urinary tract infection
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The spectrum of infectious agents changes with the passage of time and the introduction of drugs and chemicals designed to destroy them. The advent of antibiotics and the resultant development of resistant strains of bacteria have introduced new types of pathogens little known or not previously thought to be significantly dangerous to man. A few decades ago, gram-positive organisms were the most common infectious agents. Today the gram-negative microorganisms, and Proteus, Pseudomonas, and Serratia are particularly troublesome, especially in the development of hospital-acquired infections. It is predicted that in future decades other lesser known pathogens and new strains of bacteria and viruses will emerge as common causes of infections.
The development of resistant strains of pathogens can be limited by the judicious use of antibiotics. This requires culturing and sensitivity testing for a specific antibiotic to which the identified causative organism has been found to be sensitive. If the patient has been receiving a broad-spectrum antibiotic prior to culture and sensitivity testing, this should be discontinued as soon as the specific antibiotic for the organism has been found. It would be helpful, too, if the general public understood that antibiotics are not cure-alls and that there is danger in using them indiscriminately. In some instances an antibiotic can upset the normal flora of the body, thus compromising the body's natural resistance and making it more susceptible to a second infection (superinfection) by a microorganism resistant to the antibiotic.
Although antibacterials have greatly reduced mortality and morbidity rates for many infectious diseases, the ultimate outcome of an infectious process depends on the effectiveness of the host's immune responses. The antibacterial drugs provide a holding action, keeping the growth and reproduction of the infectious agent in check until the interaction between the organism and the immune bodies of the host can subdue the invaders.
Intracellular infectious agents include viruses, mycobacteria, Brucella, Salmonella, and many others. Infections of this type are overcome primarily by T lymphocytes and their products, which are the components of cell-mediated immunity. Extracellular infectious agents live outside the cell; these include species of Streptococcus and Haemophilus. These microorganisms have a carbohydrate capsule that acts as an antigen to stimulate the production of antibody, an essential component of humoral immunity.
Infection may be transmitted by direct contact, indirect contact, or vectors. Direct contact may be with body excreta such as urine, feces, or mucus, or with drainage from an open sore, ulcer, or wound. Indirect contact refers to transmission via inanimate objects such as bed linens, bedpans, drinking glasses, or eating utensils. Vectors are flies, mosquitoes, or other insects capable of harboring and spreading the infectious agent.
Special precautions for prevention of the spread of infection can vary from strict isolation of the patient and such measures as wearing gloves, mask, or gown to simply using care when handling infective material. No matter what the diagnosis or status of the patient, handwashing before and after each contact is imperative.
Unrecognized or subclinical infections pose a threat because many infectious agents can be transmitted when symptoms are either mild or totally absent.
In the care of patients for whom special precautions have not been assigned, gloves are indicated whenever there is direct contact with blood, wound or lesion drainage, urine, stool, or oral secretions. Gowns are worn over the clothing whenever there is copious drainage and the possibility that one's clothes could become soiled with infective material.
When a definitive diagnosis of an infectious disease has been made and special precautions are ordered, it is imperative that everyone having contact with the patient adhere to the rules. Family members and visitors will need instruction in the proper techniques and the reason they are necessary.
Physiologic support entails bolstering the patient's external and internal defense mechanisms. Integrity of the skin is preserved. Daily bathing is avoided if it dries the skin and predisposes it to irritation and cracking. Gentle washing and thorough drying are necessary in areas where two skin surfaces touch, for example, in the groin and genital area, under heavy breasts, and in the axillae. Lotions and emollients are used not only to keep the skin soft but also to stimulate circulation. Measures are taken to prevent pressure ulcers from prolonged pressure and ischemia. Mouth care is given on a systematic basis to assure a healthy oral mucosa.
The total fluid intake should not be less than 2000 ml every 24 hours. Cellular dehydration can work against adequate transport of nutrients and elimination of wastes. Maintenance of an acid urine is important when urinary tract infections are likely as when the patient is immobilized or has an indwelling urinary catheter. This can be accomplished by administering vitamin C daily. Nutritional needs are met by whatever means necessary, and may require supplemental oral feedings or total parenteral nutrition. The patient will also need adequate rest and freedom from discomfort. This may necessitate teaching her or him relaxation techniques, planning for periods of uninterrupted rest, and proper use of noninvasive comfort measures, as well as judicious use of analgesic drugs.
Having an infectious disease can alter patients' self-image, making them feel self-conscious about the stigma of being infectious or “dirty,” or making them feel guilty about the danger they could pose to others. Social isolation and loneliness are also potential problems for the patient with an infectious disease.
