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Urinary tract infection: treating a common problem

Article  in  Nursing and Residential Care · July 2016

DOI: 10.12968/nrec.2016.18.7.354

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CLINICAL REVIEW
Urinary tract infection: treating
a common problem
Urinary tract infection (UTI) is a fairly common problem, particularly among the older
female population. Mary Wilson offers an overview of the problem, along with advice
on the diagnosis and treatment of UTI in the care home
T
he urinary tract is comprised of the upper urinary
tract (ureters and kidneys) and lower urinary tract
(bladder and the urethra). Urinary tract infection
(UTI) occurs when a pathogenic organism invades
the urinary tract. In the past, uninfected urine was con-
sidered sterile urine; however, this has recently been ques-
tioned in favour of the existence of a bladder microbiome (of
bacterial communities), characteristic to each individual,
and generally understood to be protective against infection
(Nienhouse et al, 2014; Wolfe and Brubaker, 2015).
Who develops UTI?
Because of their shorter urethra providing less of a barrier to
ascending bacteria, and their urethral orifice being situated
closer to the anus, women are more at risk of developing UTI
than men (Haddock, 2015). One in three women compared
with one in twenty men will experience UTI within their
lifetime, and women are more susceptible to re-infection.
However, the prevalence of UTI in both genders increases
in patients over the age of 60. In men, this is often linked
to age-related changes to the prostate gland, leading to ob-
struction and turbulent flow (Schaeffer and Nicolle, 2016).
Others at risk include those who have a neurogenic urinary
tract, have diabetes, are immune-compromised, have either
stones or a foreign body (e.g. an indwelling catheter) within
the urinary tract, or are at risk of urethral contamination
from faecal incontinence (FI) (Schaeffer and Nicolle, 2016;
Haddock, 2015; Dielubanza et al, 2014; DiVito, 2014).
Mary Wilson
Retired Nurse Practitioner for Bladder and Bowel Health,
Humber NHS Foundation Trust
354
Diagnosis
UTI is classified either as ‘uncomplicated’ (as in healthy,
non-pregnant women over the age of 14, with no renal or
urinary tract abnormalities) or ‘complicated’ (referring to
men and all other women) (National Institute for Health
and Care Excellence (NICE), 2015).
Symptoms of lower urinary tract UTI include urgency,
frequency, dysuria and offensive urine; there may be frank
haematuria or suprapubic pain (Casey, 2014; Haddock,
2015). If a freshly voided urine specimen tests positive for
nitrite and leucocytes, and the patient is categorised as
complicated, a midstream urine sample (MSU) should be
sent for culture and sensitivity. Prior to collecting the speci-
men, the peri-urethral area should be cleansed; the speci-
men should be collected midstream, without stopping and
starting. In an uncomplicated patient, culture is not rec-
ommended (NICE, 2015).
Treatment and the
consequences of not treating
For all patients, paracetamol may be offered for pain relief
(NICE,2015). Without treatment, uncomplicated UTI usu-
ally resolves, although pyelonephritis can develop (Casey,
2014). However, when Knottnerus et al (2013) investigat-
ed the outcome of delaying antibiotic treatment in women
with uncomplicated UTI, after a week, the symptoms of
71% of their sample improved or resolved and none devel-
oped pyelonephritis.
For an uncomplicated patient with a symptomatic UTI
with no haematuria, but testing positive for nitrite and leu-
cocytes, a 3 day antibiotic course should be given. How-
ever, for a women with a complicated UTI, the antibiotic
course should be 5-10 days. If haematuria is present, after
infection has been excluded, further investigation should
take place (NICE, 2015). NICE (2015) also advise the treat-
ment of recurrent UTI, based on individual circumstances.
© 2016 MA Healthcare Ltd
NICE (2015) advise that pregnant women are given a 7
day antibiotic course, even if asymptomatic, as untreat-
ed, there is a the risk to the lives of mother and baby, of
maternal pyelonephritis and premature labour in the
mother, and developmental delay or cerebral palsy in
NRC | July 2016, vol 18, no 7
© kavunchik
CLINICAL REVIEW
If a freshly voided urine specimen tests positive for nitrite and leucocytes, and the patient is categorised as complicated, an MSU should be sent for culture and sensitivity
the baby. 7 days after the antibiotic course, another MSU
should be sent for culture.
NICE (2015a) also advise that male UTI should be treat-
ed by 7 day antibiotic courses. Dielubanza et al (2014) ad-
vocate that all UTI in men should be considered as compli-
cated until proven otherwise.
There are currently held concerns about antibiotic re-
sistant bacteria (Gágyor et al, 2015). Cochrane (O’Kane
et al, 2016) reviewed the over-the-counter citrate-based
preparations for urine alkalinisation, but found no good
evidence to support their use. NICE (2015) do not recom-
mend these products.
There has also been research into the effectiveness of
ibuprofen in the treatment of uncomplicated UTI. Gágyor
et al (2015) found that ibuprofen significantly reduced the
number of antibiotic courses required, although adverse
events were recorded.
Cranberry products are not recommended by NICE
(2015), owing to insufficient evidence. Jepson et al (2012),
in a Cochrane review, recognised their role in the preven-
tion of bacteria adhering to the bladder walls, which may
suggest effectiveness for women with recurrent UTIs. How-
ever, many people stop using cranberry products, consider-
ing them unacceptable for long-term use; as the products
were unstandardized, some did not contain sufficient ‘ac-
356
tive’ ingredient to be effective.
D-mannose, a sugar present in human metabolism, is
thought to similarly inhibit the adhesion of bacteria to the
bladder walls. Altarac and Papeš (2014) found that it was
effective in preventing recurrent UTIs, and had fewer side
effects than antibiotics.
Addressing other causes of UTI
After the menopause, oestrogen levels fall, glycogen pro-
duction ceases and lactic acid producing lactobacilli cease
to inhabit the vagina, which becomes more alkaline and
colonised by faecal and other UTI-causing bacteria (Lüthje
et al, 2014). However, Grin et al (2013), by use of lacto-
bacilli vaginal ‘suppositories’, and Lüthje et al (2014), by
the use of vaginal oestrogen, thus reversing the changes,
have demonstrated how recurrent UTI can be prevented by
these products.
Women should be advised to wipe from the front towards
the anus, to avoid urethral contamination (Casey, 2014).
FI can contaminate the urethral orifice leading to UTI (Di-
© 2016 MA Healthcare Ltd
Vito, 2014); this could be a possible cause that patients
may not admit to.
Conclusion
UTI is a complex topic, covering many aspects and levels
NRC | July 2016, vol 18, no 7

