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INFECTIONS OF THE URINARY TRACT Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally classified by location as infections of the lower urinary tract, involving the bladder and structur...

INFECTIONS OF THE URINARY TRACT Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally classified by location as infections of the lower urinary tract, involving the bladder and structures below the bladder, or upper urinary tract, involving the kidneys and ureters. A UTI is the second most common infection in the body. Fifty percent of all hospital-acquired infections are UTIs, and in the majority of cases these are catheter-associated urinary tract infections (CAUTI). A CAUTI is a UTI associated with indwelling urinary catheters. Lower Urinary Tract Infections The sterility of the bladder is maintained by several mechanisms, especially important since the urethra is considered a clean, not a sterile space. The physical barrier of the urethra assists in keeping bacteria away from the bladder, while urine flow helps to carry any bacteria away from the bladder. Lower UTIs include bacterial cystitis (inflammation of the urinary bladder), bacterial prostatitis (inflammation of the prostate gland), and bacterial urethritis (inflammation of the urethra). Risk factors Contributing conditions such as: Female gender Diabetes Pregnancy Neurologic disorders Gout Altered states caused by incomplete emptying of the bladder and urinary stasis Decreased natural host defenses or immunosuppression Inability or failure to empty the bladder completely Inflammation or abrasion of the urethral mucosa Instrumentation of the urinary tract (e.g., catheterization, cystoscopic procedures) Obstructed urinary flow Pathophysiology An obstruction to free-flowing urine is a condition known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder. With coughing, sneezing, or straining, the bladder pressure increases, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. Urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the bladder into one or both ureters. Normally, the ureterovesical junction prevents urine from traveling back into the ureter. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter during normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the bacteria may reach the kidneys and eventually destroy them. Bacteria enter the urinary tract in three ways: by the transurethral route (ascending infection), through the bloodstream (hematogenous spread), or by means of a fistula from the intestine (direct extension). The most common route of infection is transurethral, in which bacteria (often from fecal contamination) colonize the periurethral area and subsequently enter the bladder by means of the urethra. In women, the short urethra offers little resistance to the movement of uropathogenic bacteria. Penile-vaginal intercourse forces the bacteria from the urethra into the bladder. This accounts for the increased incidence of UTIs in women who engage in penile-vaginal intercourse. Clinical Manifestations Signs and symptoms of UTI depend on whether the infection involves the lower (bladder) or upper (kidney) urinary tract and whether the infection is acute or chronic. Signs and symptoms of an uncomplicated lower UTI include burning on urination, urinary frequency urgency, nocturia, incontinence, and suprapubic or pelvic pain. Hematuria and back pain may also be present. In older adults, these symptoms are less common. In patients with complicated UTIs, manifestations can range from asymptomatic bacteriuria to gram-negative sepsis with shock. Complicated UTIs often are caused by a broader spectrum of organisms, have a lower response rate to treatment, and tend to recur. Many patients with CAUTIs are asymptomatic; however, any patient with a catheter who suddenly develops signs and symptoms of septic shock should be evaluated for urosepsis (the spread of infection from the urinary tract to the bloodstream that results in a systemic infection). Gerontologic Considerations The incidence of bacteriuria in older adults differs from that in younger adults. Bacteriuria increases with age and disability, and women are affected more frequently than men. UTI is the most common infection of older adults and increases in prevalence with age. UTIs occur more frequently in women than in men at younger ages but the gap between the sexes narrows in later life, which is due to reduced penile-vaginal intercourse in women and a higher incidence of bladder outlet obstruction secondary to benign prostatic hyperplasia in men. Factors That Contribute to Urinary Tract Infection in Older Adults Cognitive impairment Frequent use of antimicrobial agents High incidence of multiple chronic medical conditions Immune compromised Immobility and incomplete emptying of bladder Low fluid intake and excessive fluid loss Obstructed flow of urine (e.g., urethral strictures, neoplasms, clogged indwelling catheter) Poor hygiene practices Important points Diligent hand hygiene, careful perineal care, and frequent toileting may decrease the incidence of UTIs. Escherichia coli is the most common organism seen in older patients in the community or hospital. However, patients with indwelling catheters are more likely to be infected with organisms such as Proteus, Klebsiella, Pseudomonas, or Staphylococcus. Patients who have been previously treated with antibiotics may be infected with Enterococcus species. Frequent reinfections are common in older adults. Early symptoms of UTI in postmenopausal women and older adults include malaise, nocturia, urinary incontinence, or a complaint of foul-smelling urine. Assessment and Diagnostic Findings Results of various tests, such as bacterial colony counts, cellular studies, and urine cultures, help confirm the diagnosis of UTI. In an uncomplicated UTI, the strain of bacteria determines the antibiotic of choice (Norris, 2019). Urine Cultures Urine cultures are useful for documenting a UTI and identifying the specific organism present. UTI is diagnosed by bacteria in the urine culture. A colony count greater than 100,000 CFU/mL of urine on a clean-catch midstream or catheterized specimen indicates infection. Cellular Studies Microscopic hematuria is present in about half of patients with an acute UTI. Pyuria (white blood cells [WBCs] in