurrent infection; topical vaginal steroid or estrogen creams may be of benefit.
 D. Complicated UTI:
A complicated UTI indicates a functionally, anatomically or metabolically abnormal
urinary tract, or the presence of a suspected resistant pathogen. Urine cultures are essential in this
setting because the list of potential pathogens is long, and antibiotic resistance is common. Patients
require longer courses of therapy, usually lasting at least 10 to 14 days. In the absence of systemic
illness, these infections can be treated in the ambulatory setting, although careful follow-up is essential.
While the urine culture is pending, treatment should be initiated with a broad-spectrum antibiotic, such
as a fluoroquinolone. Once susceptibilities are known, antimicrobials can be tailored to a narrower
spectrum.

E. Acute, uncomplicated pyelonephritis in women:

Patients with acute uncomplicated pyelonephritis typically present with symptoms of
cystitis, fever, chills and flank pain. Symptoms of nausea, vomiting and malaise are also common. Acute
pyelonephritis can be life-threatening, and sequelae of untreated infection include renal scarring,
impaired renal function, renal abscess formation and sepsis. In reliable patients with mild symptoms,
without nausea and vomiting, signs of significant dehydration or bacteremia, outpatient therapy is an
option. Severe symptoms, inability to tolerate oral medications and/or orthostasis are indications for
admission and intravenous antibiotics.

Uropathogenic strains of E. coli are the most common cause of this syndrome, [xiv] but urine
cultures should be performed in all patients suspected of having pyelonephritis. Determination of
pyuria, bacteriuria and hematuria can also assist in the in-office diagnosis. Blood cultures are not
indicated in the outpatient setting, but should be performed in all patients sick enough to require
admission.

Initial outpatient therapy should be a 10 to 14 day course of TMP/SMX (or a fluoroquinolone in

the case of sulfa allergy, diabetes, or recent antibiotic use). Close follow-up is required. Symptoms
should resolve within 72 hours - if they do not, a complicated infection may be present. Repeat cultures
and radiologic imaging with CT or ultrasound should be performed to rule out abscess formation,
obstruction or the presence of calculi. Follow-up culture two weeks after the completion of therapy is
generally recommended.
 F. UTIs in diabetics:
Diabetic patients comprise a large proportion of our outpatient population and deserve
special attention. Diabetics are more prone to UTIs and to upper urinary tract infections. The reason for
this predisposition is not completely understood, but the most important factor is likely to be bladder
dysfunction caused by diabetic neuropathy. Studies are limited, but many experts believe that
asymptomatic bacteriuria in diabetics should be treated because of the frequency and severity of upper
urinary tract infections in these patients.

A diabetic patient with symptoms of cystitis should be managed differently than a non-diabetic.
Urine cultures should be routinely obtained prior to treatment, and a two-week antibiotic course is
recommended. As noted, increasing TMP/SMX-resistance has changed our recommendations in favor of
a fluoroquinolone such as ciprofloxacin. Follow-up cultures two weeks after the completion of therapy
are also indicated.

G. UTIs in the elderly:

Urinary tract infections in the elderly are common, and the prevalence of asymptomatic
bacteriuria rises with age in both men and women. [xv] Acute uncomplicated cystitis in an elderly
patient can be handled exactly as recommended in younger patients. The significance of asymptomatic
bacteriuria in the elderly has been the subject of great debate. Initial series demonstrated a link
between asymptomatic bacteriuria and mortality in nursing home patients, but subsequent studies
suggest that underlying disease processes may have confounded this observation. Current thinking is
that therapy for asymptomatic bacteriuria should be reserved for immunosuppressed patients and those
undergoing genitourinary instrumentation.
III. Clinical Features
 Includes the following:

o Asymptomatic bacteriuria
o Cystitis
o Prostatitis
o Pyelonephritis

 Clinical symptoms do not always correlate with site of infection (bladder vs. kidney)
or with degree of bacteriuria.
 No test differentiates bladder infections from kidney infections
 May be acute, recurrent (repeated infections with the same or different organisms),
or complicated
 Usually affects females
 Usually caused by gram-negative bacilli

Cystitis
 Dysuria
 Urinary frequency
 Urgency
 Nocturia
 Suprapubic or back pain
 Urine cloudy, malodorous, or bloody
Acute Pyelonephritis
 Fever
 Shaking chills
 Nausea and vomiting
 Symptoms often follow cystitis symptoms
 Prostatitis
 Fever
 Chills
 Dysuria
  Frequency, urgency
 Perineal, back, or pelvic pain
 Difficulty urinating
 Prostate is enlarged, tender, and indurated

IV. Diagnosis

A doctor can confirm if you have a urinary tract infection by testing a sample of your urine. For
some younger women who are at low risk of complications, the doctor may not order a urine test and
may diagnose a urinary tract infection based on the description of symptoms.