Patients also can become discouraged because some infections tend to recur or to involve other parts of the body if they are not effectively eradicated. It is important that they know about the nature of their illness, the purposes and results of diagnostic tests, and the expected effect of medications and treatments.
Patient education should also include information about the ways in which a particular infection can be transmitted, proper handwashing techniques, approved disinfectants to use at home, methods for handling and disposing of contaminated articles, and any other special precautions that are indicated. If patients are to continue taking antibacterials at home, they are cautioned not to stop taking any prescribed medication even if symptoms abate and they feel better.
Practitioners in infection control are often nurses employed by hospitals. They have titles such as Infection Control Officer and Infection Control Nurse, and they function as liaisons between staff nurses, physicians, department heads, the infection control committee, and the local health department. Such practitioners also assume some responsibility for teaching patients and their families, as well as employees of the hospital.
The centers for disease control and prevention is an excellent source of information related to infection control; their web site is http://www.cdc.gov. Another source of help and support for infection control practitioners is the Association for Practitioners in Infection Control and Epidemiology, 1275 K St., NW, Suite 100, Washington, DC 20005-4006.
Factors that contribute to infection of the urinary tract include structural defects and systemic disorders that interfere with the free flow of urine. Examples include congenital disorders, neuromuscular disease or spinal cord injury, and renal stones. Infectious agents that cause sexually transmitted diseases can also invade the urinary tract. Moreover, urinary tract infection is a constant threat and a major cause of morbidity in patients with indwelling catheters.
Antimicrobial drugs are prescribed for treatment of urinary tract infection. Some drugs such as trimethoprim and sulfamethoxazole combinations (Bactrim or Septra), or kanamycin, can be given in a single dose, while others may be prescribed in one- to three-day doses or over a longer period of time.
Other measures are related to control or management of underlying systemic or structural disorders, meticulous catheter care for patients with an indwelling catheter, and prevention and treatment of sexually transmitted diseases.
u·ri·nar·y tract in·fec·tion (UTI),
urinary tract infectionInfection of the kidney, ureter, bladder, or urethra Epidemiology Affects ± 7 million/yr, often young ♀ with acute uncomplicated pyelonephritis or cystitis, or recurrent cystitis, and adults with asymptomatic bacteruria or with complicated UTI Epidemiology Common in young, sexually active ♀, often associated with sexual intercourse, use of a diaphragm with a spermicide, Hx of recurrent UTIs Clinical Dysuria, burning, ↑ frequency, urgency Lab Leukocyte esterase + by dipstick, 102–105 colony-forming U/mL Microbiology E coli–± 80%, Staphylococcus saprophyticus, Proteus mirabilis, K pneumoniae Treatment Oral T-S, norfloxacin, ciprofloxacin
u·ri·nar·y tract in·fec·tion(UTI) (yūr'i-nar-ē trakt in-fek'shŭn)
Urinary Tract Infection
|Mean LOS:||5.5 days|
|Description:||MEDICAL: Kidney and Urinary Tract Infections With Major CC|
Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra. Approximately 20% to 25% of women have a UTI sometime during their lifetime, and acute UTIs account for approximately 7 million healthcare visits per year for young women. About 20% of women who develop a UTI experience recurrences. Women are more prone to UTIs than men because of natural anatomic variations. The female urethra is only about 1 to 2 inches in length, whereas the male urethra is 7 to 8 inches long. The female urethra is also closer to the anus than the male urethra, increasing women’s risk for fecal contamination. The motion during sexual intercourse also increases the female’s risk for infection.
Urinary reflux is one reason that bacteria spread in the urinary tract. Vesicourethral reflux occurs when pressure increases in the bladder from coughing or sneezing and pushes urine into the urethra. When pressure returns to normal, the urine moves back into the bladder, taking with it bacteria from the urethra. In vesicoureteral reflux, urine flows backward from the bladder into one or both of the ureters, carrying bacteria from the bladder to the ureters and widening the infection. If they are left untreated, UTIs can lead to chronic infections, pyelonephritis, and even systemic sepsis and septic shock. If infection reaches the kidneys, permanent renal damage can occur, which leads to acute and chronic renal failure.
The pathogen that accounts for about 90% of UTIs is Escherichia coli. Other organisms that are commonly found in the gastrointestinal tract and may contaminate the genitourinary tract include Enterobacter,Pseudomonas, group B beta-hemolytic streptococci, Proteus mirabilis,Klebsiella species, and Serratia. Two growing causes of UTIs in the United States are Staphylococcus saprophyticus and Candida albicans.