of care. It can range from giving mild discomfort to be-
ing responsible for significant morbidity or even mortal-
ity, but is also a condition where good care can make a
significant difference. NRC
This article was subject to double-blind peer review.
Altarac S, Papeš D (2014) Use of D‐mannose in prophylaxis of recurrent
urinary tract infections (UTIs) in women. BJU Int 113(1): 9-10. doi:
10.1111/bju.12492
Casey G (2014) Understanding urinary tract infections. N Z Nurs J 20(5):
20-3
Dielubanza EJ, Mazur DJ, Schaeffer AJ (2014) Management of non-cathe-
ter-associated complicated urinary tract infection. Infect Dis Clin North
Am 28(1): 121-134. doi: 10.1016/j.idc.2013.10.005
DiVito M (2014) Management of urinary tract infection (UTI) in the com-
munity. Journal of Community Nursing 28(3): 18-26
Gágyor I, Bleidorn J, Kochen MM, Schmiemann G, Wegscheider K, Hum-
mers-Pradier E (2015) Ibuprofen versus fosfomycin for uncomplicated
urinary tract infection in women: randomised controlled trial. BMJ
2015 351: h6544. doi: 10.1136/bmj.h6544
Grin PM, Kowalewska PM, Alhazzan W, Fox-Robichaud AE (2013) Lac-
tobacillus for preventing recurrent urinary tract infections in women:
meta-analysis. Can J Urol 20(1): 6607-14
Haddock G (2015) Improving the management of urinary tract infec-
tion. Nursing and Residential Care 17(1): 22-25. doi: 10.12968/
nrec.2015.17.1.22
Jepson RG, Williams G, Craig JC (2012) Cranberries for preventing uri-
nary tract infections. Cochrane Database Syst Rev 10: CD001321. doi:
10.1002/14651858.CD001321.pub5
Knottnerus BJ, Geerlings SE, Moll van Charante EP, ter Riet G (2013)
Women with symptoms of uncomplicated urinary tract infection are
often willing to delay antibiotic treatment: a prospective cohort study.
BMC Fam Pract 14(71). doi: 10.1186/1471-2296-14-71
Lüthje P, Hirschberg AL, Brauner A (2014) Estrogenic action on innate
defense mechanisms in the urinary tract. Maturitas 77(1): 32-6 doi:
10.1016/j.maturitas.2013.10.018
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infection (lower) – women. http://cks.nice.org.uk/urinary-tract-infec-
tion-lower-women (accessed 1 June 2016)
National Institute for Health and Care Excellence (2015a) Three-day
courses of antibiotics for uncomplicated urinary tract infection. htt-
ps://www.nice.org.uk/advice/ktt10/chapter/evidence-context (ac-
cessed 1 June 2016)
Nienhouse V, Gao X, Dong Q et al (2014) Interplay between bladder mi-
crobiota and urinary antimicrobial peptides: mechanisms for human
urinary tract infection risk and symptom severity. PloS one 9(12):
e114185. doi: 10.1371/journal.pone.0114185
O’Kane DB, Dave SK, Gore N et al (2016) Urinary alkalisation for symp-
tomatic uncomplicated urinary tract infection in women. Cochrane
© 2016 MA Healthcare Ltd
NRC | July 2016, vol 18, no 7
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CLINICAL REVIEW
Key points
The urinary tract is made up of the upper urinary
zz
tract (the ureters and kidneys) and lower urinary tract
(the bladder and the urethra)
A urinary tract infection occurs when the urinary
zz
tract is invaded by a pathogenic organism
Because they have a shorter urethra and their
zz
urethral orifice is closer to their anus, women are at a
greater risk than men of developing a urinary
tract infection
Within their lifetime, one in three women compared
zz
with one in twenty men will experience a urinary
tract infection and they are more susceptible to
re-infection
Urinary tract infection is classified either as
zz
‘uncomplicated’ in healthy, non-pregnant women
over 14 years, who have no renal or urinary tract
abnormalities or ‘complicated’ in the case of men and
all other women
Symptoms of lower urinary tract urinary tract
zz
infection include urgency, frequency, dysuria and
offensive urine, although there may also be frank
haematuria or suprapubic pain.
Database Syst Rev 4: CD010745. doi: 10.1002/14651858.CD010745.
pub2
Schaeffer AJ, Nicolle LE (2016) Urnary tract infections in older men. N
Engl J Med 374(6): 562-71. doi: 10.1056/NEJMcp1503950
Wolfe AJ, Brubaker L (2015) “Sterile urine” and the presence of bacteria.
Eur Urol 68(2): 173-4. doi: 10.1016/j.eururo.2015.02.041
357