Urinary Tract Infections

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Did you know that everyday items like soap and chemicals can trigger urethritis and cystitis? This episode invites you on a comprehensive journey into the world of urinary tract infections (UTIs), urethritis, and cystitis. We begin by breaking down the differences between upper and lower UTIs and how they relate to acute and recurring UTIs. You'll also understand why bacteria from the bowel play a significant role in UTIs and how hospital-acquired infections often originate from urinary catheters.

The second part of our discussion centers on the preventive measures against UTIs and the right use of urinary catheters. We reference a handy tool by the American Nurses Association, guiding you on the proper use of catheters. Besides, we'll take a detour into home prevention methods and tackle controversial practices such as the consumption of cranberry juice. Finally, we reveal the diagnostic process for UTIs, including the potential use of a urinalysis or culture insensitivity test, CT scans, and cystoscopies for complicated cases. So, get ready to equip yourself with vital knowledge on this common health issue and how to combat it effectively. 
Here is the link to the ANA CAUTI prevention Tool mentioned in this episode! 
https://www.nursingworld.org/practice-policy/work-environment/health-safety/infection-prevention/ana-cauti-prevention-tool/

Episode Transcript

Speaker 0 (00:00):
So first let's talk about urethritis.
This is inflammation of theurethra.
It can be caused by substanceslike soap.
It can be caused by bacteria.
Most commonly it's in those whoare ages 20 to 24 and the most
common cause is sexuallytransmitted infections.
The symptoms of urethritis canbe the same symptoms as cystitis

(00:22):
, vaginitis or cervicitis, sobasically it's going to have a
lot of the same symptoms we seewith our patients who have
urinary tract infections.
Additional symptoms could bepurulent discharge, dysuria or
that burning or discomfortduring urination, itching and
just general discomfort in thearea.
Now let's talk about cystitis.

(00:42):
Cystitis is inflammation of thebladder.
Cyst C-Y-S-T should make youthink.
Bladder Cystitis can be causedby a lot of different things.
Most of the time we think aboutit in conjunction with an
infection, usually a bacterialinfection, but it can also be
caused by medications, chemicalsIf the patient needed to have
local radiation to the areairritants like feminine hygiene

(01:06):
spray, some of the spermacidaljellies, or long-term use of a
catheter.
Today I'm going to focus onurinary tract infections.
Urinary tract infections canaffect any part of the urinary
tract.
We have the upper urinary tract, which is the kidneys and
ureters.
We have the lower urinary tract, which is the bladder and
urethra.
Urinary tract infections can beclassified by upper, meaning

(01:28):
it's pylonephritis or infectionof the kidneys, or lower, which
would be the bladder or theurethra.
They're also classified byacute or recurring.
An acute urinary tractinfection is an invasion by an
infectious pathogen or organism.
A recurrent UTI is defined ashaving two or more infections in
six months, or three or moreinfections in a year.

(01:50):
We also classify them bycomplicated and uncomplicated
urinary tract infections.
A complicated urinary tractinfection typically involves a
functional or anatomicabnormality.
What would cause a complicatedurinary tract infection, you ask
?
Chronic disease such asdiabetes, an obstruction from,
maybe, urinal calculi or kidneystones and having male genitalia

(02:14):
.
Now, where do these germs comefrom?
Where do these bacteria comefrom?
Guess what?
Most of them come from thebowel.
As far as hospital-acquiredurinary tract infections, the
most common factor associatedwith that is going to be a
urinary catheter.
The risk of infection when apatient has a catheter inserted
into their urinary tract goes upby somewhere between 3 and 10%

(02:36):
per day that the catheter isactually in place.
As a good nurse, I want to makesure that I minimize my
patient's potential fordeveloping that
hospital-acquired urinary tractinfection, and I do that by
knowing when it's appropriate toinsert a urinary catheter and
when it's not.
I also will assess my patientevery day that I'm there, so
every shift the patient shouldbe assessed by an RN whether or

(02:58):
not that catheter is stillneeded.
The American Nurses Associationhas created a streamlined,
evidence-based RN tool forpreventing catheter associated
urinary tract infections.
I'll include the link in theshow notes.
The tool is just a basicalgorithm.
This tool is really easy to useto help you determine if it's
appropriate to put in a urinarycatheter and, if your patient

(03:20):
already has one, if it'sappropriate for them to continue
to have that catheter in place.
According to this algorithm, thereasons for putting in a
catheter or the criteria forindwelling urinary catheter
insertion are acute urinaryretention to improve comfort for
end-of-life care.
Critically ill and patients whoneed accurate measurements of
eyes and o's basically hourlymonitoring of output.

