CENTRAL PHILIPPINE UNIVERSITY

COLLEGE OF NURSING

Urinary Tract
Infection

Submitted by:

Karen Crystal D. Belnas

BSN 3B
CB4

Submitted to:
 Mrs. Lizel D. Zata
Clinical Instructor

Urinary Tract Infection

I. INTRODUCTION

Urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary
tract. The main etiologic agent is Escherichia coli. Although urine contains a variety of
fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria
get into the bladder or kidney and multiply in the urine, they may cause a UTI.

The most common type of UTI is acute cystitis often referred to as a bladder infection.
An infection of the upper urinary tract or kidney is known as pyelonephritis, and is
potentially more serious. Although they cause discomfort, urinary tract infections can
usually be easily treated with a short course of antibiotics. Symptoms include frequent
feeling and/or need to urinate, pain during urination, and cloudy urine.

II. SIGNS AND SYMPTOMS

The most common symptoms of a bladder infection are burning with urination
(dysuria), frequency of urination, an urge to urinate, without vaginal discharge or
significant pain. An upper urinary tract infection or pyelonephritis may additionally
present with flank pain and a fever. Healthy women have an average of 5 days of
symptoms.

The symptoms of urinary tract infections may vary with age and the part of the urinary
system that was affected. In young children, urinary tract infection symptoms may
include diarrhea, loss of appetite, nausea and vomiting, fever and excessive crying that
cannot be resolved by typical measures. Older children on the other hand may
experience abdominal pain, or incontinence. Lower urinary tract infections in adults
may manifest with symptoms including hematuria (blood in the urine), inability to
urinate despite the urge and malaise.

Other signs of urinary tract infections include foul smelling urine and urine that
appears cloudy.
Depending on the site of infection, urinary tract infections may cause different
symptoms. Urethritis, meaning only the urethra has been affected, does not usually
cause any other symptoms besides dysuria. If the bladder is however affected (cystitis),
the patient is likely to experience more symptoms including lower abdomen discomfort,
low-grade fever, pelvic pressure and frequent urination all together with dysuria.
Infection of the kidneys (acute pyelonephritis) typically causes more serious symptoms
such as chills, nausea, vomiting and high fever.

Whereas in newborns the condition may cause jaundice and hypothermia, in the
elderly, symptoms of urinary tract infections may even include lethargy and a change in
the mental status, signs that are otherwise nonspecific.

III. RISK FACTORS

 Sexual activity

In young sexually active women, sex is the cause of some bladder infections, with the
risk of infection related to the frequency of sex. The term "honeymoon cystitis" has been
applied to this phenomenon of frequent UTIs during early marriage. In post
menopausal women sexual activity does not affect the risk of developing a UTI.
Spermicide use independent of sexual frequency increase the risk of UTIs.

 Gender

Women are more prone to UTIs than men because in females, the urethra is much closer
to the anus than in males and they lack the bacteriostatic properties of prostatic
secretions. UTI's more commonly progress to bladder infections in females due to the
much shorter length of the female urethra. Among the elderly, UTI frequency is roughly
equal proportions in women and men. This is due, in part, to an enlarged prostate in
older men. An enlarged prostate means the gland has grown bigger. Prostate
enlargement happens to almost all men as they get older. As the gland grows, it can
press on the urethra and cause urination and bladder problems. As the gland grows, it
obstructs the urethra, leading to increased difficulty in micturition. Because there is less
urine flushing the urethra, there is a higher incidence of colonization.

 Urinary catheters

Urinary catheters are a risk factor for urinary tract infections. The risk of an associated
infection can be decreased by only catheterizing when necessary, using aseptic
technique for insertion, and maintaining unobstructed closed drainage of the catheter.
  Genetics

A predisposition for bladder infections may run in families.

 Others

Other risk factors include diabetics sickle-cell disease or anatomical malformations of

the urinary tract such as prostate enlargement.

While ascending infections are generally the rule for lower urinary tract infections and
cystitis, the same is not necessarily true for upper urinary tract infections like
pyelonephritis which may originate from a blood born infection.

IV. PATHOGENESIS

The most common organism implicated in UTIs (80—85 %) is E. Coli, while

Staphylococcus saprophyticus is the cause in 5—10 %.

The bladder wall is coated with various mannosylated proteins, such as Tamm-Horsfall
proteins (THP), which interfere with the binding of bacteria to the uroepithelium. As
binding is an important factor in establishing pathogenicity for these organisms, its
disruption results in reduced capacity for invasion of the tissues. Moreover, the
unbound bacteria are more easily removed when voiding. The use of urinary catheters
(or other physical trauma) may physically disturb this protective lining, thereby
allowing bacteria to invade the exposed epithelium.

