Urinary

tract infection
A urinary tract infection (UTI) is a bacterial infection that
affects any part of the urinary tract.

Although urine contains a variety of fluids, salts, and waste

products, it usually does not have bacteria in it.

When bacteria get into the bladder or kidney and multiply in

the urine, they cause a UTI.

The most common type of UTI is a bladder infection which is

also often called cystitis.

Another kind of UTI is a kidney infection, known as

pyelonephritis, and is much more serious.
 Urinary Tract Infection (UTI)
Background
1. Bacterial infections of urinary tract are a very
common reason to seek health services
2. Common in young females and uncommon in males
under age 50
3. Common causative organisms
• a. Escherichia coli (gram-negative enteral bacteria)
causes most community acquired infections
• b. Staphylococcus saprophyticus, gram-positive
organism causes 10 – 15%
• c. Catheter-associated UTI’s caused by gram-
negative bacteria: Proteus, Klebsiella, Seratia,
Pseudomonas
 Urinary Tract Infection (UTI)
Normal mechanisms that maintain sterility of urine
• a. Adequate urine volume
• b. Free-flow from kidneys through urinary meatus
• c. Complete bladder emptying
• d. Normal acidity of urine
• e. Peristaltic activity of ureters and competent
ureterovesical junction
• f. Increased intravesicular pressure preventing
reflux
• g. In males, antibacterial effect of zinc in prostatic
fluid
What are the causes of UTI?

Normally, urine is sterile. It is usually free of bacteria,

viruses, and fungi but does contain fluids, salts, and
waste products.

Most infections arise from one type of bacteria,

Escherichia coli (E. coli), which normally lives in the
colon.

Microorganisms called Chlamydia and Mycoplasma

may also cause UTIs in both men and women, but
these infections tend to remain limited to the urethra
and reproductive system.
Symptoms & signs

For bladder infections

Frequent urination along with the feeling of having to urinate

even though there may be very little urine to pass.

Nocturia: Need to urinate during the night.

Urethritis: Discomfort or pain at the urethral meatus or a

burning sensation throughout the urethra with urination (
dysuria).

Pain in the midline suprapubic region.

Pyuria: Pus in the urine or discharge from the urethra.

Hematuria: Blood in urine.

Pyrexia: Mild fever

Cloudy and foul-smelling urine

For kidney infections

The above symptoms.

Emesis: Vomiting is common.

Back, side (flank) or groin pain.

Abdominal pain or pressure.

Shaking chills and high spiking fever.

Night sweats.

Extreme fatigue.
 Different classifications have been devised

Primary or Recurrent UTIs. UTIs are classified as primary or

recurrent, depending on whether they are the first infection or
whether they are repeat events.

Community- or Hospital-Acquired. UTIs are also

sometimes grouped according to where they are acquired:

Uncomplicated and Complicated. UTIs are also sometimes

further defined as either being uncomplicated or complicated
depending on the factors that trigger the infections.
Catheter-Induced Infection

Urinary catheters are tubes made of latex or plastic.

They are inserted through the urethra into the bladder for
the purpose of draining urine.

They are a source of urethral irritation and provide a

means for entry of microorganisms into the urinary tract.

Catheter-associated bacteriuria remains the most

frequent cause of gram-negative septicemia in
hospitalized patients.
 Urinary Tract Infection (UTI)
Pathophysiology
1. Pathogens which have colonized urethra, vagina, or
perineal area enter urinary tract by ascending
mucous membranes of perineal area into lower
urinary tract
2. Bacteria can ascend from bladder to infect the
kidneys
3. Classifications of infections
• a. Lower urinary tract infections: urethritis,
prostatitis, cystitis
• b. Upper urinary tract infection: pyelonephritis
(inflammation of kidney and renal pelvis)
 Urinary Tract Infection (UTI)
Risk Factors
1. Aging
• a. Increased incidence of diabetes mellitus
• b. Increased risk of urinary stasis
• c. Impaired immune response
2. 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)
3. Males: prostatic hypertrophy, bacterial prostatitis,
anal intercourse
4. Urinary tract obstruction: tumor or calculi, strictures
5. Impaired bladder innervation
 Urinary Tract Infection (UTI)
Cystitis
1. Most common UTI
2. Remains superficial, involving bladder mucosa, which becomes
hyperemic and may hemorrhage
3. General manifestations of cystitis
• a. Dysuria
• b. Frequency and urgency
• c. Nocturia
• d. Urine has foul odor, cloudy (pyuria), bloody (hematuria)
• e. Suprapubic pain and tenderness
4. Older clients may present with different manifestations
• a. Nocturia, incontinence
• b. Confusion
• c. Behavioral changes
• d. Lethargy
• e. Anorexia
• f. Fever or hypothermia
 Urinary Tract Infection (UTI)
Pyelonephritis
1. Inflammation of renal pelvis and parenchyma (functional
kidney tissue)
2. Acute pyelonephritis
• a. Results from an infection that ascends to kidney from
lower urinary tract
Risk factors
• 1. Pregnancy
• 2. Urinary tract obstruction and congenital malformation
• 3. Urinary tract trauma, scarring
• 4. Renal calculi
• 5. Polycystic or hypertensive renal disease
• 6. Chronic diseases, i.e. diabetes mellitus
• 7. Vesicourethral reflux
 Urinary Tract Infection (UTI)
Pathophysiology
• 1. Infection spreads from renal pelvis to renal cortex
• 2. Kidney grossly edematous; localized abscesses in
cortex surface
• 3. E. Coli responsible organism for 85% of acute
pyelonephritis; also Proteus, Klebisella
Manifestations
• 1. Rapid onset with chills and fever
• 2. Malaise
• 3. Vomiting
• 4. Flank pain
• 5. Costovertebral tenderness
• 6. Urinary frequency, dysuria
 Urinary Tract Infection (UTI)
Manifestations in older adults
• 1. Change in behavior
• 2. Acute confusion
• 3. Incontinence
• 4. General deterioration in condition
 Urinary Tract Infection (UTI)
Chronic pyelonephritis
a. Involves chronic inflammation and scarring
of tubules and interstitial tissues of kidney
b.Common cause of chronic renal failure
c. May develop from chronic hypertension,
vascular conditions, severe vesicourteteral
reflux, obstruction of urinary tract
d.Behaviors
• 1. Asymptomatic
• 2. Mild behaviors: urinary frequency,
dysuria, flank pain
 Urinary Tract Infection (UTI)
Collaborative Care
• a. Eliminate causative agent
• b. Prevent relapse
• c. Correct contributing factors