(03:43):
Selected surgical proceduressuch as genital urinary surgery,
colorectal surgery, to assisthealing of an open sacral or
perineal wound in an incontinentpatient, if we need to monitor
urinary output intraoperativelyor large volumes of fluid or
diuretics are anticipated and inprolonged immobilization with a

(04:04):
potentially unstable thoracicor lumbar spine, multiple
traumatic injuries like pelvicfractures those kinds of things.
Preventing urinary tractinfections in patients at home
is something that we also wantto think about.
We can teach our patients toensure they're drinking enough
fluid so that they're urinatingthroughout the day.
Their urine should be a lightyellow color, of course.

(04:25):
Maintaining a healthy lifestyle, so a healthy diet, exercise.
For those with female genitalia,wiping front to back because
you don't want to pull bacteriafrom the backside to the front
side the recommendation is tourinate before and after
intercourse, and I'm not reallysure how long that's going on.
Don't hold your urine.
Go to the bathroom when youfeel like you need to go to the

(04:45):
bathroom.
I think the recommendation issomewhere around every three to
four hours.
You should be urinating, andthere's been conflicting
research about whether or notcranberry juice can actually
help prevent a urinary tractinfection.
I think most people are familiarwith the symptoms of a urinary
tract infection.
They include urinary frequencyhaving to go very often.
Urgency you have to go rightnow.

(05:06):
Dysuria or discomfort, maybeburning sensation when you
urinate.
Super pubic just above thatpubic bone pain.
Tenderness I've had patientscomplain of pressure there
needing to get up at night tourinate.
Having new onset incontinence.
Hematuria, meaning blood in theurine.
Pyuria, which means there'swhite blood cells in the urine

(05:26):
bacteriauria, meaning you havebacteria in your urine.
Now something to take note ofthere.
A person can have bacteria intheir urine without having a
urinary tract infection.
In that case we would saythey're colonized.
You may have been told thataltered mental status or changes
in mental status can be asymptom of urinary tract
infection, especially in theelderly.
However, we have to be supercareful with that, because a lot

(05:50):
of different things can causethose symptoms and you can't
just assume it's a urinary tractinfection.
Those symptoms have to beinvestigated.
Often if the provider feelsthat it's an uncomplicated
urinary tract infection thepatient hasn't had one before,
they haven't had one in a longtime, they don't have any
structural abnormalities orother conditions that could be
contributing to a complicatedurinary tract infection.

(06:12):
They may go ahead and prescribean antibiotic without doing a
urinalysis or cultureinsensitivity.
In that case, the importantthing to teach your patient is
going to be if they don't have aresolution of their symptoms,
then they need to come back,because they may need to have
that culture insensitivity doneto determine which antibiotic is
going to be the one that'sgoing to take care of this

(06:32):
infection.
Speaking of urinalysis andculture insensitivity.
If you have orders forurinalysis and the patient is
able to get it on their own, youneed to get a midstream clean
catch specimen.
You get that by instructing thepatient to take usually castile
towelettes.
Clean the area just like wewould clean right before we do a
urinary catheter.
They're going to clean aroundthe urethral meatus and then

(06:55):
they'll urinate a little bitinto the toilet and then a
little bit into the cup and therest into the toilet.
We only need 10 milliliters forurinalysis.
We don't need a whole cup fullof urine.
Once we take a look at thaturinalysis, a combination of
positive leukocyte, esterase andnitrate is about 68 to 88%
sensitive to the diagnosis ofUTI.

(07:16):
We might also see white bloodcells, which is called pyuria,
red blood cells, which is calledhematuria, or CAS, which are
clumps of material or cells.
These can also be indicative ofUTI.
If this is a complicated UTIwhere the patient didn't resolve
their symptoms or there's someother mechanism of action

(07:36):
affecting this urinary tractinfection, they'll do a culture
insensitivity and what that willdo is it will allow us to
identify the organism and itwill also allow us to see what
antibiotic is going to work thebest for this organism.
In the end, the diagnosis of aurinary tract infection needs to
be left to a provider, becausethese tests that I have

(07:58):
mentioned aren't necessarilyindicative 100% of a urinary
tract infection.
If the provider suspects acomplicated urinary tract
infection, they may do a CT scan, which is going to help us to
see more soft tissue than anX-ray would.
A CT scan is going to be usedto look for the presence of
renal calculi or kidney stonesor to identify if there's

(08:20):
another kind of obstruction.
Another procedure that may bedone is called cystoscopy and
there's that CYST againCystoscopy.
We're going to take anendoscope and go into the
bladder to look around.
That's really going to bereserved for a complicated
urinary tract infection, whereit's a recurrent, and they're
looking to see what kind ofstructural or other
abnormalities may be present.

