Urinary Tract infection

1. By Belete N(Bsc, Msc in AHN)
DBU
By: Belete N 1

2. Urinary Tract Infections
Is an infection of the urinary tract caused by the
presence of pathogenic microorganism in the
urinary tract with or without signs & symptoms
The most common sites of infections
Urethra – Urethritis
Bladder – Cystitis Lower UTI
Prostate – Prostatitis
Ureter – Ureteritis
Renal pelvis– Pyelonephritis Upper UTI
Kidney-Interstitial nephritis
Renal abscess
By: Belete N 2

3. Urinary Tract Infections…
Risk factors
Iatrogenic/Drugs
Indwelling catheter
Antibiotic use and spermicides
Behavioral
Voiding dysfunction
Frequent or recent sexual intercourse
Anatomic/physiologic
Vesico-urethral reflux
Female sex and Pregnancy
By: Belete N 3

4. Urinary Tract Infections…
Genetic
Susceptible uroepithelial cells(secrete less
IgA)
Vaginal mucus properties
Etiology
Ascending infections (that enter via urinary
meatus)
Obstructive abnormalities (strictures,
prostatic tumors or hyperplasia)
Upper urinary tract disease may occasionally
cause recurrent bladder infections
By: Belete N 4

5. Urinary Tract Infections…
Pathophysiology
The bacteria causing UTIs usually originate from
bowel flora of the host acquired via three
possible routes
Ascending
Hematogenous or
Lymphatic pathways
Three factors determine the development of
UTIs
The size of the inoculum
Virulence of the microorganism, and
Competency of the natural host defense
By: Belete N 5

6. Urinary Tract Infections…
An important virulence factor of bacteria is their ability
to adhere to urinary epithelial cells by fimbriae
Other virulence factors include hemolysin, a cytotoxic
protein produced by bacteria
Lyses a wide range of cells including
erythrocytes, polymorphonuclear leukocytes, and
monocytes ; and aerobactin
★Facilitates the binding and uptake of iron by
Escherichia coli
By: Belete N 6

7. Urinary Tract Infections…
The most common cause of uncomplicated UTIs is E.
coli
Accounting for more than 85% of community
acquired infections
Sign and symptoms
Dysuria, frequency, urgency, and nocturia
Suprapubic pain and discomfort
Hematuria and back pain
Syndromes of urosepsis- If complicated
Diagnosis
1. Urine dipstick-may react positively for blood WBC
2. Urine microscopy- shows RBC and many WBC-
HPF By: Belete N 7

8. Urinary Tract Infections…
Other Classification
Uncomplicated UTI
UTI that occurs in individuals who lack
structural or functional abnormalities in the UT
that interfere with the normal flow of urine
★Mostly in healthy females of childbearing
age
Complicated UTI
UTI that occurs in individuals with structural
or functional abnormalities i.e. congenital
distortion of the UT, a stone, a catheter,
prostatic hypertrophy, obstruction, or
neurological deficit
★UTI in men are usually complicated-why?
By: Belete N 8

9. Urinary Tract Infections…
Recurrent UTI
Refers to multiple symptomatic UTIs with
asymptomatic periods in between
It is considered significant when there is two
or more symptomatic episodes per year or it
interferes with patient’s quality of life
It is usually a reinfection than a relapse
By: Belete N 9

10. Urinary Tract Infections…
Management
The management of a patient with a UTI includes
Initial evaluation
Selection of an antibacterial agent and
duration of therapy, and
Follow-up evaluation
Selection of antimicrobial agent for the treatment
of UTI is based on
The severity of the presenting signs and
symptoms
The site of infection
Whether the infection is complicated or
uncomplicated
By: Belete N 10

11. Urinary Tract Infections…
The general Management principle includes
1. Relieve discomfort and provide rest
(catheterization if needed)
2. Antibiotic
3. Follow up culture to prove treatment
effectiveness
4. Increase fluid intake- water is best
5. Avoid irritants - Coffee, tea, alcohol, cola
drinks
6. Promote urinary output- Q 2 to 3 hrs
By: Belete N 11

12. Urinary Tract Infections…
Antibiotic therapy according to ESTG
Acute, uncomplicated UTI in women
First line:
★Ciprofloxacin, 500mg P.O., BID, for 3 days
or
★Norfloxacin, 400mg P.O.,BID, for 3 days.
Alternatives:
★Nitrofurantoin 50mg P.O., QID for 7 days or
★Cotrimoxazole 160/800mg P.O, BID for 3
By: Belete N 12

13. Pyelonephritis
Pyelonephritis is an inflammation of the renal pelvis,
calyces, and medulla
The infection usually arises in the lower urinary tract
with organisms ascending into the renal pelvis
Begins in the interstitium & rapidly extending to
involve the tubules, glomeruli & blood vessels
Classifications
Acute pyelonephritis
Chronic pyelonephritis
By: Belete N 13

14. Pyelonephritis…
Acute pyelonephritis
It is sudden onset & self-limited bacterial disease
of the kidneys.
Etiology
Bacteria: E-coli (80%), Proteus, Pseudomonas,
S. aures, Strep. faecalis (entrococcus)
Procedures: Catheterization, Cystoscopy,
Urologic surgery
Systemic infections (such as tuberculosis)
Other causes: Urinary obstruction, Neurogenic
bladder (Vesicourethral reflux)
By: Belete N 14

15. Pyelonephritis…
Acute pyelonephritis is an active bacterial infection
that can cause:
Interstitial inflammation
Tubular cell necrosis
Abscess formation in the capsule, cortex, or
medulla
Temporarily altered renal function, and may
rarely progresses to renal failure
By: Belete N 15