Urine Tests
Urinalysis. A urinalysis is an evaluation of various components of a urine sample. It involves
looking at the urine color and clarity, using a special dipstick to do different chemical testing, and
possibly inspecting some of the urine underneath a microscope. A urinalysis usually provides enough
information for a doctor or nurse to start treatment.
Urine Culture. If necessary, the doctor may order a urine culture, which involves incubating and growing
the bacteria contained in the urine. A urine culture can help identify the specific bacteria causing the
infection, and determine which type of antibiotics to use for treatment. A urine culture may be ordered
if the urinalysis does not show signs of infection but the doctor still suspects a UTI is causing the
symptoms. It may also be ordered if the doctor suspects complications from the infection.
Clean-Catch Sample. To obtain an untainted urine sample, doctors usually request a so-called
midstream, or clean-catch, urine sample. To provide this, the following steps are taken:
o Patients must first wash their hands thoroughly, then wash the penis or vulva and
surrounding area four times, with front-to-back strokes, using a new soapy sponge each
time.
o The patient must then begin urinating into the toilet and stop after a few ounces.
o The patient then positions the container to catch the middle portion of the stream.
Ideally, this urine will contain only the bacteria and other evidence of the urinary tract
infection.
o The patient then urinates the remainder into the toilet.
 o The patient securely screws the container cap in place without touching the inside of
the rim.
o The sample is generally given to the doctor or sent to the laboratory for analysis.

Collection with a Catheter

Some patients (small children, elderly people, or hospitalized patients) cannot provide a urine
sample. In such cases, a catheter may be inserted into the bladder to collect urine. This is the best
method for providing a contaminant-free sample.

Other Tests
If the infection does not respond to treatment, the doctor may order other tests to determine
what is causing symptoms. Imaging tests can help identify:
 Serious and recurrent cases of pyelonephritis
 Structural abnormalities
 Obstruction or abscess
 Possible obstruction or vesicoureteral reflux in children ages 2 - 24 months

Ultrasound
Ultrasound is a noninvasive imaging test that can be used to screen for hydronephrosis
(obstructions of the flow of urine), kidney stones that predispose to infection, and kidney abscesses. In
men, ultrasound can detect enlargement or abscesses of the prostate and is an accurate method for
detecting incomplete emptying of the bladder, a common cause of UTI in men over age 50. In children
with urinary tract infections, it also can be used to detect vesicoureteral reflux, the defect of the valve-
like mechanism between the ureter and bladder.

X-Rays
Special x-rays can be used to screen for structural abnormalities, urethral narrowing, or
incomplete emptying of the bladder, which can cause stagnation of urine and predispose to infection.
Due to the possible risks to the fetus, x-rays are not performed on pregnant women.
 Voiding cystourethrogram is an x-ray of the bladder and urethra. To obtain a cystourethrogram,
a dye, called contrast material, is injected through a catheter inserted into the urethra and
passed through the bladder.
  An intravenous pyelogram (IVP) is an x-ray of the kidney. For a pyelogram, the contrast matter is
injected into a vein and eliminated by the kidneys. In both cases, the dye passes through the
urinary tract and reveals any obstructions or abnormalities on x-ray images

V. Treatment

Self-Care at Home
Because the symptoms of a urinary tract infection mimic those of other conditions, you should
see your health-care provider if you think you have a urinary tract infection. A urine test is needed to
confirm that you have an infection. Self-care is not recommended.
You can help reduce the discomfort by taking the following steps:
 Follow your health-care provider's treatment recommendations.
 Finish all antibiotic medication even if you are feeling better before the medication is gone.
 Take a pain-relieving medication.
 Use a hot-water bottle to ease pain.
 Drink plenty of water.
 Avoid coffee, alcohol, and spicy foods, all of which irritate the bladder.
 Quit smoking. Smoking irritates the bladder and is known to cause bladder cancer.

Medical Treatment

The usual treatment for both simple and complicated urinary tract infections is antibiotics. The
type of antibiotic and duration of treatment depend on the circumstances.

