Urinary Tract Disorders/Infection

Urinary Tract Infection DefinedDefinition

Women:Presence of at least 100,000 colony-forming units (cfu)/mL in a pure culture of voided clean-catch urine

Men:Presence of just 1,000 cfu/mLindicates urinary tract infection

*Some labs do not routinely identify & determine the sensitivity of organisms for specimens with

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 long-term care setting

Urinary Tract InfectionLowerurethritiscystitisprostatitisUpperpyelonephritisintrarenal and perinephric abscess

Urinary Tract Infection}

Prevalence

Community-dwelling elders 25% Swart, Soler & Holman, 2004

Long-term care elders 25-50% of women (chronically bacteriuric) 15-40% of men Juthani-Mehta et al., 2005

Marked increases in women & men after age 65Wagenlehner, 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 elderlyNicolle, 2005

History & Physical ExaminationAge-related Risk Factors for UTI

Advanced AgeFecal incontinence/impactionIncomplete bladder emptying or neurogenic bladderVaginal atrophy/estrogen deficiencyPelvic prolapse/cystoceleInsufficient fluid intake/dehydrationIndwelling foley catheter or urinary catheterization or instrumentation procedures

Urinary Tract InfectionPathogenic microorganisms in urine, urethra, bladder, kidney, prostateUsually growth > 105 organisms per milliliterFrom midstream clean catch urine sampleIf sx or from catheter specimen can be significant with 102 or 104 organisms per mL

EtiologyMost common is Gram neg. bacteriaE. coli = 80% of uncomp. acute UTIProteus assoc. with stonesKlebsiella assoc. with stonesEnterobacterSerratiaPseudomonas

EtiologyGram pos. cocciStaphylococcus saprophyticus 10-15 % acute sx UTI in young femalesEnterococci occas. in acute uncomp. cystitisStaphylococcus aureus assoc. with renal stones, instrumentation, increased susp. of bacteremic kidney infection

EtiologyUrethritis from chlamydia, gonorrhea, acute sx female with sterile pyuria

Candida or other fungal species commonly assoc. with cath. or DMMycobacteria

PathogenesisUsually ascent of bacteria from urethra to bladder to kidneyVaginal introitus, distal urethra colonized by normal floraGram negative bacilli from bowel may colonize at introitus, periurethra

?Predisposing conditions to UTIFemaleShort urethra, proximity to anus, termination beneath labiaSexual activityPregnancy2-3% have UTI in preg, 20-30% with asx bacteriuria may lead to pyeloIncreased 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 DMVesicoureteral refluxBacterial virulenceGeneticsChange in urine nutrients, DM, gout

Urethritis ?Acute dysuria, frequencyOften need to suspect sexually transmitted pathogens esp. if sx more than 2 days, no hematuria, no suprapubic pain, new sexual partner, cervicitis

CystitisSx: frequency, dysuria, urgency, suprapubic painCloudy, malodorous urine (nonspec.)Leukocyte esterase positive = pyuriaNitrite positive (but not always)WBC (2-5 with sx) and bacteria on urine microscopy

PyelonephritisFeverchills, diarrhea, tachycardia, gen. muscle tenderness tenderness with deep abdominal tendernessPossibly signs of Gram neg. sepsis

?PyelonephritisLeukocytosisPyuria with leukocyte casts, and bacteria and hematuria on microscopyComplications: 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 Infections10-15% of hosp. patients with indwelling catheter develop bacteriuriaRisk of infection is 3-5% per day of catheterizationUTI after one-time bladder cath approx. 2%Gram neg. bacteremia most significant complication of cath-induced UTIGreater antimicrobial resistance

Diagnosis of UTIHistoryPhysical examLabUrinalysis with micro = WBC, bacteriaUrine culture Sensitivities of culture for tailored antibiotic therapyMay dx acute uncomp. cystitis based on hx, PE, no need for culture to treat

DiagnosisUrinalysisLeuk. Esterase pos. = pyuriaNitrite pos. from urea prod. bact. (but not always)Micro WBC (even 2-5 in patient with sx)Micro Bacteria

DiagnosisUrine cultureOnce 105 colonies per mL considered standard for dx but misses up to 50%Now, 102 to 104 accepted as significant if patient symptomaticNeeded in upper UTI, comp. UTI, and in failed treatment or reinfectionSensitivities for better tailoring of tx

Treatment ?Uncomp. cystitis with less than 48 hours of sx, non-pregnant, usu. 3 days tx sufficientBactrim DS, Septra DSCipro or other FQ (avoid in preg.)Nitrofurantoin (7 days)AugmentinBladder analgesis, Pyridium

TreatmentUncomp. cystitis in pregnant patientRequires longer tx of 7-14 daysCephalosporin, nitrofurantoin, augmentin, sulfonamides .