Predisposing factors are urethral damage from childbirth, catheterization, or surgery; decreased frequency of urination; other medical conditions such as diabetes mellitus; and, in women, frequent sexual activity and some forms of contraceptives (poorly fitting diaphragms, use of spermicides).
Increased susceptibility to UTIs has been observed in women and female children who have no anatomic predisposing factors, making genetic contributions suspect. Incidence of UTIs among first-degree female relatives has been reported to be 50% higher than in nonrelatives. In some families, the predisposition has suggested a dominantly inherited trait determined by a single gene, while in others, recessive or polygenic inheritance seems more likely.
Gender, ethnic/racial, and life span considerations
UTIs are uncommon in children. The largest group of individuals with UTI is adult women, and the incidence increases with age. Once young and adult women become sexually active, the incidence of UTI increases dramatically. UTIs are common during pregnancy and are caused by the hormonal changes and urinary stasis that result from ureteral dilation. Men secrete prostatic fluid that serves as an antibacterial defense, particularly during their teen and early adulthood years. As men age past 50, however, the prostate gland enlarges, which increases the risk for urinary retention and infection. As women age, vaginal flora and lubrication change; decreased lubrication increases the risk of urethral irritation in women during intercourse. By age 70, prevalence is similar for men and women. There are no known ethnic and racial considerations.
Global health considerations
In men living in developed nations, the incidence is comparable to that in the United States, but in developing nations with a shorter life expectancy, rates are lower than in the United States. Urinary tract infections in both developed and developing nations are extremely common in women.
The patient with a UTI has a variety of symptoms that range from mild to severe. The typical complaint is of one or more of the following: frequency, burning, urgency, nocturia, blood or pus in the urine, and suprapubic fullness. If the infection has progressed to the kidney, there may be flank pain (referred to as costovertebral tenderness) and low-grade fever.
Question the patient about risk factors, including recent catheterization of the urinary tract, pregnancy or recent childbirth, neurological problems, volume depletion, frequent sexual activity, and presence of a sexually transmitted infection (STI). Ask the patient to describe current sexual and birth control practices because poorly fitting diaphragms, the use of spermicides, and certain sexual practices such as anal intercourse place the patient at risk for a UTI.
Physical examination is often unremarkable in the patient with a UTI, although some patients have costovertebral angle tenderness in cases of pyelonephritis. On occasion, the patient has fever, chills, and signs of a systemic infection. Inspect the urine to determine its color, clarity, odor, and character. Surveillance for STIs is recommended as part of the examination.
UTIs rarely result in disruption of the patient’s normal activities. The infection is generally acute and responds rapidly to antibiotic therapy. The general guidelines to increase fluid intake and concomitant frequent urination may be problematic for some patients in restrictive work environments. The accompanying discomfort may result in temporary restriction of sexual activity, especially if an STI is diagnosed.
General Comments: UTIs are very easy to diagnose; follow-up testing demonstrates the effectiveness of treatment.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Leukocyte esterase dip test||Negative||Positive (purple shade)||Presence of leukocyte esterase indicates UTI; 90% accurate in detecting white blood cells (WBCs) in the urine|
|Urine culture and sensitivity||< 10,000 bacteria/mL||> 10,000 bacteria/mL or > 100 in acutely symptomatic patients||Identifies causative organism; determines appropriate antibiotic|
|Urinalysis||WBCs: 0–4; red blood cells (RBCs): ≤ 2; nitrites: none; pH: 4.6–8; no crystals; clear, aromatic||Increased WBCs, RBCs, pH, nitrites, crystals; cloudy, odor present||Presence of bacteria in the urine is indicated by several changes noted in a urinalysis|
Other Tests: Voiding cystoureterography may detect congenital anomalies that predispose patients to recurrent UTI; dynamic computed tomography.
Primary nursing diagnosis
DiagnosisAltered urinary elimination related to infection
OutcomesUrinary elimination; Knowledge: Medication, Symptom control
InterventionsMedication prescribing; Urinary elimination management
Planning and implementation
An acid-ash diet may be encouraged. A diet of meats, eggs, cheese, prunes, cranberries, plums, and whole grains can increase the acidity of the urine. Foods not allowed on this diet include carbonated beverages, anything containing baking soda or powder, fruits other than those previously stated, all vegetables except corn and lentils, and milk and milk products. Because the action of some UTI medications is diminished by acidic urine (nitrofurantoin), review all prescriptions before instructing patients to follow this diet.