Lower urinary tract infection (cystitis)

In an otherwise healthy young female, a three-day course of antibiotics is usually enough. Some
providers prefer a seven-day course of antibiotics. Occasionally, a single dose of an antibiotic is used.
Your health-care provider will determine which of these options is best for you.
 Adult males with a UTI require seven to 14 days of antibiotics. If the prostate is also infected
(prostatitis), four weeks of antibiotic treatment may be required. Adult females with potential for or
early involvement of the kidneys, urinary tract abnormalities, or diabetes are usually given a five- to
seven-day course of antibiotics. Children with uncomplicated cystitis are usually given a 10-day course of
antibiotics.
To alleviate burning pain during urination, phenazopyridine (Pyridium) or a similar drug, can be
used for one to two days.

Upper urinary tract infection (pyelonephritis)

Young, otherwise healthy females with symptoms of pyelonephritis can be treated as
outpatients. They may receive IV fluids and antibiotics or an injection of antibiotics in the emergency
department, followed by 10-14 days of oral antibiotics. They should follow up with their health-care
provider in one to two days to monitor improvement.
If you are very ill, dehydrated, or unable to keep anything in your stomach because of vomiting,
an IV will be inserted into your arm. You will be admitted to the hospital and given fluids and antibiotics
through the IV until you are well enough to switch to an oral antibiotic.
A complicated infection may require treatment for several weeks.
You may be hospitalized if you have symptoms of pyelonephritis and any of the following:
•appear very ill;
•are pregnant;
•have not gotten better with outpatient antibiotic treatment;
•have underlying diseases that compromise the immune system (diabetes is one example) or are taking
immunosuppressive medication;
•are unable to keep anything in your stomach because of nausea or vomiting;
•had previous kidney disease, especially pyelonephritis within the last 30 days;
•have a device such as a urinary catheter in place; or
•have kidney stones.
Urethritis in men and women can be caused by the same bacteria as sexually transmitted diseases
(STDs). Therefore, people with symptoms of STDs (vaginal or penile discharge for example) should be
treated with appropriate antibiotics.
 Follow-up

Follow your health-care provider's treatment recommendations. Finish all medications even if
you are feeling better before the medication is gone. Your health-care provider will want to see you
again to repeat the urinalysis and make sure you are getting better.
•Children and adults with kidney involvement should be seen again in one to two days.
•People recovering from uncomplicated lower urinary tract infections should be seen within one week.
Occasionally, the infection does not go away with the first treatment. If you are being treated for an
infection and have any of the following, call your health-care provider promptly.
•Fever or pain with urination is not gone after two days of antibiotic treatment.
•You cannot keep the medication down or it has severe side effects.
•You are unable to keep foods, fluids, or medication down because of nausea or vomiting.
•You develop signs of kidney involvement (such as flank pain, shaking chills, high fever).
•Your symptoms are worse rather than better after two days of antibiotics.

IV. Nursing Management

Relieving Pain
Pain associated with UTI is quickly relieved once effective antimicrobial therapy is initiated
Antispasmodic agents may also be useful in relieving bladder irritability and pain
Aspirin and applying heat to the perineum help relieve pain and spasm.
The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to promote renal
blood flow and to flush the bacteria from the urinary tract.
Urinary tract irritants (coffee, tea, citrus, spices, colas, alcohol) are avoided.
Frequent voiding (every 2 to 3 hours) is encouraged to empty bladder completely because this can
significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection.
Monitoring and Managing Potential Complications
The patient must be taught to recognize early signs and symptoms, to test for bacteriuria, and to initiate
treatment as prescribed.
Appropriate antimicrobial therapy, liberal fluid intake, frequent voiding, and hygienic measures are
commonly prescribed for managing UTI.
The patient is instructed to notify the physician if fatigue, nausea, vomiting, or pruritus occurs.
 Periodic monitoring of renal function (creatinine clearance, blood urea nitrogen [BUN] and
serum creatinine levels) may be indicated for patients with repeated UTI.
If extensive renal damage does occurs, dialysis may be necessary.
Indwelling catheters should be avoided if at all possible and remove at the earliest opportunity.
Blood cultures that are positive for infection and elevated WBC counts are reported to the physician. At
the same time, appropriate antibiotic therapy and increased fluid intake are prescribed.
Preventing sepsis is key because the mortality rate for gram-negative sepsis is significant, especially in
elderly patients.
 
Promoting Home and Community- Based Care
In helping patients learn about and prevent or manage a recurrent UTI, the nurse needs to
implement teaching that meets individual patient needs (hygiene, fluid intake, voiding habits, therapy).
Urinary Tract Infection
(UTI)
A Case Study