Urinary Tract

Disorders/Infectio
n

Urinary Tract Infection

Defined
Definition

Women: Presence of at least 100,000 colonyforming units (cfu)/mL in a pure

culture of voided clean-catch urine
Men: Presence of just 1,000 cfu/mL
indicates urinary tract infection
*Some labs do not routinely identify & determine the
sensitivity of organisms for specimens with <10,000
cfu/mL. May have to special request.
Swart, Soler & Holman, 2004

Urinary Tract Infection

GNPs Role

Develop and implement evidence-based health

promotion strategies, as well as prevention and
treatment criteria in UTI management of the
older adult, both in the community and longterm care setting

Urinary Tract Infection

Lower
urethritis
cystitis
prostatitis
Upper
pyelonephritis
intrarenal and perinephric abscess

Urinary Tract Infection

Prevalence

Community-dwelling elders 25%

Long-term care elders
(chronically bacteriuric)

Swart, Soler & Holman, 2004

25-50% of women
15-40% of men
Juthani-Mehta et al., 2005

Marked increases in women & men after age 65

Wagenlehner, Naber & Weidner, 2005

Urinary Tract Infection

Urinary tract infectionmost common source of

bacteremia, a dangerous systemic infection in
long-term care facilities

Bacteremia40 times more likely to occur in

catheterized than non-catheterized residents

Bacteremia leads to significant morbidity and

mortality in the vulnerable elderly

Nicolle, 2005

History & Physical

Examination

Age-related Risk Factors for UTI

Advanced Age
Fecal incontinence/impaction
Incomplete bladder emptying or neurogenic bladder
Vaginal atrophy/estrogen deficiency
Pelvic prolapse/cystocele
Insufficient fluid intake/dehydration
Indwelling foley catheter or urinary catheterization or
instrumentation procedures

Urinary Tract Infection

Pathogenic microorganisms in urine, urethra,
bladder, kidney, prostate
Usually growth > 105 organisms per milliliter
From midstream clean catch urine sample
If sx or from catheter specimen can be
significant with 102 or 104 organisms per mL

Etiology
Most common is Gram neg. bacteria

E. coli = 80% of uncomp. acute UTI

Proteus assoc. with stones
Klebsiella assoc. with stones
Enterobacter
Serratia
Pseudomonas

Etiology
Gram pos. cocci
Staphylococcus saprophyticus 10-15 %
acute sx UTI in young females
Enterococci occas. in acute uncomp.
cystitis
Staphylococcus aureus assoc. with renal
stones, instrumentation, increased susp. of
bacteremic kidney infection

Etiology
Urethritis from chlamydia, gonorrhea,
acute sx female with sterile pyuria
Candida or other fungal species
commonly assoc. with cath. or DM
Mycobacteria

Pathogenesis
Usually ascent of bacteria from urethra to
bladder to kidney
Vaginal introitus, distal urethra colonized
by normal flora
Gram negative bacilli from bowel may
colonize at introitus, periurethra

Predisposing
conditions
to
Female
UTI Short urethra, proximity to anus, termination
beneath labia
Sexual activity

Pregnancy
2-3% have UTI in preg, 20-30% with asx bacteriuria
may lead to pyelo
Increased risk of pyelo = decreased ureteral tone,
decreased ureteral peristalsis, temp. incomp of
vesicoureteral valves

Predisposing
conditions

Neurogenic bladder dysfunction or bladder

diverticulum (incomplete emptying)
Age - Postmenopausal women with uterine or
bladder prolapse (incomplete emptying), lack
of estrogen, decreased normal flora,
concomitant medical conditions such as DM
Vesicoureteral reflux
Bacterial virulence
Genetics
Change in urine nutrients, DM, gout

Urethritis
?

Acute dysuria, frequency

Often need to suspect sexually
transmitted pathogens esp. if sx more
than 2 days, no hematuria, no
suprapubic pain, new sexual partner,
cervicitis

Cystitis
Sx: frequency, dysuria, urgency,
suprapubic pain
Cloudy, malodorous urine (nonspec.)
Leukocyte esterase positive = pyuria
Nitrite positive (but not always)
WBC (2-5 with sx) and bacteria on urine
microscopy

Pyelonephritis
Fever
chills, diarrhea, tachycardia, gen. muscle
tenderness
tenderness with deep abdominal
tenderness
Possibly signs of Gram neg. sepsis

Pyelonephritis
Leukocytosis
Pyuria with leukocyte casts, and bacteria
and hematuria on microscopy
Complications: sepsis, papillary necrosis,
ureteral obstruction, abscess, decreased
renal function if scarring from chronic
infection, in pregnancy may increase
incidence of preterm labor

Catheter-Associated
?
Urinary Tract
Infections

10-15% of hosp. patients with indwelling

catheter develop bacteriuria
Risk of infection is 3-5% per day of
catheterization
UTI after one-time bladder cath approx. 2%
Gram neg. bacteremia most significant
complication of cath-induced UTI
Greater antimicrobial resistance

Diagnosis of UTI

History
Physical exam
Lab

Urinalysis with micro = WBC, bacteria

Urine culture
Sensitivities of culture for tailored antibiotic therapy
May dx acute uncomp. cystitis based on hx, PE, no
need for culture to treat

Diagnosis
Urinalysis
Leuk. Esterase pos. = pyuria
Nitrite pos. from urea prod. bact. (but not
always)
Micro WBC (even 2-5 in patient with sx)
Micro Bacteria

Diagnosis
Urine culture
Once 105 colonies per mL considered
standard for dx but misses up to 50%
Now, 102 to 104 accepted as significant if
patient symptomatic
Needed in upper UTI, comp. UTI, and in
failed treatment or reinfection
Sensitivities for better tailoring of tx

Treatment
?

