Stop UTIs in their tracts
Judy C. Arbique ART(CSMLS), CLS(NCA) 

July/August 2009 
Volume 5 Number 4
Pages 28 - 31

FOR BACTERIA, an indwelling urinary catheter is like a red carpet to the urinary tract. Any invasive device placed in the bladder gives urinary pathogens (uropathogens) a direct route in, making the patient highly susceptible to urinary tract infections (UTIs).

Catheterized and other susceptible patients develop UTIs when uropathogens ascend and inflame the urethra or bladder in the lower urinary tract or the ureters or kidneys in the upper urinary tract. Besides causing painful symptoms, UTIs can lead to serious complications such as bacteremia and extend the patient's length of stay.

In this article, I'll describe symptoms of UTIs, patients who are particularly susceptible, and ways to prevent or treat UTIs in your patients.

Identifying susceptible patients

Patients with indwelling urinary catheters aren't the only ones susceptible to UTIs. Because women have a shorter urethra and more bacteria near their urethral opening, they're more susceptible than men. Sexual activity, diaphragm use, and menopause create conditions conducive to UTI development in women.

Patients with chronic prostatitis, chronic pyelonephritis (inflammation of the renal pelvis), or infected bladder stones are also susceptible to developing UTIs because these conditions supply uropathogens to the urinary tract. Patients who are immunocompromised or have diabetes are susceptible because their bodies may lack the ability to fight off uropathogens.

Free-flowing and uncomplicated

A UTI is considered either uncomplicated or complicated, depending on its cause, signs, and symptoms. Uncomplicated UTIs, common in women of reproductive age who are sexually active, usually involve the lower urinary tract and occur in patients with normal urinary tract structure. Bacteria from the perineum, periurethral area, vagina, or lower gastrointestinal tract infect the urethra (urethritis), the bladder (cystitis), or the upper urinary tract.

A patient with an uncomplicated lower UTI typically complains of dysuria and urinary frequency and urgency; however, she likely won't have a fever or systemic symptoms. About 20% of women with an uncomplicated UTI have suprapubic tenderness and pain. Signs and symptoms such as fever, nausea and vomiting, abdominal pain, and costovertebral-angle tenderness are more likely to occur in a patient with pyelonephritis. If your patient is symptomatic, the healthcare provider will order a routine urinalysis and possibly a urine culture to support a diagnosis of UTI.

* Routine urinalysis requires a clean-catch urine specimen. If the results are positive for nitrites (which indicates bacteriuria), leukocyte esterase (associated with pyuria), or protein (associated with presence of protein-containing substances such as white blood cells, mucus, and bacteria), a urine culture is necessary.
* A urine culture can identify causative pathogens, which commonly include Escherichia coli or Staphylococcus saprophyticus (in child-bearing women) in uncomplicated UTI. Instructing your patient on the proper way to collect the specimen is essential to prevent contamination.
Complicated, recurrent, and resistant

Difficult to resolve and likely to recur, a complicated UTI usually involves the upper urinary tract and may involve the bloodstream. Complicated UTIs commonly occur in patients with urinary tract abnormalities such as bladder stones, prostatitis, strictures, tumors, neurogenic disorders, bladder diverticula, and vesicoureteral reflux. These abnormalities contribute to urinary retention and stagnation, increasing the risk of a complicated UTI.

The spectrum of bacteria that cause complicated UTIs is much larger than in uncomplicated UTIs and includes more antibiotic-resistant microorganisms. Older people also have a broad range of pathogens and more antibiotic resistance relative to younger people with uncomplicated UTIs, such as E. coli, enterococci, staphylococci, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter species, Pseudomonas aeruginosa, and Serratia species, depending on underlying conditions.

A patient with an upper UTI may have pyuria, fever, chills, suprapubic pain, and costovertebral-angle tenderness. She may also have an increased white blood cell count and proteinuria.

A complicated UTI may be a recurrence or a reinfection. Recurrent lower or upper infection caused by the original pathogen occurs within 2 weeks of completing antibiotic therapy. Reinfection caused by the original or a different pathogen occurs 2 weeks or more after completing antibiotic therapy. The healthcare provider should further evaluate a patient with a reinfection or a recurrent infection, paying particular attention to underlying causes.

