Urinary tract infections

1. Case scenario….
An 40 yrs old woman came to hospital with complaints of painful
urination,urgency,lower back pain and burning micturition.Urine culture
indicates 105colony- forming units/ml. She was treated with
Trimethoprim–sulfamethoxazole 1 tablet (160 mg trimethoprim–800 mg
sulfamethoxazole) twice daily for 3 days and some pain medication
were given..And after the treatment her symptoms reduced.

2. URINARY TRACT
INFECTIONS
Moderator: Ms.Manju
Lecturer,CON,AIIMS
Presenter,
Jiya Maria Thomas
MSc Nsg 1 st year

3. OBJECTIVES
At the end of the class students should be able to :
 Define UTI
 Enlist the etiology of UTI
 Understand the pathogenesis.
 Enlist the risk factors of UTI.
 Enlist the symptoms of UTI.
 Understand different diagnostic measures .
 Understand management of UTI.

4. INTRODUCTION
• UTI is the symptomatic presence of microorganisms within urinary
tract ie, kidney ,uretera,bladder and urethra.
• Associated with inflammation
of urinary tract.
• Associated with presence of more than 100 000
organism/ml in midstream sample of urine.

5. Normal mechanisms that maintain sterility of urine :
 Adequate urine volume
 Free-flow from kidneys through urinary meatus
 Complete bladder emptying
 Normal acidity of urine
 Peristaltic activity of ureters and competent ureterovesical junction
 In males, antibacterial effect of zinc in prostatic fluid

6. ETIOLOGY
BACTERIA VIRUSES FUNGI PROTOZOA
 E.Coli
 Klebsiella
 Proteus
 Streptococcus
 Enterococcus faecalis
 Pseudomonas
 Staphylococcus
(saprophyticus/epidermidis)
 Rubella
 Mumps
 HIV
 Herpes
 Candida
 Histoplasma
 T.Vaginalis
 S.Hematobium

7. RISK FACTORS…
• In females-
-short uretha,
-sexual intercourse
-poor hygiene
- Altered vaginal pH during pregnancy
& post menopause.
-Barrier Contraceptives
-Allergens & irritants

8. RISK FACTORS
 Inability or failure to empty the bladder completely
• Obstructed urinary flow because of….
• Congenital anomalies
• Strictures
• Bladder tumors
• Calculi
• Compression of the ureters

9. RISK FACTORS…
• Decreased host defences or immunosuppression.
• Instrumentation of urinary tract.
• Ageing
• Contributing conditions –DM, pregnancy,
neurologic disorders, & urinary stasis.

10. PATHOGENISIS
• Four well recognised routes are…
1.Ascending Infection
2.Hematogenous spread
3.Direct extension from another organ.
4. Lymphatogenous spread

11. • Ascending infection
• Most common route.
• Organism ascend through
urethra into bladder.
Organism
Colonize in perineal
and periurethral areas
Ascend into the
bladder
UTI

12. • Hematogenous spread
• Blood borne spread to kidney.
• Occurs in bacteraemia.
• Mostly S.aureus.

13. • Lymphatogenous spread
Men through rectal and colonic lymphatic vessels to prostate and
bladder.
Women through periuterine lymphatic to urinary tract.
• Direct extension from other organ
PID
Genito urinary tract fistula

14. CLASSIFICATION
UTI
Prostatitis pyelonephritis(acute/chronic)
Cystistis Ureteritis
Urethritis Renal and peri renal abscess
Lower Upper

15. LOWER UTI

16. LOWER UTI
• URETHRITIS: Inflammation of the urethra with bacteria (or with
protozoa, viruses, or fungi) .
• CYSTITIS:
It is an inflammation of bladder.
• PROSTATITIS:
Inflammation of prostate gland.

17. MANIFESTATIONS OF LOWER UTI
 Frequent urination
 Pain in the midline,
suprapubic region, back pain.
 Nocturia
 Urethritis
• Pyuria
• Hematuria
• Pyrexia
 Cloudy and foul-smelling urine

18. UPPER UTI

19. UPPER UTI
• 1.PYELONEPHRITIS: is an exudative purulent localized inflammation of
the renal pelvis (collecting system) and kidney.
• 2.RENAL ABSCESS: These condition are suppurative infections
localized either within the Parenchyma of the kidney ( intarenal
abscess) .
• 3.URETERITIS: Inflammation of ureter,commonly associated with
pyelonephritis.

20. MANIFESTATIONS OF UPPER UTI
• Back pain or flank pain
• Severe abdominal pain (occurs occasionally)
• Fatigue
• Fever with Chills
• General ill feeling
• Mental changes or confusion*

21. MANIFESTATIONS OF UPPER UTI
• Skin changes
• Flushed or reddened skin
• Moist skin (diaphoresis)
• Urination problems
• Cloudy or abnormal urine color
• Foul or strong urine odor
• Increased urinary frequency or urgency
• nocturia
• Painful urination

22. DIAGNOSIS
1) Urinalysis
• Nitrite positive
• Leukocyte esterase positive
• Urine microscopy reveals presence of pyuria.
2)Urine culture:
≥105colony- forming units/ml =indicates an infection .
3) Cellular studies:
• Microscopic hematuria: >4 RBC’S

23. DIAGNOSIS
4) Rapid Diagnostic Method:
Multistrip dipstick testing
WBC’s
Protein
glucose
5) Gram Stain
6) Tests for STD’s

24. IMAGING
• Intravenous pyelogram (IVP)
• Cystoscopy
• Renal ultrasound
• Doppler studies
• CT scan

26. MANAGEMENT
• A mild urinary tract infection may go away on its own without
treatment.
• ANTIBIOTICS are usually recommended because there is a risk
that the infection can spread to the kidneys.
• Can be………..
1) SHORT TERM THERAPY(3-7days)
2) LONG TERM THERAPY( upto 6mths or yrs)

27. MANAGEMENT
Empirical therapy must be broad spectrum with definitive therapy based on
culture and sensitivity.
For uncomplicated acute bacterial cystitis,
• Trimethoprim–sulfamethoxazole: 1 tablet (160 mg trimethoprim–800 mg
sulfamethoxazole) twice daily for 3 days.

