Urinary Tract Infections: Contemporary Management

SERIES

David D. Rahn

nfections of the upper and Urinary tract infections (UTIs) are an increasingly prevalent problem lower urinary tract account for women. The diagnosis and management of uncomplicated acute for more than 6 million cystitis is relatively straightforward, while complicated and recurrent office visits per year in the infections require more specialized assessment and treatment. This IU.S., costing more than $2.5 bil- article will review the current management of UTIs. lion annually (Griebling, 2005; Karram & Siddighi, 2008; Na- Key Words: Urinary tract infections, cystitis, epidemiology, pathophysiology, tional Center for Health Statistics, diagnosis, treatment, prophylaxis, management, bacteruria. 1977). Since 50% to 60% of women report at least one urinary Objectives tract infection (UTI) in their life- 1. Define cystitis. time, UTIs have become a common condition diagnosed and 2. Discuss the evaluation and diagnosis of UTIs. treated by gynecologists, urolo- 3. Identify several treatments for patients with UTIs. gists, and other health care providers for women (Foxman, 2002). This article will review the This definition may simply be a hospital-acquired infection, or epidemiology of UTIs, the patho- clinical diagnosis in the setting of UTIs commensurate with in- physiology of this disease, the irritative voiding symptoms and dwelling catheters or recent uri- appropriate clinical and laborato- dysuria. When infectious in etiol- nary tract instrumentation. UTIs ry investigation, current treat- ogy, “cystitis” will often refer to a not fitting into one of these scenar- ment recommendations and algo- bacteriologic finding from a urine ios are commonplace and are con- rithms, and the management of culture, but cystitis may also be sidered “uncomplicated” (Johnson UTIs in different clinical scenar- based on histologic or cystoscop- & Stamm, 1987). ios, including catheter-associated ic findings. Non-bacterial cystitis Other definitions relevant to infections, infection during preg- may occur after radiation expo- the topic of UTI include urethri- nancy, and acute pyelonephritis. sure or in a disease known as tis, trigonitis, bacteriuria, and interstitial cystitis, which by defi- urethral syndrome. Urethritis nition, has sterile urine (Karram & indicates inflammation of the Definitions and Epidemiology Siddighi, 2008). Complicated infec- urethra; in women, this is clini- Cystitis refers to any inflam- tions refer to those which occur cally indistinguishable from cys- matory condition of the bladder. concomitant with the conditions titis. Trigonitis refers to a local- listed in Table 1, such as UTIs in ized hyperemia of the bladder men, patients with diabetes melli- trigone. Bacteriuria denotes the David D. Rahn, MD, FACOG, is an tus, women who are pregnant, presence of bacteria in the urine. Assistant Professor, Department of relapsing or recurrent infections, A UTI may be diagnosed when as Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Texas Southwestern Urologic Nursing Editorial Board Statements of Disclosure Medical Center, Dallas, TX. Christine Bradway, PhD, RN, disclosed that she is on the Consulting Board for Boehringer Note: This review was presented at the Ingelheim Pharmaceuticals, Inc. SUNA 2008 Annual Symposium in Tampa, FL. Kaye K. Gaines, MS, ARNP, CUNP, disclosed that she is on the Speakers’ Bureau for Pfizer, Inc., and Novartis Oncology. Note: The author reported no actual or potential conflict of interest in relation to this Susanne A. Quallich, ANP,BC, NP-C, CUNP, disclosed that she is on the Consultants’ continuing nursing education article. Bureau for Coloplast. Note: Objectives and CNE Evaluation Form All other Urologic Nursing Editorial Board members reported no actual or potential conflict appear on page 342. of interest in relation to this continuing nursing education article.

UROLOGIC NURSING / October 2008 / Volume 28 Number 5 333 SERIES

Table 2. Most Common Urinary Isolates from Outpatient Table 1. Urinary Tract Infections – North American Urinary “Complicated” Urinary Tract Infections Tract Infection Collaborative Alliance (NAUTICA)

