Urinary Tract Infection (Nursing)


Learning Outcome

  1. List the causes of urinary tract infections
  2. Describe the presentation of urinary tract infections
  3. Summarize the treatment of urinary tract infections
  4. Recall the role of the nurse in the management of a patient with a urinary tract infection

Introduction

Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated. Many cases of uncomplicated UTI will resolve spontaneously, without treatment, but many patients seek treatment for symptoms. Treatment is aimed at preventing spread to the kidneys or developing into upper tract disease/pyelonephritis, which can cause the destruction of the delicate structures in the nephrons and lead to hypertension.[1][2][3]

Nursing Diagnosis

  • Impaired urine elimination
  • Pain
  • Deficiency in knowledge
  • Altered sleep
  • Anxiety
  • Fever

Causes

Pathogenic bacteria ascend from the perineum, causing UTI. Women have shorter urethras than men and therefore are more susceptible to UTI. Very few uncomplicated UTIs are caused by blood-borne bacteria. Escherichia coli is the most common organism in uncomplicated UTI by a large margin.[4]

Risk Factors

Urinary tract infections are very frequent bacterial infection in women. They usually occur between the ages of 16 and 35 years, with 10% of women getting an infection yearly and more than 40% to 60% having an infection at least once in their lives. Recurrences are common, with nearly half getting a second infection within a year. Urinary tract infections occur four times more frequently in females than males.[5][6]

Assessment

Symptoms of uncomplicated UTI are a pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitation), sudden onset of the need to urinate (urgency), and blood in the urine (hematuria). Usually, patients with uncomplicated UTI do not have fever, chills, nausea, vomiting, or back pain, which are signs of kidney involvement or upper tract disease/pyelonephritis. Clinical symptoms can overlap, and in some cases, it is hard to distinguish uncomplicated UTI from a kidney infection. When in doubt, treat aggressively for possible upper renal tract disease. Diagnosis is a combination of signs, symptoms, and urinalysis. Be careful of literature that is based on the results of urinalysis of asymptomatic patients.

Evaluation

A good, clean, urinalysis (UA) specimen is vital to the workup. A clean-catch specimen in nonobese women is preferred. Most obese women cannot give a clean specimen, and epithelial cells in the UA means the urine sample was exposed to the genital surface and did not come directly out of the urethra. Get a clean sample, with very few epithelial cells. In-and-out catheterization of the bladder will cause UTI in uninfected women 1% of the time. Men should start the urine stream to clean the urethra and then obtain a midstream sample. Urine should be sent to the lab immediately or refrigerated because bacteria grow rapidly when a sample is left at room temperature, causing an overestimate of the infection's severity.[7][8]

Do not base the diagnosis upon visual inspection of the urine. Cloudy urine can be aseptic; the cloudiness can come from protein in the sample, not necessarily infection. Crystal clear urine can be grossly infected. All urines undergo dipstick testing, which can be done at the bedside. Helpful values are pH, nitrites, leukocyte esterase, and blood. Remember that in patients with symptoms of UTI, a negative dipstick does not rule out UTI, but positive findings can help make the diagnosis. Look for the presence of bacteria and/or white blood cells (WBC) in the urine.

Normal urine pH is slightly acidic, with usual values of 6.0 to 7.5, but the normal range is 4.5 to 8.0. A urine pH of 8.5 or 9.0 is indicative of a urea-splitting organism, such as Proteus, Klebsiella, or Ureaplasma urealyticum; therefore, an asymptomatic patient with a high pH means UTI regardless of the other urine test results. Alkaline pH also can signify struvite kidney stones, which are also known as “infection stones.”

The most accurate dipstick test is the nitrite test because bacteria must be present in the urine to convert nitrates to nitrites. This takes 6 hours. This is why urologists request the first-morning urine, particularly in males. The specificity of this test is greater than 90%. This is direct confirmation of bacteria in the urine, which is UTI by definition in patients with symptoms. Several bacteria do not convert the nitrates to nitrites, but those are usually involved in complicated UTIs, such as those involving Enterococcus, Pseudomonas, and Acinetobacter.

