Infections of The Urinary Tract
Infections of The Urinary Tract
Infections of The Urinary Tract
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
Acute pyelonephritis Chronic pyelonephritis Interstitial nephritis Renal abscess Perirenal abscess
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
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
Staphylococcus
Staphylococcus pseudocolored
Routes of infection
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
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
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
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
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.
Evaluation