URINARY TRACT INFECTION

INTRODUCTION
Urinary tract infection (UTI) in adults can be categorized into five groups: women with acute
uncomplicated cystitis, women with recurrent cystitis, and women with acute uncomplicated
pyelonephritis, complicated UTI, and asymptomatic bacteriuria. Complicated UTI is defined as
UTI that increases the risk for serious complications or treatment failure. Patients with various
conditions, such as those presented in Box 51.1, are at increased risk for complicated UTI.
Complicated UTIs may require different pretreatment and post treatment evaluation and type and
duration of antimicrobial treatment than for uncomplicated UTI. On occasion, complicated UTIs
are diagnosed only after a patient has a poor response to treatment.
DEFINITION
Lower Urinary tract infection also known as cystitis, inflammation of the bladder wall,
usually caused by ascending bacteria or obstructive voiding patterns that lead to decreased flow
or stasis of urine.
EPIDEMILOGY
 Leading cause of morbidity and health care expenditures in persons of all ages. „
 An estimated 50 % of women report having had a UTI at some point in their lives. „
 8.3 million Office visits and more than 1 million hospitalizations, for an overall annual
cost > $1 billion.
 Acute uncomplicated UTIs are extremely common, with several million episodes of acute
cystitis and atleast 250,000 episodes of acute pyelonephritis in US.
 The incidence of cystitis in sexually active young women is about 0.5 per 1 person year.
 Acute uncomplicated cystitis may recur in 27-44% of healthy women.
 Pyelonephritis in young women is about 3 per 1000 person-years.
 Symptomatic UTI in post menopausal women is about 10% per year.
 Symptomatic UTI in adult men younger than 50 years is much lower than in women,
ranging from 5-8 per 10,000 men annually.
 Asymptomatic bacteriuria is found in about 5% of young adult women, but rarely in men
younger than 50. The prevalence increases up to 16% of ambulatory women and 19% of

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 ambulatory men older than 70 and up to 50% elderly women and 40% of elderly men
who are institutionalized.
TYPES OF URINARY TRACT INFECTION
 5 types
 Women with acute uncomplicated cystitis
 Women with recurrent cystitis
 Women with acute uncomplicated pyelonephritis
 Complicated UTI
 Asymptomatic bacteriuria
Acute uncomplicated cystitis
Acute uncomplicated cystitis in women is defined as an uncomplicated lower UTI in a pre-
menopausal, non-pregnant woman with no known urological abnormalities or comorbidities.
Classical lower urinary tract symptoms include dysuria, urinary frequency, urgency and
sometimes haematuria.
Recurrent Cystitis
Recurrent cystitis is usually defined as three episodes of urinary tract infection (UTI) in the
previous 12 months, or two episodes in the previous six months. It is common in young, healthy
women.
Acute uncomplicated pyelonephritis
Acute pyelonephritis is an infection of the upper urinary tract, specifically the renal parenchyma and renal
pelvis. Acute pyelonephritis is considered uncomplicated if the infection is caused by a typical pathogen
in an immunocompetent patient who has normal urinary tract anatomy and renal function.
Complicated UTI
A complicated UTI is an infection associated with a condition, such as structural or functional
abnormalities of the genitourinary tract or the presence of an underlying disease, which increases
the risks of acquiring an infection or of failing therapy.
Asymptomatic bacteriuria
The presence of two separate consecutive clean voided urine specimens, both with 10 5 or more
colony forming units per milliliter(cfu/ml) of the same uropathogen in the absence of symptoms
referable to the urinary tract. Asymptomatic bacteriuria is very common in clinical practice.

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ETIOLOGY
 Acute complicated cystitis

 Recurrent acute uncomplicated cystitis in healthy women

 Acute uncomplicated pyelonephritis in healthy women

 Complicated urinary tract infection

 Male sex
 Pregnancy
 Poorly controlled diabetes mellitus
 Obstruction or other structural factor, Urolithiasis, Malignancies, ureteral and
urethral strictures. bladder diverticula, renal cysts, fistulas, ileal conduits, other
urinaly diversions.

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  Functional abnormality: Neurogenic bladder ,vesicoureteral reflux

ETIOLOGICAL AGENTS

ORGANISMS UNCOMPLICATED COMPLICATED

GRAM NEGATIVE ORGANISMS %

Escherichia coli 70-95 21-54

Proteus mirabilis 1-2 1-10

Klebsiella saprophyticus 1-2 2-17

Citrobacter spp <1 5

Enterobacter spp <1 2-10

Psuedomonas aeruginosa <1 2-19

Other <1 6-20

GRAM POSITIVE ORGANISMS

Coagulase negative staphylococci 5-20 or more 1-4

Enterococci 1-2 1-23

Group B streptococci <1 1-4

Staphylococcus aureus <1 1-2

Other <1 2

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CLINICAL MANIFESTATIONS

 Dysuria

 Frequency, urgency

 Dribbling of urine or innability to void

 Incomplete emptying of bladder

 Cloudy urine

 Haematuria

 Suprapubic tenderness

  Chills and sweats, Fever

 Flank pain (may radiate to groin, often dull and constant)

DIAGNOSTIC EVALUATION

 Urinalysis:This test will examine the urine for red blood cells, white blood cells and
bacteria. The number of white and red blood cells found in your urine can actually
indicate an infection.
 Urine dipstick test 
 Nitrite: positive due to bacterial reduction of endogenous nitrates to nitrites;
classically positive in Gram negative Enterobacteriaceae family of enteric
uropathogens. However, nitrite dipstick may also be clinically useful in
detecting Enterococcus and Staphylococcus bacteria.
 Leukocyte esterase: positive as neutrophil granules contain enzymes with esterase
activity; presence of neutrophils in urine due to inflammation and leukocyte
migration into the urinary tract.
 Urine culture: A urine culture is used to determine the type of bacteria in your urine.
This is an important test because it helps determine the appropriate treatment.