16. Pyelonephritis…
Risk Factors
Women over 65 years of age
Older men with prostate problems
Chronic urinary stone disorders
Spinal cord injury
Pregnancy
Congenital malformations
Bladder tumors
Chronic illness (diabetes mellitus,
hypertension, chronic cystitis)
By: Belete N 16

17. Pyelonephritis…
Clinical Manifestation
Flank pain
Low back pain
Costovertebral angle tenderness
Dysuria (Painful or difficulty of urination)
Nocturia, hematuria, cloudy urine with fishy
odor
Burning, urgency, frequency, nocturia
Shaking chills, generalized fatigue
Fever, tachycardia, tachypnea
Anorexia, nausea and vomiting, headache,
malaise By: Belete N 17

18. Pyelonephritis…
Diagnosis
Appropriate history taking, & Physical
examination
Urinalysis:
Dark color, cloudy appearance, foul odor
Proteinuria, glycosuria, rarely ketonuria
Leucocytes, Few red blood cell
Casts, decreased urine specific gravity
Positive leukocyte esterase (85 to 90%
specific)
Positive nitrate (95% specific)
Urine culture reveals the causative organism
By: Belete N 18

19. Pyelonephritis…
Diagnosis…
CBC
Elevated WBC (>10,000mm3), elevated
neutrophils
Erythrocyte sedimentation rate (ESR) will be
elevated
Intravenous pyelogram
If functional and structural renal abnormalities
are suspected (calculi, structural, or vascular
abnormalities)
Ultrasound or CT scan
Radionuclide imaging
May be useful to identify sites of infection that
By: Belete N 19

20. Pyelonephritis…
Complications
Secondary arteriosclerosis
Calculi formation
Renal damage
Renal abscess
★Metastasize to the other organs
Septic shock
Chronic pyelonephritis
Chronic renal failure
Hypertension
By: Belete N 20

21. Pyelonephritis…
Medical Management
According to ESTG
Acute uncomplicated Pyelonephritis in non-pregnant
women:
Mild and moderate acute uncomplicated
pyelonephritis (able to tolerate oral therapy with no
vomiting, no dehydration, no evidence of sepsis):
First line
★Ciprofloxacin, 500mg P.O., BID, oral for 7-10
days
Alternatives
★Cotrimoxazole(Trimethoprim-
sulphamethoxazole), 160/800mg P.O, BID for 14
days
By: Belete N 21

22. Pyelonephritis…
Severe acute uncomplicated pyelonephritis
(high fever, high white blood cell count, vomiting,
dehydration, or evidence of sepsis) or fails to
improve during an initial outpatient treatment
period
Intravenous therapy should be started and
continued until the patient improves (usually
at 48–72 hours)
On discharge oral therapy is continued to
complete 10-14 days course
Antibiotics should be started after urine
culture sample is collected
By: Belete N 22

23. Pyelonephritis…
First line
Ciprofloxacin, 400mg, I.V, BID till patient
improves and continue oral ciprofloxacin
500mg, PO, BID to complete 10-14 days
course
Alternatives
Ceftriaxone, 2gm, I.V, daily or 1gm, I.V, BID
till patient improves and continue oral
ciprofloxacin 500mg, PO, BID to complete 10-
14 days course
If no response in 48-72 hrs. ultrasound is
warranted therapy to evaluate for obstruction,
abscess, or other complications of pyelonephritis
By: Belete N 23

24. Pyelonephritis…
Complicated UTIs and UTI in men-similar to
uncomplicated UTIs but needs prolonged duration
Recurrent UTI in women
First line: Cotrimoxazole, 240mg, P.O., daily or 3x
per week or postcoital
Alternatives:
★Cephalexin, 125–250mg, P.O., once daily or
postcoital or
★Norfloxacin, 200mg, P.O., once daily or
postcoital or
★Ciprofloxacin, 125mg, P.O., once daily or
postcoital
Duration of antibiotics-for six months followed by
observation
If recurrent UTI comes again the prophylaxis can be
prolonged for 1-2years By: Belete N 24

25. Pyelonephritis…
Nursing interventions
Administer antipyretic & Antibiotics
Fluids (2-3 L/d) to empty the bladder of
contaminated urine & prevent calculus formation
Catheterize with strict sterile technique
Instruct the patient to perform appropriate perineal
care
Teach proper technique for collecting a clean catch
urine specimen
Emotional support
Personal hygiene
Advice routine checkups for patient with history of
UTIs By: Belete N 25

26. Pyelonephritis…
Chronic pyelonephritis
It is a persistent inflammation of kidneys
Repeated infections that cause progressive
inflammation & scarring
Etiology:
Bacteria
Urinary obstruction
Vesicourethral reflux
By: Belete N 26

27. Pyelonephritis…
Clinical manifestations
Usually have no symptoms of infection
Noticeable signs
★Fatigue
★Headache
★Poor appetite
Polyuria /Low specific gravity of urine/
Excessive thirst
Weight loss
Flank pain
By: Belete N 27

28. Pyelonephritis…
Diagnosis
History taking & physical examination
Laboratory investigations
Urinalysis
Proteinuria (Albuminuria)
Intermittent bacteriuria
Leukocytes in urine
Low specific gravity of urine
Urine culture to identify the pathogen
Blood
 Decreased Hgb
 Measuring BUN & creatinine/may increase
 Decrease HCI
Radiologic IV Urogram
By: Belete N 28

29. Pyelonephritis…
Complications
End-stage renal disease (from progressive
loss of nephrons secondary to chronic
inflammation and scarring)
Hypertension
Formation of kidney stones (from chronic
infection with urea-splitting organisms)
Management
The same as acute pyelonephritis (Long-term
use)
Monitor HTN
Monitor intake and out put
By: Belete N 29

30. The End
By: Belete N 30