Leukocyte esterase (LE) identifies the presence of WBCs in the urine. The WBCs release the LE, presumably in response to bacteria in the urine. This is why LE is a subsequent test with a specificity of only 55% for UTI. LE is good at detecting WBCs in the urine, but WBCs can be in the bladder for other reasons, like inflammatory disorders.

Hematuria can be helpful because bacterial infection of the transitional cell lining of the bladder can cause bleeding. This helps distinguish UTI from vaginitis and urethritis which do not cause blood in the urine.

In many labs, the presence of nitrites or leukocyte esterase will automatically trigger a microscopic evaluation of the urine for bacteria, WBCs, and RBCs. On microscopy, there should be no bacteria in uninfected urine, so any bacteria on a gram-stained urine under microscopy is highly correlated to UTI. A good urine sample with greater than 5 to 10 WBC/HPF is abnormal and highly suggestive of UTI in symptomatic patients.

Urine cultures are not needed in uncomplicated UTI. Urine should be cultured in all men and patients with diabetes mellitus, who are immunosuppressed, and women who are pregnant. Classic teaching on urine culture sets the gold standard for infected urine at greater than 10 colony forming units (CFU). Recent literature states that a patient who presents with symptoms and greater than 10 CFU is diagnostic of infection. Urine cultures rarely help in the emergency department, except with recurrent UTI.

Medical Management

Treatment has varied historically from 3 days to 6 weeks. There are excellent rates with “mini-dose therapy” which involves three days of treatment. E. coli resistance to common antimicrobials varies in different areas of the country, and if the resistance rate is greater than 50% choose another drug.

Trimethoprim/Sulfamethoxazole for 3 days is good mini-dose therapy, but resistance rates are high in many areas. First generation cephalosporins are good choices for mini-dose therapy. Nitrofurantoin is a good choice for uncomplicated UTI, but it is bacteriostatic, not bacteriocidal, and must be used for 5 to 7 days. Fluoroquinolones have high resistance but are a favorite of urologists for some reason. Recent precautions from the FDA about fluoroquinolone side effects should be heeded.[9][10][11]

Nursing Management

  • Assess the symptoms of UTI
  • Encourage patient to drink fluids
  • Administer antibiotic as ordered
  • Encourage patient to void frequently
  • Educate patient on proper wiping (from front to the back)
  • Educate patient on drinking acidic juices which help deter growth of bacteria
  • Take antibiotics as prescribed
  • Void as soon as possible after sexual intercourse

When To Seek Help

Fever

Flank pain (think pyelonephritis)

Outcome Identification

The majority of women with a UTI have an excellent outcome. Following treatment with an antibiotic, the duration of symptoms is 2-4 days. Unfortunately, nearly 30% of women will have a recurrence of the infection. Morbidity is usually seen in older debilitated patients, those with renal calculi and in patients. Other factors linked to recurrence include the presence of diabetes, underlying malignancy, chemotherapy and chronic catheterization of the bladder. The mortality after a UTI is close to zero, but the infection does have a significant impact on finance. Women often have to miss work, see the physician and purchase the antibiotic. [12][13](Level V)

Coordination of Care

UTI is best managed in a multidisciplinary fashion, and besides physicians, most nurses will encounter a patient with a UTI. The key to preventing recurrences is the education of the patient. Once a UTI has been diagnosed the patient should drink more fluids. Sexually active women should try to void right after sexual intercourse as this can help flush the bacteria out of the bladder. Some women with recurrent UTIs may benefit from prophylactic use of antibiotics. Several other non-medical remedies may help some women with UTI. Anecdotal reports indicate that the use of cranberry juice and probiotics may help reduce the severity and frequency of UTI in some women.[14][15] (Level V)

Pearls and Other issues

Although there is no proof of prevention, women should urinate after sexual intercourse because bacteria in the bladder can increase by ten-fold after intercourse. After urination, women should wipe from front to back, not from the anal area forward, which seems to drag pathogenic organisms nearer to the urethra. Vigorous urine flow is helpful to prevention.