28. MANAGEMENT
• Ciprofloxacin 250 mg twice daily for 3 days, levofloxacin 250 mg
once daily for 3 days, norfloxacin 400 mg twice daily for 3 days, or
gatifloxacin 200 mg, once daily for 3 days.
• Nitrofurantoin macrocrystals 50 to 100 mg 4 times daily for 7 days, or
nitrofurantoin monohydrate 100 mg twice daily for 7 days.

29. Therapies that may help manage
symptoms include …
• Alpha blockers:
Include:
• Alfuzosin (uroxatral) and doxazosin (cardura).
• Common side effects include headaches and a decrease in blood
pressure.

30. Therapies that may help manage
symptoms include …
•Pain relievers
• Such as aspirin or ibuprofen (advil, motrin, others)
• Overuse of pain medication can cause serious side effects
• Abdominal pain,
• Intestinal bleeding or
• Ulcers.

31. LONG TERM TREATMENT
• INDICATED FOR:
• Recurrent UTI’s
• Pyelonephritis
• Other complicated UTI’s.
• Chronic UTI

32. • A urinary tract infection is considered chronic if any of the following
occur:
• The infection does not respond to usual treatment
• It lasts longer than 2 weeks
• It occurs more than
twice in 6 months

33. SURGICAL MANAGEMENT
If there is……..
• Obstruction
• Kidney stones
• Abscess
• Congenital abnormalities

34. NUTRITIONAL MANAGEMENT
• Stay hydrated .
• Increase flavonol intake(cranberry,plum,apple,berries)
• Consume food that contain probiotic bacteria(eg.fermented diary products)
• Food rich in vit A and betacarotene (eg.carrot,sweet potato,pumkin spinach).
• Avoid irritating foods ( alcohol,citrus fruits,caffeine,chocolate,spicy foods,
artifical sweetners,aged cheese etc).

35. PROGNOSIS
• A urinary tract infection is uncomfortable, but treatment is usually
successful.
• Symptoms of a bladder infection usually disappear within 24 - 48
hours after treatment begins.
• A kidney infection, it may take 1 week or longer for your symptoms to
go away.

36. COMPLICATIONS
 Kidney damage or scarring
 Kidney infection
 Urosepsis
Risk is greater among ….
 Pts with indwelling catheters
 Complicated UTI’s
 Untreated UTI in
Immunocompromised (HIV)
Immunosuppression therapy
chemotherapy.

37. PREVENTION
• Practice good toilet and personal hygiene.
Wash hands after using toilet.
Practice proper wiping technique (front to back) to prevent rectal bacteria
from entering the utero genitial area.
Choose sanitary pads instead of tampons.
Do not douche or use feminine hygiene sprays or powders.
 As a general rule, do not use any product containing perfumes in the
genital area.
Keep your genital area clean.

38. PREVENTION
Avoid spermicidal jellies and bubble baths and other chemicals in
bathwater.
Clean the genital and anal areas before and after sexual activity.
Urinate before and after sexual activity.
• Always urinate as soon as you feel the need.
• Dress for prevention
Avoid tight-fitting pants.
Wear cotton-cloth underwear and change at least once a day.

39. • Dietary meaures to prevent UTI.
 Plenty of fluids.
• Watch your back.
Maintain proper posture.

40. NURSING
MANAGEMENT

41. NURSING ASSESSMENT
Assessment:
• Presence of pain
• Frequency, urgency
• Changes in urine (color changes,cloudiness)
• Sexual behaviour
• Contraceptive practices
• Personal hygiene
• Pt’s knowledge about preventive measures for UTI’s.

42. NURSING MANAGEMENT
 Acute pain related to inflammation & infection of
urinary tract
• Administer prescribed medications for pain
• Encourage increased fluid intake, antibiotic therapy.
• Sitz bath to decrease muscle spasms.

43. NURSING MANAGEMENT
Altered urinary elimination:
• To control the urgency & frequency pt may limit rather than increasing
fluid intake.
• Eliminate fluids that increase urgency & frequency (caffeinated
beverages).
• Avoid intake of irritating fluids.
• To increase the intake of other fluids to 3-4 L/day to flush the urinary
system.

44. NURSING MANAGEMENT
Risk for deficient fluid volume related to fever,
nausea,vomiting & possible diarrhea.
• Maintain proper intake/output chartings.
• I/V replacement may be required for severe nausea & vomoting.

45. NURSING MANAGEMENT
Anxiety related to diagnosis and
Disturbed self-esteem related to changes in sexual function:
 Educate the pt regarding sexual transmission of UTI.
 Advice to avoid coitus until the manifestations suside or treatment of
STD is completed.
 Advice use of a barrier contraception.
 Use of lubricants if there is pain.

46. SUMMARY
• Definition
• Risk factors
• Etiology
• Pathophysiology
• Clinical manifestations
• Diagnostic methods
• Management

47. References
• Harrison’s Principles of internal medicine ,18th edition page no2567-
2587
• Roger Gabriel.Practial Renal Medicine ,page no: 91-123.
• Schrier W.Robert, Diseases of kidney and urinary tract. 7th
ed.Lippincott Williams &Wilkins,2001.
• Brunner & Suddarth’s, Textbook of Medical Surgical Nursing.10th ed.
Lippincott Williams
• http://kidney.niddk.nih.gov/Kudiseases/pubs/utiadult