Transcript NURS 541 - UTIsx

Urinary Tract Infections
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NURS 541 – Women’s
Healthcare: Diagnosis &
Management
Objectives
 Definitions
 Etiology and pathophysiology of UTIs
 Risk factors for UTIs
 Clinical presentation
 Approach to assessment
 Approach to patient management
Definitions
 Asymptomatic bacteriuria
 Presence of bacteria in an uncontaminated urine specimen
without signs or symptoms of UTI
 Acute cystitis (bladder infection)
 Uncomplicated
 Infection in an otherwise healthy premenopausal woman
 Complicated
 Recurrent infections, resistant infections, post-menopausal
infections, infections in men, co-existing conditions
 Pyelonephritis (kidney infection)
 Uncomplicated
 Complicated
Etiology
 In reproductive ages
 Most often seen in women 15-29 years of age
 Infections in younger men (<50 years of age) uncommon
 Not common with children
Pathophysiology
 Urinary tract mechanisms for infection prevention
 Mucus lining in urethra to trap ascending bacteria
 Length of urethra (protective for men)
 Sphincters at bladder/ureter junction to prevent retrograde flow
to kidneys
 Urine with high acidity/high osmolality – ‘hostile’ environment
 Urine containing multiple bacteria-fighting proteins
 Sensitive immunosupport system in epithelial lining of urinary
tract
Pathophysiology
 Most UTIs caused by uropathogenic E. coli (~50-90%)
 Other potential pathogens
 Staph saprophyticus
 Proteus mirabilis
 Enterobacter species
 Pseudomonas species
Risk factors
 For premenopausal women
 Sexual intercourse
 New sexual partners
 Use of spermicide (diaphragms)
 Close family history of frequent UTIs
 Pregnancy
 Previous UTI (or maternal family hx UTI)
 Diabetes mellitus
 Sickle cell trait/disease
 Urinary calculi (stones)
 For postmenopausal women
 Others, PLUS hormonal changes to epithelial cells/mucus lining
 Vaginal atrophy
 Urinary incontinence
 Genital organ prolapse (cystocele, rectocele)
 Others
 Bladder catheterization
 Prostate issues
Clinical presentation
 Symptoms may include the following:
 Dysuria
 Most commonly at the end of the urine stream
 Frequency/urgency
 Pelvic pain/cramping
 Suprapubic
 With the absence of any vaginal symptoms
 For older adults:
 Above symptoms may be subtle or may include irritability,
confusion, change in mental status, or lethargy
Clinical presentation
 Signs of a UTI may include:
 Pyuria
 Cloudy appearance to urine usually due to WBCs (+ leukocytes)
 Hematuria
 Presence of blood in urine (+ blood)
 Foul odor to urine (with some bacteria)
 Presence of nitrites in urine
 Bacteria converting urinary nitrates to nitrites (+ nitrites)
 S/Sx of pyelonephritis also include:
 Fever
 Flank pain/CVA tenderness
Scenario #1
 Susanna , 22 y.o woman, comes into your office with the
concern of dysuria, frequency, and urgency x 2 days.
 What do you want to know?
Approach to Assessment
 Focused history:
 Physical exam:
 HPI/presenting symptoms
 Overall appearance
 Thorough medical history
 Temperature
 Co-existing medical
 Abdominal palpation
conditions
 Structural abnormalities of
bladder, ureters, kidneys
 CVA tenderness
 Family history of relevant
conditions
 Menstrual and sexual history
 Pelvic exam (if indicated)
Scenario #1
 You gather Susanna’s focused medical history:
 Medical history uncomplicated
 New sexual partner (male), using condoms with spermicide
 Also on oral contraception x 6 months
 No history of prior UTIs
 Denies any vaginal symptoms
 What type of exam would be appropriate?
 Temperature 97.9F
 No CVA tenderness
 Some suprapubic tenderness upon palpation
Approach to Assessment
 Do you need to do a pelvic exam?
 NOT NECESSARILY!
 Do a pelvic exam IF:
 There are vaginal symptoms needing investigation
 You choose to do STI screening and need a vaginal specimen
Scenario #1
 What labwork would you want for Susanna today?