Men Escherichia coli (57.5%) Patients with diabetes mellitus Klebsiella pneumoniae (12.4%) Pregnant women Enterococcus spp. (6.6%) History of UTI in childhood Proteus mirabilis (5.4%) History of acute pyelonephritis in past year Pseudomonas aeruginosa (2.9%) Documented relapsing UTI in past year Citrobacter spp. (2.7%) Greater than or equal to 3 UTIs in past year Staphylococcus aureus (2.2%) Uropathogen with multiple drug resistance Enterobacter cloacae (1.9%) Hospital-acquired UTI Coagulase-negative staphylococci (1.3%) Indwelling urethral catheter S. saprophyticus (1.2%) Recent urinary tract instrumentation Other Klebsiella spp. (1.2%) Functional or anatomic abnormality of the urinary tract Enterobacter aerogenes (1.1%) Recent antimicrobial treatment (within past month) Streptococcus agalactiae (1.0%)

few as 102 colony forming units Bacteriuria is found in 2% to 3% Ottesen, & Cook, 1982). A recent of bacteria per milliliter (cfu/mL) of women 15 to 24 years of study of nearly 2,000 outpatient are found in a symptomatic age, 20% in women 65 to 80 urinary isolates sampled from 41 patient. Asymptomatic bacteri- years, and 25% to 50% in centers from various geographic uria refers to greater than 105 women greater than 80 years regions in the U.S. and Canada cfu/mL in a patient without com- (Mulholland, 1986). The U.S. presented the most common uri- plaints consistent with a UTI population of women greater than nary pathogens (see Table 2) (Norden & Kass, 1968; Stamm et 65 years of age is projected to dou- (Zhanel et al., 2005). al., 1982). Finally, “urethral syn- ble between 2000 and 2030, Urinary tract infections may drome” is a term that has been increasing to more than 40 mil- rarely result from hematogenous ascribed to patients with urinary lion women (U.S. Census Bureau, or lymphatic spread of an existing frequency, urgency, dysuria, 2008). Therefore, one may antici- infection elsewhere in the body, suprapubic discomfort, voiding pate that UTI diagnoses will but the most common route is an difficulties, and pyuria (white increase in coming years. infection ascending from vagi- blood cells in the urine) but in nal/perineal or perianal areas. the absence of organic pathology This likely explains the markedly Pathophysiology (for example, negative urine cul- higher rate of infection in women tures) (Maskell, 1974; Maskell, Approximately 80% of the compared with men (Cox et al., Pead, & Allen, 1979). bacteria isolated in UTIs are 1968). UTIs are mostly found in gram-negative bacilli from the There are many host defenses women, occurring in an 8:1 ratio large family Enterobacteriaceae. to the development of a UTI. First, in women to men (Cox, Lacy, & These include Escherichia coli, urine is high in osmolality and Hinman, 1968). Aside from being Klebsiella, Enterobacter, Proteus, low in pH due to high concentra- common in the community, 2% of and Serratia. Another gram-nega- tions of urea and organic acids hospitalized patients acquire tive bacteria, Pseudomonas, and (Kaye, 1968). Second, vaginal, UTIs, accounting for more than many gram-positive bacteria periurethral, and perineal colo- 500,000 nosocomial infections (Staphylococcus epidermidis, S. nization by gram-positive bacte- per year (Mayer, 1980; Turck & aureus, S. agalactiae, S. sapro- ria, diphtheroids, and lactobacilli, Stamm 1981). There are at least phyticus, and Enterococcus) are and the normally acidic vaginal 100,000 annual hospitalizations other common pathogens (Echols, pH (4.0 in healthy premenopausal for renal infections, which are Tosiello, Haverstock, & Tice, 1999; women) inhibit migration of usually the result of ascending Hooton, Besser, Foxman, Fritsche, microorganisms from the rectum infection from the lower urinary & Nicolle, 2004). Less common to the bladder (Stamey, 1980). tract. Beginning at about 1 year of pathogens include anaerobic bac- Third, normal periodic voiding age, there is only about a 1% teria as well as yeast, trematodes, limits the ability of bacteria to infection rate until puberty. and tapeworms (Nash, Cheever, reach concentrations that are high

