1.  Urinary Tract Infections NURS 541 – Women’s Healthcare: Diagnosis & Management

2. Objectives  Definitions  Etiology and pathophysiology of UTIs  Risk factors for UTIs  Clinical presentation  Approach to assessment  Approach to patient management

3. 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

4. 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

5. 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

6. Pathophysiology  Most UTIs caused by uropathogenic E. coli (~50-90%)  Other potential pathogens  Staph saprophyticus  Proteus mirabilis  Enterobacter species  Pseudomonas species

7. 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)

8.  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

9. 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

10. 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

11. 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?

12. Approach to Assessment  Focused history:  HPI/presenting symptoms  Thorough medical history  Co-existing medical conditions  Structural abnormalities of bladder, ureters, kidneys  Family history of relevant conditions  Menstrual and sexual history  Physical exam:  Overall appearance  Temperature  Abdominal palpation  CVA tenderness  Pelvic exam (if indicated)

13. 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

14. 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

15. 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)

16. 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

17. Laboratory Assessment

18. 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!

19. 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

20. 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

21. 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

22. Management of uncomplicated UTI  ACOG recommended antibiotic regimens (2010)  Trimethoprim-sulfamethoxazole (Bactrim) one tab PO BID x 3 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Questions?