the urine) occurs in all patients with UTI; however, it is not specific for bacterial infection. Pyuria can also be seen with renal calculi, interstitial nephritis, and renal tuberculosis. Other Studies X-ray images, computed tomography (CT) scan, ultrasonography, and kidney scans are useful diagnostic tools. A CT scan may detect pyelonephritis or abscesses. Ultrasonography and kidney scans are extremely sensitive for detecting obstruction, abscesses, tumors, and cysts. Medical therapy Because the organism in initial, uncomplicated UTIs in women is most likely E. coli or other fecal flora, the agent should be effective against these organisms. Various treatment regimens have been successful in treating uncomplicated lower UTIs in women: single-dose administration, short-course (3-day) regimens, or 7-day regimens. The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs, because most cases are cured after 3 days of treatment. Longer medication courses are indicated for men, pregnant women, and women with pyelonephritis and other types of complicated UTIs. Medications Cephalosporin like Cefadroxil for treatment of UTI. Fluoroquinolone like Ciprofloxacin for treatment of UTI, and Ofloxacin for treatment of Pyelonephritis. Fluoroquinolone like levofloxacin for treatment lf Uncomplicated UTI. Penicillin like ampicillin and amoxicillin not used alone because of Escherichia coli resistance for treatment of UTI and pyelonephritis. Trimethoprim like sulfamethoxazole combination for treatment of Pyelonephritis and Co-trimoxazole for treatment of UTI. Urinary analgesic agent is Phenazopyridine. NURSING DIAGNOSES Based on the assessment data, nursing diagnoses may include the following: Acute pain associated with infection within the urinary tract Lack of knowledge about factors predisposing the patient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATION Potential complications may include the following: Sepsis (urosepsis) The long term result of either extensive infective or inflammatory processes have the potential to result in either acute kidney injury or chronic kidney disease. Preventing Recurrent Urinary Tract Infections The nurse instructs the patient on the following basic information: Hygiene Shower rather than bathe in the tub because bacteria in the bathwater may enter the urethra. Clean the perineum and urethral meatus from front to back after each bowel movement. This will help reduce concentrations of pathogens at the urethral opening and, in women, the vaginal opening. Fluid Intake Drink liberal amounts of fluids daily to flush out bacteria. It may be helpful to include at least one glass of cranberry juice per day. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants. Voiding Habits Void every 2 to 3 hours during the day, and completely empty the bladder. This prevents overdistention of the bladder and compromised blood supply to the bladder wall. Both predispose the patient to urinary tract infection. Precautions expressly for women include voiding immediately after penile-vaginal intercourse. Interventions Take medication exactly as prescribed. Special timing of administration may be required. Keep in mind that if bacteria continue to appear in the urine, long-term antimicrobial therapy may be required to prevent colonization of the periurethral area and recurrence of infection. For recurrent infection, consider daily consumption of cranberry juice or capsules. If prescribed, test urine for presence of bacteria following manufacturer’s and health care provider’s instructions. Notify the primary provider if fever occurs or if signs and symptoms persist. Consult the primary provider regularly for follow-up. Upper Urinary Tract Infections Upper UTIs are much less common than those in the lower urinary tract. Acute pyelonephritis and chronic pyelonephritis are thought to be the most likely type, with interstitial nephritis (inflammation of the kidney) and kidney abscesses also a potential cause. Upper UTIs are a common cause of urosepsis. Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Causes involve either the upward spread of bacteria from the bladder or spread from systemic sources reaching the kidney via the bloodstream. Bacteria from a bladder infection can ascend into the kidney, resulting in pyelonephritis. An incompetent ureterovesical valve or obstruction occurring in the urinary tract increases the susceptibility of the kidneys to infection (see Fig. 49-1), because static urine provides a good medium for bacterial growth. Bladder or prostate tumors, strictures, benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction that can lead to infections. Systemic infections (such as tuberculosis) can spread to the kidneys and result in abscesses. Pyelonephritis may be acute or chronic. Acute Pyelonephritis Acute pyelonephritis is the cause of more than 25,000 hospital admissions annually and usually leads to enlargement of the kidneys with interstitial infiltrations of inflammatory cells. Abscesses may be noted on or within the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. Clinical Manifestations The patient with acute pyelonephritis has chills, fever, leukocytosis, bacteriuria, and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Physical examination reveals pain and tenderness in the area of the costovertebral angle In addition, symptoms of lower urinary tract involvement, such as urgency and frequency, are common. Chronic Pyelonephritis Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis. When pyelonephritis becomes chronic, the kidneys become scarred, contracted, and nonfunctioning. Chronic pyelonephritis is a cause of chronic kidney disease that can result in the need for renal replacement therapy (RRT) such as transplantation or dialysis. Complications Complications of chronic pyelonephritis include end-stage kidney disease (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of renal calculi (from chronic infection with urea-splitting organisms). Nursing Management The patient may require hospitalization or may be treated as an outpatient. When the patient requires hospitalization, fluid intake and output are carefully measured and recorded. Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. The nurse assesses the patient’s temperature every 4 hours and administers antipyretic and antibiotic agents as prescribed.