Uncomp. cystitis with less than 48 hours

of sx, non-pregnant, usu. 3 days tx
sufficient

Bactrim DS, Septra DS

Cipro or other FQ (avoid in preg.)
Nitrofurantoin (7 days)
Augmentin
Bladder analgesis, Pyridium

Treatment
Uncomp. cystitis in pregnant patient

Requires longer tx of 7-14 days

Cephalosporin, nitrofurantoin, augmentin,
sulfonamides .

Asymptomatic
?

Bacteriuria
10 org/mL growth
5

Empiric treatment of all asymptomatic

bacteriuria (ASB) in pregnancy. Screening
at first visit.
ASB if untreated = 20-30% develop pyelo.

Asymptomatic
Bacteriuria
Treatment failures: repeat tx based on
sensitivities for 1 week, then prophylactic
therapy for remainder of pregnancy
Prophylaxis: Nitrofurantoin, Ampicillin,
TMP/SMX

Treatment
Recurrent uncomp.
UTI
3 or more episodes in one year, 2 in 6
months
Bactrim DS ( or septra DS) QD for 3-6
months once infection eradicated,Single
dose at symptom onset
Measures for prevention: voiding after
intercourse, good hydration, frequent and
complete voiding

Treatment of
Pyelonephritis -- Outpatient

Uncomp. Nonpreg pyelo

Primary any FQ x 7 days, cipro
Alt. -- Augmentin, TMP/SMX, for 14 days

Treatment of
Pyelonephritis
?
Inpatient
Treat IV until patient is afebrile 24-48 hours.
Then, complete 2 week course with PO meds
Use FQ or amp/gent or ceftriaxone or
piperacillin
If no improvement on IV, consider imaging
studies to look for abscess or obstruction
All pregnant patients with pyelo get inpatient tx,
appropriate IV antibiotics immediately

Treatment of
Complicated UTI
Catheter related
Amp/gent or Zosyn or ticaricillin/clav or
imipenem or meropenem x 2-3 weeks
Switch to PO FQ or TMP/SMX when
possible
Rule out obstruction
Watch out for enterococci and
pseudomonas

Nephrolithiasis
?

Supersat. of urine by stone forming

constituents
Crystals of foreign bodies
Freq. stone types: Calcium (most
common), oxalate, uric acid, staghorn
Risk factors: metabolic disturbances,
previous UTI, gout, genetic

Nephrolithiasis
Incidence = 2-3%
Morbidity
Obstruction pain
Chronic obstruction, may be asx loss of
renal function
Hematuria (rarely dangerous by itself)
Dangerous = obstruction + infection

Nephrolithiasis
?

More prev. in Asians and whites

Males > females, 3:1
Struvite stones from infection,
increased in females
Ages 20-49
Recurrent
Uncommon after 50 y.o.

Nephrolithiasis
Patient History
?

Often dramatic pain, poss. infection,

hematuria
Even nonobst. May cause sx
Bladder irritating sx
Renal colic because of stone in ureter
Severe, undulating cramps because of
ureter peristalsis, sever pain,
Pain may migrate

Nephrolithiasis
Patient History

Duration, char, location of pain

Hx of stones?
UTI?
Loss of renal function?
FHx of stones
Solitary/ transplanted kidney

Nephrolithiasis
Physical Exam

Dramatic , may migrate as stone moves

Usu. Lacking peritoneal signs
Calculus often in area of maximum
discomfort

Nephrolithiasis
Workup
Urinalysis

Evid. Of hematuria and infection

24-hour urinalysis helpful in identifying
cause

uric acid,
Calcium, oxalate, uric acid in the 24 hour
urine

Nephrolithiasis
Workup

Plain abd film (KUB)

Renal USG
IVP
Helical CT without contrast (stone
protocol)

Nephrolithiasis
Treatment
If no obstruction or infection, stones < 56mm may likely pass
Restore fluid volume if dehyd.
Analgesics narcotics, nsaids
Antiemetics
Occasionally nifedipine to relax ureteral
smooth muscle and prednisone used
Urology consult

Nephrolithiasis
Treatment
?

Surgical intervention (call urology)

Extracorporeal shock-wave lithotrypsy (not in
pregnancy)
Ureteral stent
Percutaneous nephrostomy
Ureteroscopy
Indications = pain, infection, obstruction
Contraindications = active untx infection,
uncorrected bleeding diathesis,
pregnancy (relative)

Nephrolithiasis
Prophylaxis
?

Increase fluid intake (2 liters per day of

UOP)
24 hour urine, eval calcium, oxalate, uric
acid to determine dietary prevention
metabolic tests to determine cause (Ex:
hyperparathyroidism)
Decrease salt intake