During cystitis, uropathogenic Escherichia coli (UPEC) subvert innate defenses by

invading superficial umbrella cells and rapidly increasing in numbers to form
intracellular bacterial communities (IBCs). By working together, bacteria in biofilms
build themselves into structures that are more firmly anchored in infected cells and are
more resistant to immune system assaults and antibiotic treatments This is often the
cause of chronic urinary tract infections.

V. PREVENTION

The following are measures that studies suggest may reduce the incidence of urinary
tract infections.
  A prolonged course ( 6 months to a year ) of low-dose antibiotics (usually
nitrofurantoin or TMP/SMX) is effective in reducing the frequency of UTIs in
those with recurrent UTIs.
 Cranberry (juice or capsules) may decrease the incidence of UTI in those with
frequent infections. Long term tolerance however is an issue.
 For post-menopausal women intravaginal application of topical estrogen cream
can prevent recurrent cystitis. This however is not as useful as low dose
antibiotics.
 Studies have shown that breastfeeding can reduce the risk of UTIs in infants.

A number of measures have not been found to affect UTI frequency including: the use
of birth control pills or condoms, voiding after sex, the type of underwear used,
personal hygiene methods used after voiding or defecating, and whether one takes a
bath or shower.

VI. DIAGNOSIS

Multiple bacilli (rod-shaped bacteria, here shown as black and bean-shaped) shown
between white cells at urinary microscopy. This is called bacteriuria and pyuria,
respectively. These changes are indicative of a urinary tract infection.

In straight forward cases a diagnosis may be made and treatment given based on
symptoms alone without further laboratory confirmation. In complicated or
questionable cases confirmation via urinalysis looking for the presence of nitrites,
leukocytes or leukocyte esterase or via urine microscopy looking for the presence of red
blood cells, white blood cells, and bacteria maybe useful.

Urine culture showing a quantitative count of greater than or equal to 103 colony
forming units (CFU) per mL of a typical urinary tract organism along with antibiotic
sensitives is useful to guide antibiotic choice. However women with negative cultures
may still improve with antibiotic treatment.

Most cases of lower urinary tract infections in females are benign and do not need
exhaustive laboratory work-ups. However, UTI in young infants may receive some
imaging study, typically a retrograde urethrogram, to ascertain the presence/absence of
congenital urinary tract anomalies. All males with a confirmed UTI should be
investigated further. Specific methods of investigation include x-ray, nuclear medicine,
MRI and CAT scans.

VII. TREATMENT
  Uncomplicated

Uncomplicated UTIs can be diagnosed and treated based on symptoms alone. Oral
antibiotics such as trimethoprim, cephalosporins, nitrofurantoin, or a fluoroquinolone
such as ciprofloxacin substantially shorten the time to recovery. About 50% of people
will recover without treatment within a few days or weeks. The Infectious Diseases
Society of America recommends a combination of trimethoprim and sulfamethoxazole
as a first line agent in uncomplicated UTIs rather than fluoroquinolones. Resistance has
developed in the community to all of these medications due to their widespread use.

A three-days treatment with trimethoprim, TMP/SMX, or a fluoroquinolone is usually

sufficient while nitrofurantoin requires 7 days. Trimethoprim is often recommended to
be taken at night to ensure maximal urinary concentrations to increase its effectiveness.
While trimethoprim / sulfamethoxazole was previously internationally used (and
continues to be used in the U.S. and Canada); the addition of the sulfonamide gives
little additional benefit compared to the trimethoprim component alone. It is
responsible however for a high incidence of mild allergic reactions and rare but
potentially serious complications. For simple UTIs children often respond well to a
three-day course of antibiotics.

 Pyelonephritis

Pyelonephritis is treated more aggressively than a simple bladder infection using either
a longer course of oral antibiotics or intravenous antibiotics. Regimens vary, and
include SMX/TMP and fluorquinolones. In the past, they have included
aminoglycosides (such as gentamicin) used in combination with a beta-lactam, such as
ampicillin or ceftriaxone. These are continued for 48 hours after fever subsides.

If there is a poor response to IV antibiotics (marked by persistent fever, worsening renal

function), then imaging is indicated to rule out formation of an abscess either within or
around the kidney, or the presence of an obstructing lesion such as a stone or tumor.

 Recurrent

Women with recurrent simple UTIs may benefit from self-treatment upon occurrence of
symptoms with medical follow up only if the initial treatment fails. Effective treatment
can also be delivered over the phone.