If infection does not respond to treatment or if you keep getting infections over and over again,
your doctor may use the following tests to examine your urinary tract for disease or injury:

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  Ultrasound: In this test, sound waves create an image of the internal organs. This test is
done on top of your skin, is painless and doesn’t typically need any preparation.
 Cystoscopy: This test uses a special instrument fitted with a lens and a light source
(cystoscope) to see inside the bladder from the urethra.
 CT scan: Another imaging test, a CT scan is a type of X-ray that takes cross sections of
the body (like slices). This test is much more precise than typical X-rays.
MANAGEMENT
 Trimethoprim-sulfamethoxazole
Inhibition of microbial DNA synthesis by inhibiting the folic acid synthesis and
consequently the purines required for DNA
Eg: Bactrim, Septra
 Fluoroquinolones
Inhibition of microbial DNA synthesis by blocking DNA gyrase and topoisomerase IV
needed for successful DNA replication and transcription.
Eg: Ciprofloxacin, Levofloxacin, Ofloxacin
 Nitrofurantoin
The mechanism is not fully understood, but it directly causes selective damage to
microbial DNA, which metabolises the toxic intermediates of nitrofurantoin more rapidly
than human cells. 
Eg: Macrobid
 Cefpodoxime proxetil
Cefpodoxime is a bactericidal agent that acts by inhibition of bacterial cell wall synthesis.
Cefpodoxime has activity in the presence of some beta-lactamases, both penicillinases
and cephalosporinases, of Gram-negative and Gram-positive.
Eg: Cefoprox, Cefcep
 Amoxicillin- clavulanate
 Cefixime
 Cefaclor

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NURSING MANAGEMENT
1. Impaired urinary elimination related to irritation and inflammation of the bladder mucosa
 Encourage the patient to take oral fluids 3-4L/day to flush the urinary system.
 Instruct the patient to drink 10 ounces of cranberry juice daily to acidify the urine
and decrease the bacterial attachment to the bladder wall.
 Educate the patient to avoid alcohol, caffeinated beverages, spicy foods and
tomatoes because these causes bladder irritation.
 Provide instructions regarding antibiotic therapy and activity restrictions needed
during antibiotic therapy.
2. Acute pain related to irritation and inflammation of bladder and urethral mucosa
 Monitor the quality and characteristics of pain.
 Provide warm sitz bath and forcing fluids to dilute urine decrease urethral smooth
muscle spasms.
 Apply heating pad to the suprapubic area to reduce bladder spasms and
suprapubic pain.
 Administer analgesics such as phenazopyridine(Pyridium)
3. Knowledge deficit related to unfamiliarity with nature and treatment of UTI as evidenced
by multiple questions and verbalizing inaccurate information
 Explain to the client about UTI risk factors, prevention, and treatment
 Encourage the patients to finish all prescribed antibiotics even if symptoms
resolve
 Encouraging the reporting of signs and symptoms of recurrence
 Teach the client the importance of perineal hygiene
 Avoid wearing tight-fitting or constricting undergarments made of non-breathing
materials
4. Disturbed sleep Pattern related to nocturia, pain as evidenced by restlessness, irritability

 Identify the client’s sleeping habits/routine and changes

 Provide comfort measures such as warm bath, back rub.
 Encourage the client to drink milk.
 Reduce environ mental distractions such as noise, light
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  Limit fluid intake during night time.
5. Hyperthermia related to inflammation as evidenced by increased body temperature and
flushed skin, warm to touch.
 Monitor vital signs
 Encourage adequate fluid intake
 Provide tepid sponge bath
 Encourage the use of hypothermia blanket and wrap extremities with bath towels.
 Maintain bed rest
 Administer antipyretic drugs as indicated.
CONCLUSION
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects
the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper
urinary tract it is known as a kidney infection (pyelonephritis). Symptoms from a lower urinary
tract infection include pain with urination, frequent urination, and feeling the need to urinate
despite having an empty bladder. Symptoms of a kidney infection include fever and flank
pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody. In
the very old and the very young, symptoms may be vague or non-specific.
BIBLIOGRAPHY

1. Richard J. Johnson & John Feehally & Jurgen Floege & Marcello Tonelli.
Comprehensive Clinical Nephrology, .6th Edition
2. Joyce M Black, Jane Hokanson Hawks. Medical Surgical Nursing. Elsevier. South East
Asia.8 th edition.
3. Brunner and Suddharth. Text book of medical and surgical nursing. South East Asia
4. https://www.hindawi.com/journals/ijmicro/2019/4246780/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027397/
6. https://en.wikipedia.org/wiki/Urinary_tract_infection
7. https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-
causes/syc-20353447
8. https://www.urologyhealth.org/urologic-conditions/urinary-tract-infections-in-adults