UTI and pyelonephritis
Infection of the urinary system (kidneys, bladder, urethra) that can lead to pyelonephritis
E. coli is the most common bacterial pathogen and infection in women
Pathophysiology and clinical manifestations
UPPER urinary system (kidneys and ureters):
1. Pyelonephritis – inflammation of renal parenchyma; CM: Upper back and flank pain, high fever, shaking and chills, N/V/
LOWER urinary system (urinary bladder and urethra):
1. Cystitis – inflammation of the bladder; CM: Pelvic pressure, lower abdominal discomfort, dysuria, urinary frequency, hematuria
- Urethritis – inflammation of the urethra; CM: Burning with urination
Upper vs. lower UTI
UPPER UTI – S/S: Fever, flank pain, N/V/
LOWER UTI:
1. Emptying symptoms – Hesitancy, intermittency, post void dribbling, incomplete emptying
- Storage symptoms – Urinary frequency, urgency, incontinence, nocturia, nocturia enuresis (bedwetting)
Classification
- UNCOMPLICATED – UTI that occurs in a normal, unobstructed genitourinary tract, with no history of recent instrumentation, and whose symptoms are confined to the lower urinary tract (bladder)
- COMPLICATED – Urinary tract infection and coexisting obstruction, stones, or catheters; DM or neurologic diseases, or pregnancy-induced changes; At risk for urosepsis, pyelonephritis, and renal disease
Risk factors
UTI risk factors:
1. Urinary stasis – Due to tumor, stricture, BPH; and/or urinary retention (poor bladder wall, neurogenic bladder)
- FB – Calculi, catheters, stents, instrumentation
- Anatomic factors – Congenital defects, fistula, obesity
- Immune response – Aging, HIV
- Functional disorders – Constipation, voiding dysfunction
- Other – Pregnancy, multiple sex partners, poor hygiene, nurse’s bladder
Diagnostics
Tests:
1. Urinalysis dipstick – Nitrates, WBC, leukocyte esterase (indicates pyuria)
- Urine culture – clean catch
- Other studies – CT, ultrasound if recurring infections occur
Medical management
Lower UTI:
- Antibiotics – Trimethoprim (5 days) and Ciprofloxacin (3 days)
- No follow-up necessary, unless recurrence
Acute pyelonephritis:
- Antibiotics – Empiric, then culture specific
- Force fluids
- NSAIDs or antipyretic drug therapy
Empiric therapy
Antibiotic therapy based on experience, not data (most UTIs respond to broad spectrum treatment)
Risk – Organism may not be sensitive or may have resistance to the antibiotic
Benefit – Quick treatment, no wait on culture
Nursing management
LOWER UTI:
- Force fluid intake – Flush out bacteria regardless of increased discomfort
- Decrease irritants – Coffee, caffeine, ETOH, citrus, chocolate, spiced foods
- Pain control – Heat to suprapubic area
- Drug therapy – Antibiotics
PYELONEPHRITIS:
- Antibiotics (14-21 days) – longer than lower UTI
- Fever and pain management
- IVF – discharge once patient can tolerate fluids (antibiotics prescribed for 14-21 more days)
- Educate pt to be vigilant of new S/S – should resolve within 48-72 hrs.
- Urosepsis can result if bacteriuria and bacteremia present
Pt education
Lower UTI:
1. Encourage fluid intake
- Nutrition – Assess common diet at home, offer substitutions
- Pain control – Non-pharmacologic actions
- Drug therapy – Encourage pts to complete full round of antibiotics
- Avoid – Holding urine for long periods of time, irritating urethra (restrictive clothing), and avoid deodorants or feminine products in genital area
- Promote – Wiping front to back after BM, showers (NOT baths), emptying bladder after intercourse, cranberry juice or proanthrocyanidin (reduce recurrent bladder infections)
- Notify PCP – Symptoms to not diminish, S/S: Fever, N/V/, flank pain (indicative of increasing infection to upper urinary tract)
Care coordination
Coordinate outpatient therapy with family
Ensure pt has adequate water supply and access to a bathroom