Details

Nurse Editor

Chaddie Doerr

Updated:

11/28/2022 7:20:42 PM

References

[1]

. Five-day nitrofurantoin is better than single-dose fosfomycin at resolving UTI symptoms. Drug and therapeutics bulletin. 2018 Nov:56(11):131. doi: 10.1136/dtb.2018.11.000039. Epub 2018 Oct 8     [PubMed PMID: 30297448]

[2]

Long B, Koyfman A. The Emergency Department Diagnosis and Management of Urinary Tract Infection. Emergency medicine clinics of North America. 2018 Nov:36(4):685-710. doi: 10.1016/j.emc.2018.06.003. Epub 2018 Sep 6     [PubMed PMID: 30296999]

[3]

Tang M, Quanstrom K, Jin C, Suskind AM. Recurrent Urinary Tract Infections are Associated With Frailty in Older Adults. Urology. 2019 Jan:123():24-27. doi: 10.1016/j.urology.2018.09.025. Epub 2018 Oct 6     [PubMed PMID: 30296501]

[4]

Behzadi P, Behzadi E, Yazdanbod H, Aghapour R, Akbari Cheshmeh M, Salehian Omran D. A survey on urinary tract infections associated with the three most common uropathogenic bacteria. Maedica. 2010 Apr:5(2):111-5     [PubMed PMID: 21977133]

[5]

Yamaji R, Friedman CR, Rubin J, Suh J, Thys E, McDermott P, Hung-Fan M, Riley LW. A Population-Based Surveillance Study of Shared Genotypes of Escherichia coli Isolates from Retail Meat and Suspected Cases of Urinary Tract Infections. mSphere. 2018 Aug 15:3(4):. doi: 10.1128/mSphere.00179-18. Epub 2018 Aug 15     [PubMed PMID: 30111626]

[6]

Li R, Leslie SW. Cystitis. StatPearls. 2023 Jan:():     [PubMed PMID: 29494042]

[7]

Sakamoto S, Miyazawa K, Yasui T, Iguchi T, Fujita M, Nishimatsu H, Masaki T, Hasegawa T, Hibi H, Arakawa T, Ando R, Kato Y, Ishito N, Yamaguchi S, Takazawa R, Tsujihata M, Taguchi M, Akakura K, Hata A, Ichikawa T. Chronological changes in epidemiological characteristics of lower urinary tract urolithiasis in Japan. International journal of urology : official journal of the Japanese Urological Association. 2019 Jan:26(1):96-101. doi: 10.1111/iju.13817. Epub 2018 Oct 11     [PubMed PMID: 30308705]

[8]

Alperin M, Burnett L, Lukacz E, Brubaker L. The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause (New York, N.Y.). 2019 Jan:26(1):103-111. doi: 10.1097/GME.0000000000001209. Epub     [PubMed PMID: 30300297]

[9]

Maharjan G, Khadka P, Siddhi Shilpakar G, Chapagain G, Dhungana GR. Catheter-Associated Urinary Tract Infection and Obstinate Biofilm Producers. The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale. 2018:2018():7624857. doi: 10.1155/2018/7624857. Epub 2018 Aug 26     [PubMed PMID: 30224941]

[10]

Richards KA, Cesario S, Best SL, Deeren SM, Bushman W, Safdar N. Reflex urine culture testing in an ambulatory urology clinic: Implications for antibiotic stewardship in urology. International journal of urology : official journal of the Japanese Urological Association. 2019 Jan:26(1):69-74. doi: 10.1111/iju.13803. Epub 2018 Sep 16     [PubMed PMID: 30221416]

[11]

Araujo da Silva AR, Marques AF, Biscaia di Biase C, Zingg W, Dramowski A, Sharland M. Interventions to prevent urinary catheter-associated infections in children and neonates: a systematic review. Journal of pediatric urology. 2018 Dec:14(6):556.e1-556.e9. doi: 10.1016/j.jpurol.2018.07.011. Epub 2018 Jul 21     [PubMed PMID: 30126746]