Asymptomatic ? Bacteriuria105 org/mL growthEmpiric treatment of all asymptomatic bacteriuria (ASB) in pregnancy. Screening at first visit.ASB if untreated = 20-30% develop pyelo.

Asymptomatic BacteriuriaTreatment failures: repeat tx based on sensitivities for 1 week, then prophylactic therapy for remainder of pregnancyProphylaxis: Nitrofurantoin, Ampicillin, TMP/SMX

TreatmentRecurrent uncomp. UTI3 or more episodes in one year, 2 in 6 monthsBactrim DS ( or septra DS) QD for 3-6 months once infection eradicated,Single dose at symptom onsetMeasures for prevention: voiding after intercourse, good hydration, frequent and complete voiding

Treatment of Pyelonephritis -- OutpatientUncomp. Nonpreg pyeloPrimary any FQ x 7 days, ciproAlt. -- Augmentin, TMP/SMX, for 14 days

Treatment ofPyelonephritis Inpatient ?Treat IV until patient is afebrile 24-48 hours. Then, complete 2 week course with PO medsUse FQ or amp/gent or ceftriaxone or piperacillinIf no improvement on IV, consider imaging studies to look for abscess or obstructionAll pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediately

Treatment of Complicated UTICatheter relatedAmp/gent or Zosyn or ticaricillin/clav or imipenem or meropenem x 2-3 weeksSwitch to PO FQ or TMP/SMX when possibleRule out obstructionWatch out for enterococci and pseudomonas

Nephrolithiasis ?Supersat. of urine by stone forming constituentsCrystals of foreign bodies Freq. stone types: Calcium (most common), oxalate, uric acid, staghornRisk factors: metabolic disturbances, previous UTI, gout, genetic

NephrolithiasisIncidence = 2-3%MorbidityObstruction painChronic obstruction, may be asx loss of renal functionHematuria (rarely dangerous by itself)Dangerous = obstruction + infection

Nephrolithiasis ?More prev. in Asians and whitesMales > females, 3:1Struvite stones from infection, increased in femalesAges 20-49RecurrentUncommon after 50 y.o.

NephrolithiasisPatient History ?Often dramatic pain, poss. infection, hematuriaEven nonobst. May cause sxBladder irritating sxRenal colic because of stone in ureterSevere, undulating cramps because of ureter peristalsis, sever pain, Pain may migrate

NephrolithiasisPatient HistoryDuration, char, location of painHx of stones?UTI?Loss of renal function?FHx of stonesSolitary/ transplanted kidney

NephrolithiasisPhysical ExamDramatic , may migrate as stone movesUsu. Lacking peritoneal signsCalculus often in area of maximum discomfort

NephrolithiasisWorkupUrinalysisEvid. Of hematuria and infection24-hour urinalysis helpful in identifying cause uric acid, Calcium, oxalate, uric acid in the 24 hour urine

NephrolithiasisWorkupPlain abd film (KUB)Renal USGIVPHelical CT without contrast (stone protocol)

NephrolithiasisTreatmentIf no obstruction or infection, stones < 5-6mm may likely passRestore fluid volume if dehyd.Analgesics narcotics, nsaidsAntiemeticsOccasionally nifedipine to relax ureteral smooth muscle and prednisone usedUrology consult

NephrolithiasisTreatment ?Surgical intervention (call urology)Extracorporeal shock-wave lithotrypsy (not in pregnancy)Ureteral stentPercutaneous nephrostomyUreteroscopyIndications = pain, infection, obstructionContraindications = active untx infection, uncorrected bleeding diathesis, pregnancy (relative)

NephrolithiasisProphylaxis ?Increase fluid intake (2 liters per day of UOP)24 hour urine, eval calcium, oxalate, uric acid to determine dietary preventionmetabolic tests to determine cause (Ex: hyperparathyroidism)Decrease salt intake

*These are key indicators you must consider in eliciting a thorough history & ROS to determine risk for each elder*