Infections of the urinary tract

Risk factors for urinary tract infection

1. Inability or failure to empty the bladder completely 2. Obstruction to the urinary flow congenital or acquired calculi in the kidney or ureter urethral strictures compression of the ureters neurological abnormalities 3. Decreased natural host defenses or immunosuppression 4. Instrumentation catheters, cystoscope 5. Inflammation or abrasion of the urethral mucosa 6. Contributing conditions : diabetes mellitus, pregnancy, neurologic conditions causing stasis

Urinary tract is sterile above the urethra Infections of the Urinary Tract are Classified as lower urinary tract infections
and structures below the bladder)
and ureters) (Includes bladder (includes kidneys

Introduction

upper urinary tract infections

Upper Urinary Tract Infections

Acute pyelonephritis Chronic pyelonephritis Interstitial nephritis Renal abscess Perirenal abscess

Further divided into complicated and uncomplicated.

Lower Urinary Tract Infections

Cystitis Prostatitis Urethritis

Further classified into complicated and uncomplicated

Lower Urinary Tract Infections (contd)

Mechanisms that maintain the sterility of the bladder :physical barrier of the urethra, urine flow ureterovesical junction competence antibacterial enzymes antibodies antiadherent effects mediated by mucosal cells of the bladder

 Most of the time the faecal organisms ascend from the perineum into the urethra and into the bladder and settle in the mucosa Glycosaminoglycan (CAG) a hydrophilic protein exerts nonadherent effect on bacteria may become impaired Normal bacterial flora of the vagina and urethral area protect Urinary immunoglobulin IgA in the urethra also a barrier to bacteria

Pathophysiology

Reflux

Urethrovesical reflux Ureterovesical reflux Vesicoureteral reflux

Uropathogenic Bacteria

Bacteriuria - >10 5 colonies of bacteria per millimeter of urine Midstream urine sampled For men >10 4 Common E.coli from lower GIT In males and catheterized patients gradually pseudomonas and enterococcus are coming up

Escherichia coli

 A 5000x scanning electron microscope image of E. Coli bacteria. It is a normal resident of human intestines and provides vitamin K and some of the B

Pseudomonas aerugenosa

Pseudomonas aeruginosa

Enterococcus species

Proteus mirabilis
Proteus mirabilis

Klebsiella sp

Stapylococcal skin infection - impetigo

Staphylococcus

Staphylococcus pseudocolored

Routes of infection

Urethra (commonest route) Blood stream Fistula from the intestine

Clinical manifestations Lower UTI 50 % of people with bacteriuria no symptoms Increased frequency of urination Burning micturition Pain on urination Urgency Nocturia Incontinence Suprapubic or pelvic pain Haematuria Back pain

Clinical Manifestations Upper UTI Fever Chills, Flank Low back pain Nausea and vaomiting Headache, Malaise and Painful urination Pain and ternderness in the area of the costovertebral angles

Costovertebral angle (Renal Angle)

Clinical manifestations

Complicated UTI Asymptomatic bacteriuria Gram-negative sepsis with shock Many patients with catheter associated UTIs are asymptomatic however any patient who suddenly develops signs and symptoms of septic shock should be evaluated for urosepsis

Assessment and Diagnostic Findings

All pregnant women be screened for asymptomatic bacteriuria bladder normally does not empty completely in them Colony counts 10 5 in women 10 4 in men suprapubic needle aspiration the presence of any bacteria uti

Cellular studies

Microscopic haematuria : > 4 RBCs / HPF In acute infection Pyuria : > 4 WBCs / HPF not specific for bacterial infection; can occur in stones, nephritis and renal TB

Urine Cultures

E.coli most common When bacteriuria present urine culture and sensitivity should be done

Testing methods Multistrip dipstick testing for WBCs known as the leukocyte esterase test, and nitrite testing (Griess nitrate test) are common If the leucocyte esterase test + ve pyuria assumed If Griess nitrate test + ve bacteria that reduce normal urinary nitrates into nitrites Evaluation for STD, Chlamydia trochomatis, herpes simplex or acute vaginitis infections caused by Trichomonas or candida species CAT scan, USGM to detect congenital abnormalities, cysts, pyelonephritis, ureteral and other urinary stones, enlarged prostated, IVP to locate ureters, to visualise bladder and micturating cystourethrogram for valves and strictures

Gerontologic considerations Bacteriuria increases with age UTI most common cause for bacterial sepsis in pts > 65 Catheterization for stroke and other disorders UTI chances In postmenopausal women absence of oestrogen colonization and adherence of bacteriuria to the vagina and urethra; local oestrogen replacement done In elderly men the antibacterial activity of the prostatic secretions decreases and protection to the urethra and bladder are lost Chronic bacterial prostatitis in elderly is another cause of recurrent UTIs

Nosocomial infections

In institutional patients infecting pathogens are often resistant to many antibiotics Causes of infection : chronic illness, frequent use antibiotics, infected pressures, immobility and incomplete emptying of bladder, use of bedpan rather than a commode or toilet Measures to take : diligent hand washing, careful perineal care, and frequent toileting Common apart from E.coli, Proteus, Klebsiella, Psudomonas, Staphylococcus, Enterococcus species

 The most common symptom of uti in older adults is generalized fatigue Cognitive function affected in older individuals with the onset of uti

Medical Management

The nurse has to teach about medical treatment and about methods of prevention Short course 3-5 days Long course 7-10 days Complication in women yeast vaginitis Complicated UTI e.g., pyelonephritis a cephalosporin or an ampicillin/aminoglycoside combination Other common antibiotics for uti : bactrim, nitrofurantoin, ciprofloxacin, levofloxacin, Long term therapy - 6-7 months

Nursing process : lower urinary tract infection

Assessment
History : symptoms and signs H/O pain, frequency, urgency, and hesitancy and changes in urien Patients usual pattern of voiding : infrequent emptying of the bladder association of symptoms of uti with sexual intercourse contraceptive practices and personal hygiene Patients knowledge regarding drugs, preventive health measures assessed

 Acut pain related to inflammation and infection Decide about the level of knowledge
Renal failure due to extensive damage Sepsis Relief of pain and discomfort Knowledge of prevention Absence of complications
Planning and goals Collaborative problems/potential complications

Nursing diagnosis

Nursing Interventions
Antibiotic Antispasmodics for bladder also Applying heat to perineum Increase water intake Urinary tract irritants like coffee, tea, citrus, spices, colas, alcohol avoided Frequent voiding (every 2 to 3 hours) encouraged Complete emptying of bladder preferable
Relieving pain

Monitoring and managing potential complications

Prompt treatment prevents complications like sepsisand renal failure Patient is instructed to notify the physician if fatigue,nausea, vomiting, or pruritus occurs Periodical checking of urea, cratinine Indwelling catheters avoided if possible or removed as early as possible If indwelling catheter is needed :1. Use aspetic technique to insert 2. tape to prevent movement Secure cath with 3. Frequent examine the urien for color consistency etc 4. Meticulous daily perineal care with soap and water 5. Maintain a closed system 6. Using the catheters port to obtain urine specimen

Careful asessment of vital signs ans level of consciousness may warn of ipending sepsis. Blood cultures that are positive for infection and elevated WBC counts are reported to the physician.

Promoting Home And Community-based Care

Teach patients self care Discuss with the family

Evaluation

Expected patient outcomes Relief of pain Follows treatment regimen No complications