UTIs are treated with antibiotics specific to the invading organism. Usually, a 7- to 10-day course of antibiotics is prescribed, but shortened and large single-dose regimens are currently under investigation. Most elderly patients need a full 7- to 10-day treatment, although caution is used in their management because of the possibility of diminished renal capacity. Women being treated with antibiotics may contract a vaginal yeast infection during therapy; review the signs and symptoms (cheesy discharge and perineal itching and swelling) and encourage the woman to purchase an over-the-counter antifungal or to contact her primary healthcare provider if treatment is indicated.
|Medication or Drug Class||Dosage||Description||Rationale|
|Cephalosporins||Varies with drug||Ceftriaxone (Rocephin), cephalexin monohydrate (Keflex)||Bacteriocidal|
|Ciprofloxacin (Cipro)||250–500 mg PO bid||Quinolone||Bacteriocidal|
|Sulfisoxazole (Gantrisin)||Initially 2–4 g PO, then 1–2 g qid for 10–14 days||Anti-infective, sulfonamide||Bacteriocidal|
|Cotrimoxazole (Bactrim, Septra)||160 mg q 12 hr for 7–14 days||Anti-infective, sulfonamide||Bacteriocidal|
|Nitrofurantoin (Macrodantin)||50–100 mg PO qid for 10–14 days||Urinary antiseptic||Bacteriocidal; concentrates in the urine and kidneys to kill bacteria|
|Phenazopyridine (Pyridium)||100–200 mg PO tid until pain subsides||Urinary analgesic||Relieves pain|
Other Drugs: Tobramycin (Nebcin), Ertapenem (Invanz), amoxicillin/clavulanate (Augmentin)
Encourage patients with infections to increase fluid intake to promote frequent urination, which minimizes stasis and mechanically flushes the lower urinary tract. Strategies to limit recurrence include increasing vitamin C intake, drinking cranberry juice, wiping from front to back after a bowel movement (women), regular emptying of the bladder, avoiding tub and bubble baths, wearing cotton underwear, and avoiding tight clothing such as jeans. These strategies have been beneficial for some patients, although there is no research that supports the efficacy of such practices.
Encourage the patient to take over-the-counter analgesics unless contraindicated for mild discomfort but to continue to take all antibiotics until the full course of treatment has been completed. If the patient experiences perineal discomfort, sitz baths or warm compresses to the perineum may increase comfort.
Evidence-Based Practice and Health Policy
Chant, C., Smith, O.M., Marshall, J.C., & Friedrich, J.O. (2011). Relationship of catheter-associated urinary tract infection to mortality and length of stay in critically ill patients: A systematic review and meta-analysis of observational studies. Critical Care Medicine, 39(5), 1167–1173.
- Results of a meta-analysis of 11 studies comparing 2,745 critically ill patients with a catheter-associated urinary tract infection (CAUTI) to 60,719 patients critically ill patients without a CAUTI revealed an increased mortality risk by nearly double among patients with a CAUTI (95% CI, 1.72 to 2.31; p < 0.00001).
- Patients with a CAUTI experienced an increased length of stay in an intensive care unit by a mean of 12 days (95% CI, 9 to 15; p < 0.00001) and an increased hospital length of stay by a mean of 21 days (95% CI, 11 to 32; p < 0.0001).
- Physical response: Pain, burning on urination, urinary frequency; vital signs; nocturia; color and odor of urine; patient history that may place the patient at risk
- Location, duration, frequency, and severity of pain; response to medications
- Absence of complications such as pyelonephritis
Discharge and home healthcare guidelines
Treatment of a UTI occurs in the outpatient setting. Teach the patient an understanding of the proposed therapy, including the medication name, dosage, route, and side effects. Explain the signs and symptoms of complications such as pyelonephritis and the need for follow-up before leaving the setting.
Explain the importance of completing the entire course of antibiotics even if symptoms decrease or disappear. If the patient experiences gastrointestinal discomfort, encourage the patient to continue taking the medications but to take them with a meal or milk unless contraindicated. Warn the patient that drugs with phenazopyridine turn the urine orange.
u·ri·nary tract in·fec·tion(UTI) (yūr'i-nar-ē trakt in-fek'shŭn)
Patient discussion about urinary tract infection
Q. How to prevent getting a bladder infection? I am worried about getting another bladder infection like I just had now. I am during my second trimester. How can I avoid getting it again?