(08:41):
The most common antibiotics thatare going to be given for an
uncomplicated urinary tractinfection are nitrofurentine, a
combination medication calledtrimethoprim, sulfamethoxazole
or Bactrim and Phosomycin.
Now, these are given foruncomplicated urinary tract
infections with a low risk forresistant bacteria.
The big thing to know aboutsulfamethoxazole trimethoprim is

(09:04):
that it should be stopped ifthere's any kind of a skin rash
and the patient should notifytheir provider.
To help your patient with theirsymptoms, especially if they're
having dysuria, you can educatethem to use a Sitzbath, or I've
even had patients, if they'revery uncomfortable, to sit in a
Sitzbath or in a little bit ofwater and urinate there, because
it helps to dilute the urine asit comes out and it's less

(09:24):
burning.
Make sure they're drinkingplenty of fluids, unless it's
contraindicated, and there is amedication called venasopydidine
that can help with the symptoms, but make sure your patient
understands that it can changetheir urine to an orange color.
The last thing on this topic forus to talk about is
pylonephritis, which refers toan infection that's in the

(09:45):
kidneys.
Pylonephritis can be acute,meaning it is a single episode,
sudden onset, or it can bechronic, which is something that
occurs often over time.
The chronic pylonephritisusually is associated with
structural deformities, urinarystasis obstruction or urinary
reflux.
Depending on the severity ofthe disease, the patient may be

(10:07):
able to be treated at home orthey may be treated in the
hospital.
Some things that maynecessitate a hospitalization is
bacteremia or the bacterialeaving the kidney and escaping
into the bloodstream, or whenthe patient becomes
hemodynamically unstable andthey can't take oral medication.
This is where you might seecost over tibial angle

(10:28):
tenderness.
You may even notice thatthere's some enlargement there,
some asymmetry, edema orerythema, which is redness.
Other symptoms that usually comealong with acute pylonephritis
are fever chills they're alsocalled rigors where you have the
shivering, tachycardia,tachypnea, general malaise or
not feeling well, fatigue,nausea, vomiting, and they may

(10:50):
have the other symptoms of anuncomplicated urinary tract
infection.
We might also see an elevationin their serum white blood cells
, so the amount of white bloodcells that are in their
bloodstream, and somenonspecific markers for
inflammation, like C-reactiveprotein or erythrocyte
sedimentation rate.
We're going to make sure thatwe're also monitoring our

(11:10):
patient's blood, urea nitrogenor BUN and their creatinine to
make sure that we have thebaseline and that we can trend
for recovery or deterioration.
We're also going to get anestimate of the glomerular
filtration rate because that canbe used to trend kidney
function as well.
The provider may order a CTscan or an x-ray of the kidney's

(11:30):
ureters and bladder, which isoften called a KUB, and this is
just to look at the anatomy,looking for inflammation, fluid
accumulation, abscess formationand if there's any defects in
the kidneys or the urinary tract.
We can also identify stones,tumors, cysts and prostate
enlargement with these imagingtests.
Treatment for these patients isgoing to probably include a

(11:52):
pseudomenophen, which ispreferred over an NSAID because
it doesn't interfere with kidneyauto-regulation of blood flow
like NSAIDs do.
It's also going to help reduceany fever or pain.
We typically will do a urineculture insensitivity, but we'll
also probably get bloodcultures to see if there's any
bacteria remia going on.
In the hospital, patients aretypically given IV antibiotics

(12:13):
and our big goal is preventingchronic kidney disease.
And of course, our last biggoal is to educate our patients
to take all of their antibiotics, no matter how they feel.
Two or three days in, they feelmuch better.
They feel great.
Please keep taking yourantibiotics.
That's all I've got for todayon urinary tract infections.
Join me next time on Nursingwith Dr Hobbock and we'll talk

(12:34):
about acute kidney injury andchronic kidney disease.