 Urine specimen (clean-catch)
 Urine dipstick and urinalysis
 Types of urine specimens
 Random (contaminated)
 Clean-catch (uncontaminated)
 Wipe front to back with antiseptic wipes x 2 or 3
 Start urination, collect sample midstream, complete urination in
toilet
 Catheter derived sample (uncontaminated)
Laboratory Assessment
 Urine dipstick
 Leukocyte esterase, blood, nitrites, high specific gravity
 Urinalysis
 Determine presence of:
 Epithelials cells (indicator of contamination)
 WBCs
 RBCs
 Urine culture
 Isolation and culture of bacteria in urine
 Sensitivities to antibiotics
Laboratory Assessment
When is a urine culture necessary?
 In pregnancy
 Signs of an upper UTI (pyelonephritis)
 Recent or recurrent UTI
 Recent antibiotic treatment (for anything)
 Chronic disease affecting the immune system
 Any complicated UTI presentation!
Scenario #1
 You examine Susanna’s urine specimen in the lab:
 Urine dipstick
 + nitrites, + leukocytes, specific gravity 1.030
 Urinalysis (per HPF)
 Epithelial cells – 3 (>5 = contaminated)
 WBCs – TMTC (too many to count)
 RBCs – 2-3
 Mucus seen
Scenario #1
 What is Susanna’s diagnosis?
 Uncomplicated UTI/cystitis
 For non-pregnant women
 Should include:
 Hallmark symptoms of UTI (dysuria, frequency, urgency)
 Positive finding in urine dipstick, urinalysis or urine culture
 Differential diagnosis
 STI
 Vaginal infection
 Pyelonephritis
 Kidney stones/urinary calculi
Diagnosis Criteria
 Why is Susanna’s diagnosis “uncomplicated” UTI?
 No co-existing medical issues that would affect treatment
 No history of UTIs or failed treatment for UTIs
 She is female and premenopausal
 Typical presentation for UTI
Management of uncomplicated UTI
 ACOG recommended antibiotic regimens (2010)
 Trimethoprim-sulfamethoxazole (Bactrim) one tab PO BID x 3
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days
Trimethoprim 100mg PO BID x 3 days
Ciprofloxacin 250mg PO BID x 3 days
Levofloxacin 250mg PO BID x 3 days
Norfloxacin 400mg PO BID x 3 days
Gatifloxacin 200mg PO BID x 3 days
Nitrofurantoin monohydrate (Macrobid) 100mg PO BID x 7 days
Fosfomycin tromethamine 3g single dose
Management of associated discomfort
 Phenazopyridine (Pyridium)
 OTC medication for pain relief of bladder symptoms
 Turns urine bright orange
 For short-term use ONLY
 Associated with many side effects
 Headaches
 Rash
 GI upset
 G6PD deficiency – hemolysis
 Nephrotoxicity if chronic use
Back to Susanna…
 Rx
 You prescribe nitrofurantoin 100mg orally BID x 7 days
 Encourage using pyridium if needed for 2-3 days
 Education
 Review preventive measures
 Review medication taking, finish entire course of antibiotics
 Follow-up
 To call if symptoms do not resolve within 3 days
Management of complicated UTI
 Urine culture and sensitivities to guide antibiotic treatment
 Longer course of antibiotics (3 7 days, 7 10 days)
 Test of cure may be indicated
Management of uncomplicated
pyelonephritis
 For non-pregnant, otherwise healthy individuals who can
tolerate oral medications
 Fluoroquinolones orally, 7-10 day course
 Urine culture
 Follow up in 2-3 days to assure treatment effectiveness
 Reduction in symptoms
Management of complicated
pyelonephritis
 Often requires inpatient parenteral antibiotic treatment
 Indications for hospitalization
 Severe illness
 Pregnancy (in most cases)
 Immunocompromise
 Inability to tolerate oral treatment
 Inability to adequately follow up
Prevention of UTI
 Little evidence to support prevention recommendations
 Adequate hydration
 Wiping front to back after using bathroom
 Urination after intercourse
 Avoidance of delayed urination
 Solid evidence to support:
 Use of cranberry products – decrease recurrence, ability of bacteria to
colonize
 Post-coital antibiotics
 For those with UTI associated with sexual activity
 Bactrim, macrobid, and fluoroquinolones all effective as single-dose
post-coital treatment
Questions?