[12]

Karki N, Leslie SW. Struvite and Triple Phosphate Renal Calculi. StatPearls. 2023 Jan:():     [PubMed PMID: 33760542]

[13]

Suresh J, Krishnamurthy S, Mandal J, Mondal N, Sivamurukan P. Diagnostic Accuracy of Point-of-care Nitrite and Leukocyte Esterase Dipstick Test for the Screening of Pediatric Urinary Tract Infections. Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia. 2021 May-Jun:32(3):703-710. doi: 10.4103/1319-2442.336765. Epub     [PubMed PMID: 35102912]

[14]

Chernaya A, Søborg C, Midttun M. Validity of the urinary dipstick test in the diagnosis of urinary tract infections in adults. Danish medical journal. 2021 Dec 15:69(1):. pii: A07210607. Epub 2021 Dec 15     [PubMed PMID: 34913433]

[15]

Anger J, Lee U, Ackerman AL, Chou R, Chughtai B, Clemens JQ, Hickling D, Kapoor A, Kenton KS, Kaufman MR, Rondanina MA, Stapleton A, Stothers L, Chai TC. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. The Journal of urology. 2019 Aug:202(2):282-289. doi: 10.1097/JU.0000000000000296. Epub 2019 Jul 8     [PubMed PMID: 31042112]

[16]

O'Grady MC, Barry L, Corcoran GD, Hooton C, Sleator RD, Lucey B. Empirical treatment of urinary tract infections: how rational are our guidelines? The Journal of antimicrobial chemotherapy. 2019 Jan 1:74(1):214-217. doi: 10.1093/jac/dky405. Epub     [PubMed PMID: 30295780]

[17]

Ditkoff EL, Theofanides M, Aisen CM, Kowalik CG, Cohn JA, Sui W, Rutman M, Adam RA, Dmochowski RR, Cooper KL. Assessment of practices in screening and treating women with bacteriuria. The Canadian journal of urology. 2018 Oct:25(5):9486-9496     [PubMed PMID: 30281006]

[17]

Sabih A, Leslie SW. Complicated Urinary Tract Infections. StatPearls. 2023 Jan:():     [PubMed PMID: 28613784]

[18]

Ganzeboom KMJ, Uijen AA, Teunissen DTAM, Assendelft WJJ, Peters HJG, Hautvast JLA, Van Jaarsveld CHM. Urine cultures and antibiotics for urinary tract infections in Dutch general practice. Primary health care research & development. 2018 Aug 31:20():e41. doi: 10.1017/S146342361800066X. Epub 2018 Aug 31     [PubMed PMID: 30168406]

[19]

Ferrante KL, Wasenda EJ, Jung CE, Adams-Piper ER, Lukacz ES. Vaginal Estrogen for the Prevention of Recurrent Urinary Tract Infection in Postmenopausal Women: A Randomized Clinical Trial. Female pelvic medicine & reconstructive surgery. 2021 Feb 1:27(2):112-117. doi: 10.1097/SPV.0000000000000749. Epub     [PubMed PMID: 31232721]

[21]

Li F, Song M, Xu L, Deng B, Zhu S, Li X. Risk factors for catheter-associated urinary tract infection among hospitalized patients: A systematic review and meta-analysis of observational studies. Journal of advanced nursing. 2019 Mar:75(3):517-527. doi: 10.1111/jan.13863. Epub 2018 Dec 21     [PubMed PMID: 30259542]

[22]

Lengetti E, Kronk R, Ulmer KW, Wilf K, Murphy D, Rosanelli M, Taylor A. An innovative approach to educating nurses to clinical competence: A randomized controlled trial. Nurse education in practice. 2018 Nov:33():159-163. doi: 10.1016/j.nepr.2018.08.007. Epub 2018 Sep 8     [PubMed PMID: 30253916]

[23]