Coming from the catheter

Uropathogens can easily make their way up a urinary catheter and into the urinary tract. Although most patients with a catheter-related UTI are asymptomatic, fever and signs of sepsis may signal infection.

Complications of UTI due to short-term catheterization include fever, acute pyelonephritis, bacteremia, and rarely, death. In older adults, confusion or changes in alertness may be the first sign of a UTI. Complications from long-term catheterization include catheter obstruction, bladder stones, local periurethral infection, chronic renal inflammation, chronic pyelonephritis, bladder cancer, renal failure, and the same complications as from short-term catheterization.

To reduce the incidence of UTIs and their complications in catheterized patients, wash your hands with water and a conventional antiseptic-containing soap or use an alcohol-based gel or foam before and after donning gloves to care for your patient's catheter. Keep the catheter drainage system closed and remove the catheter as soon as possible.

Treating a UTI in a catheterized patient includes removing or replacing the catheter and administering an antibiotic based on urine culture results. For asymptomatic bacteriuria (colonization of bacteria in the urine), antibiotics are indicated only if your patient is pregnant, has had a kidney transplant, or is about to have urinary tract surgery.

Hampering hospital patients

Outbreaks of hospital-acquired infection often involve patients with UTIs. Approximately 40% of hospital-acquired infections are UTIs, and up to 80% of these are from urinary catheterization.

Factors that increase a hospital patient's risk of developing a UTI include being female or older than age 60 or having severe underlying disease, fecal incontinence, or anindwelling urethral catheter. Manipulating the catheter during diagnostic or therapeutic procedures also encourages UTI development. You can help prevent UTIs in the hospital by consistently following hand hygiene recommendations and avoiding the use of urinary catheters.

Links to long-term care

Factors that may contribute to UTIs in older patients in long-term-care facility patients include high incidence of chronic illness, frequent use of antimicrobial agents, infected pressure ulcers, immobility and incomplete emptying of the bladder, and the use of a bedpan rather than commode or toilet. In this population, UTIs are the most common cause of infection. In older long-term-care patients, UTIs are the most common cause of bacteremia.

The incidence of UTIs in long-term care increases dramatically when indwelling urinary catheters are used. If a patient becomes confused, agitated, lethargic, incontinent, or has more falls, she may have a UTI; however, these nonspecific signs can indicate other conditions too, such as dehydration.

Antibiotic therapy should be initiated in a resident who doesn't have an indwelling catheter but has acute dysuria or a temperature greater than 100° F (37.8° C) and at least one of the following criteria:

* new or worsening urinary frequency or urgency, suprapubic pain, or incontinence
* new costovertebral-angle tenderness
* gross hematuria.

Antibiotic therapy should be initiated in a resident who has an indwelling catheter and at least one of the following criteria:

* temperature greater than 100° F (37.8° C)
* chills
* new costovertebral-angle tenderness
* new onset of delirium.

Antibiotics shouldn't be initiated in a resident simply because his urine is cloudy or smells foul. Someone with asymptomatic bacteriuria shouldn't receive antibiotics.

A urinalysis to measure bacteria levels, nitrites, white blood cells, and leukocyte esterase isn't a reliable indicator of UTIs in asymptomatic residents. One study found that 50% of women and 40% of men in long-term care had significant amounts of bacteria in their urine (colonization), but didn't have a UTI.

Choosing the right treatment

To treat a UTI, the healthcare provider will prescribe an antibiotic specific for the uropathogen identified by the urine culture. Until culture results are available, however, an antibiotic is chosen based on local susceptibility patterns. Common antibiotic choices for treating UTIs include trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim), nitrofurantoin (Macrodantin, Furadantin), amoxicillin, and ampicillin. Nitrofurantoin shouldn't be used in patients with renal insufficiency, and ciprofloxacin should be used when resistant microorganisms are present. Duration of treatment depends on the microorganism, the patient's age and sex, and whether the infection is uncomplicated or complicated.

Teach your patient to take an active role in prevention by informing her of everyday choices that can help her and her family avoid these painful infections in the future.

The power of prevention

By following hand hygiene recommendations, knowing which patients are susceptible, and recognizing signs and symptoms, you can help patients avoid UTIs.

Selected references

Arbique JC. Stop UTIs in their tracts. Nursing. 2003; 33(6):32hn1-32hn4.

Mayo Clinic Staff. Urinary tract infection. .

Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

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