Diagnostic Tests
a. Urinalysis: assess pyuria, bacteria, blood cells in urine;
Bacterial count >100,000 /ml indicative of infection
b. Rapid tests for bacteria in urine
• 1. Nitrite dipstick (turning pink = presence of bacteria)
• 2. Leukocyte esterase test (identifies WBC in urine)
c. Gram stain of urine: identify by shape and characteristic
(gram positive or negative); obtain by clean catch urine or
catheterization
 Urinary Tract Infection (UTI)
d. Urine culture and sensitivity: identify infecting organism
and most effective antibiotic; culture requires 24 – 72 hours
for results; obtain by clean catch urine or catheterization
e. WBC with differential: leukocytosis and increased number
of neutraphils
6. Diagnostic Tests for adults who have recurrent infections or
persistent bacteriuria
a. Intravenous pyelography (IVP) or excretory urography
• 1. Evaluates structure and excretory function of kidneys,
ureters, bladder
• 2. Kidneys clear an intravenously injected contrast
medium that outlines kidneys, ureters, bladder, and
vesicoureteral reflux
• 3. Check for allergy to iodine, seafood, radiologic contrast
medium, hold testing and notify physician or radiologist
 Urinary Tract Infection (UTI)
b. Voiding cystourethrography: instill contrast medium
into bladder and use xray to assess bladder and
urethra when filled and during voiding
c. Cystoscopy
• 1. Direct visualization of urethra and bladder
through cystoscope
• 2. Used for diagnostic, tissue biopsy, interventions
• 3. Client receives local or general anesthesia
d. Manual pelvic or prostate examinations to assess
structural changes of genitourinary tract, such as
prostatic enlargement, cystocele, rectocele
How is UTI treated?

UTIs are treated with antibacterial drugs.

The choice of drug and length of treatment depend on

the patient's history and the urine tests that identify the
offending bacteria.

The sensitivity test is especially useful in helping the

doctor select the most effective drug.

The drugs most often used to treat routine,

uncomplicated UTIs are trimethoprim (Trimpex),
trimethoprim/sulfamethoxazole (Bactrim, Septra,
Cotrim), amoxicillin (Amoxil, Trimox, Wymox),
nitrofurantoin (Macrodantin, Furadantin), and ampicillin
(Omnipen, Polycillin, Principen, Totacillin).
Longer treatment is also needed by patients with
infections caused by Mycoplasma or Chlamydia,
which are usually treated with tetracycline,
trimethoprim/sulfamethoxazole (TMP/SMZ), or
doxycycline.
 Urinary Tract Infection (UTI)
Medications
• a. Short-course therapy: 3 day course of antibiotics for
uncomplicated lower urinary tract infection; (single
dose associated with recurrent infection)
• b. 7 – 10 days course of treatment: for pyelonephritis,
urinary tract abnormalities or stones, or history of
previous infection with antibiotic-resistant infections;
clients with severe illness may need hospitalization and
intravenous antibiotics
• c. Antibiotics commonly used for short and longer
course therapy include trimethoprim-sulfamethoxazole
(TMP-SMZ), or quinolone antibiotic such as
ciprofloxacin (Cipro)
• d. Intravenous antibiotics used include ciprofloxacin,
gentamycin, ceftriaxone (Rocephin), ampicillin
 Urinary Tract Infection (UTI)
Surgery
• a. Surgical removal of large calculus from renal
pelvis or cystoscopic removal of bladder calculi
which serve as irritant and source of bacterial
colonization; may also use percutaneous ultrasonic
pyelolithotomy or extracorporeal shock wave
lithotripsy (ESWL)
• b. Ureteroplasty: surgical repair of ureter for
stricture or structural abnormality; reimplantation if
vesicoureteral reflux; clients usually return from
surgery with catheter and ureteral stent in place for 3
–5 days