Hooton TM, Vecchio M, Iroz A, Tack I, Dornic Q, Seksek I, Lotan Y. Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial. JAMA internal medicine. 2018 Nov 1:178(11):1509-1515. doi: 10.1001/jamainternmed.2018.4204. Epub     [PubMed PMID: 30285042]

[24]

Liu Y, Xiao D, Shi XH. Urinary tract infection control in intensive care patients. Medicine. 2018 Sep:97(38):e12195. doi: 10.1097/MD.0000000000012195. Epub     [PubMed PMID: 30235665]

[25]

Sobel JD. New aspects of pathogenesis of lower urinary tract infections. Urology. 1985 Nov:26(5 Suppl):11-6     [PubMed PMID: 3904135]

[26]

Ipe DS, Horton E, Ulett GC. The Basics of Bacteriuria: Strategies of Microbes for Persistence in Urine. Frontiers in cellular and infection microbiology. 2016:6():14. doi: 10.3389/fcimb.2016.00014. Epub 2016 Feb 8     [PubMed PMID: 26904513]

[27]

Chambers ST, Lever M. Betaines and urinary tract infections. Nephron. 1996:74(1):1-10     [PubMed PMID: 8883013]

[28]

Kucheria R, Dasgupta P, Sacks SH, Khan MS, Sheerin NS. Urinary tract infections: new insights into a common problem. Postgraduate medical journal. 2005 Feb:81(952):83-6     [PubMed PMID: 15701738]

[29]

Carlsson S, Wiklund NP, Engstrand L, Weitzberg E, Lundberg JO. Effects of pH, nitrite, and ascorbic acid on nonenzymatic nitric oxide generation and bacterial growth in urine. Nitric oxide : biology and chemistry. 2001 Dec:5(6):580-6     [PubMed PMID: 11730365]

[30]

Cornish J, Lecamwasam JP, Harrison G, Vanderwee MA, Miller TE. Host defence mechanisms in the bladder. II. Disruption of the layer of mucus. British journal of experimental pathology. 1988 Dec:69(6):759-70     [PubMed PMID: 3064799]

[31]

Paudel S, John PP, Poorbaghi SL, Randis TM, Kulkarni R. Systematic Review of Literature Examining Bacterial Urinary Tract Infections in Diabetes. Journal of diabetes research. 2022:2022():3588297. doi: 10.1155/2022/3588297. Epub 2022 May 17     [PubMed PMID: 35620571]

[32]

Hudson PL, Hung KJ, Bergerat A, Mitchell C. Effect of Vaginal Lactobacillus Species on Escherichia coli Growth. Female pelvic medicine & reconstructive surgery. 2020 Feb:26(2):146-151. doi: 10.1097/SPV.0000000000000827. Epub     [PubMed PMID: 31990804]

[33]

Allen KJ, Leslie SW. Autonomic Dysreflexia. StatPearls. 2023 Jan:():     [PubMed PMID: 29494041]

[34]

Mulvey MA, Lopez-Boado YS, Wilson CL, Roth R, Parks WC, Heuser J, Hultgren SJ. Induction and evasion of host defenses by type 1-piliated uropathogenic Escherichia coli. Science (New York, N.Y.). 1998 Nov 20:282(5393):1494-7     [PubMed PMID: 9822381]

[35]

Abraham SN, Miao Y. The nature of immune responses to urinary tract infections. Nature reviews. Immunology. 2015 Oct:15(10):655-63. doi: 10.1038/nri3887. Epub 2015 Sep 21     [PubMed PMID: 26388331]

[36]

Bunduki GK, Heinz E, Phiri VS, Noah P, Feasey N, Musaya J. Virulence factors and antimicrobial resistance of uropathogenic Escherichia coli (UPEC) isolated from urinary tract infections: a systematic review and meta-analysis. BMC infectious diseases. 2021 Aug 4:21(1):753. doi: 10.1186/s12879-021-06435-7. Epub 2021 Aug 4     [PubMed PMID: 34348646]