334 UROLOGIC NURSING / October 2008 / Volume 28 Number 5 SERIES enough in the bladder to establish women with type B or AB blood, temperature and to document the a significant infection, and gly- and recurrent UTIs correlate with abdominal examination and cosaminoglycans of the bladder women bearing the human presence or absence of costover- lining and Tamm-Horsfall pro- leukocyte antigen A3 subtype tebral angle tenderness. De- teins of the loop of Henle further (Lomberg et al., 1986; Stapleton, pending on the patient’s com- decrease bacterial adherence (Cox Nudelman, Clausen, Hakomori, plaints, a pelvic examination is & Hinman, 1961; Orskov, Ferencz, & Stamm, 1992). required to evaluate for vaginitis & Orskov, 1980). The known risk Bacteria have developed dif- or cervicitis. factors for the development of ferent means by which to over- UTIs generally involve a break- come host defenses. The best Laboratory Diagnosis down in these protective barriers. studied of the bacterial virulence When a UTI is suspected by The physiologic changes mechanisms are “adhesins” on history, the initial laboratory associated with menopause re- bacterial surfaces and fimbriae, evaluation is often an office urine sult in decreased vaginal glyco- also known as pili. These kit, a “dipstick.” The gold stan- gen and an increase in pH. It has adhesins enhance the ability of dard for urine specimen collec- been found that intravaginal bacteria to adhere to mucosal tion is suprapubic aspiration, but estrogen replacement in post- cells of the bladder lining while this typically is not necessary nor menopausal women results in bacterial motility is enhanced via well-tolerated by patients for the reappearance of normal lacto- flagellae (Bryan, Sutcliffe, & assessment of most UTIs (Stamm bacilli and a reacidification, McGee, 1973; Lane & Mobley, et al., 1980). The next most pre- with a decrease in uropathogen 2007; Servin, 2005; Vaisanen et ferred method of urine collection growth and decreased incidence al., 1981). Other virulence factors is a midstream clean catch; this of UTIs (Jackson et al., 2004; Raz include the ability of some bacte- requires local disinfection fol- & Stamm, 1993). ria to produce hemolysins and lowed by spreading the labia or Any condition that results in colicin V, while Proteus produces holding back the foreskin and inefficient bladder emptying and urease, which can ultimately con- then collecting a midstream stagnant urine in the bladder tribute to the formation of struvite urine specimen in a sterile cup. increases the likelihood of infec- stones (Mobley, Island, & Massad, In patients unable to negotiate a tion, including uterovaginal pro- 1994). Multiple drug resistant clean midstream collection, lapse or cystocele with obstruc- bacteria are increasingly being transurethral catheterization is tive voiding; neurogenic bladder observed in urinary isolates permissible. For most office dip- as in patients with diabetes mel- from community-dwelling women sticks, the presence of nitrites litus, multiple sclerosis, and across North America (Zhanel et provides the most useful infor- spinal cord injuries; and anti- al., 2005). mation. In order to have nitrites cholinergic medications, which in the urine, bacteria with nitrate are frequently prescribed for reductase must be present (for Evaluation symptoms of overactive bladder. example, some E. coli and Other risk factors include Proteus), and there must be decreased functional ability, as Clinical Presentation dietary nitrate to convert. This found in patients with dementia, A UTI may present with test is very specific (92% to cardiovascular accidents, neuro- diverse symptoms and signs. The 100%) but not too sensitive (only logic deficits, and fecal inconti- most common complaints are 25%). False positives may occur nence (Karram & Siddighi, 2008). acute painful voiding (dysuria), when the urine is turned red, as Systemic factors may also urinary frequency and urgency, with beets or phenazopyridine. include diabetes mellitus, severe nocturia, and suprapubic discom- Leukocyte esterase is an enzyme vascular disease, gouty nephro- fort. Mild incontinence, hema- present in neutrophil granules. pathy, sickle cell trait, and cystic turia, and systemic symptoms The sensitivity of this test is renal disease (Jackson et al., may be reported. On average, a directly related to bacterial load 2004). Sexual intercourse, espe- UTI results in 6.1 days of symp- (75% to 96%) and is very specif- cially when in combination with toms, 2.4 days of decreased activ- ic (94% to 98%) (Pappas, 1991; diaphragm and spermicide use, ity, 1.2 days of lost time at work or Rahn, Boreham, Allen, Nihira, & increases the likelihood of infec- school, and 0.4 days in bed Schaffer, 2005). tion (Fihn et al., 1996, 1998; (Foxman, 2002). A progression to Urine microscopy is then Hooton, Fennell, Clark, & Stamm, upper tract infection should be generally performed on an un- 1991; Hooton et al., 1996). suspected when the patient also centrifuged specimen. In an Interestingly, some women appear reports fever, chills, malaise, uncontaminated specimen, there to be more genetically predis- nausea and vomiting, and flank are few epithelial cells. Pyuria posed to infection; there is a pain. On examination, it is (literally, pus in the urine) means greater risk of infection in important to note the patient’s there are more than 10 white

UROLOGIC NURSING / October 2008 / Volume 28 Number 5 335 SERIES blood cells per microliter (or diagnose Trichomonas, candidia- Treatment 10,000 per milliliter); the pres- sis, Chlamydia trachomatis, Neis- ence of pyuria is 80% to 95% seria gonorrhoeae, or herpes sim- General Measures, Initial or sensitive and 50% to 75% specif- plex virus. Uncomplicated Infections ic for an infection (Stamm, 1983; In patients with dysuria but For the patient with an Wilson & Gaido, 2004). The without pyuria, the differential uncomplicated acute UTI, prelim- absence of pyuria strongly sug- diagnosis includes trauma relat- inary interventions may include gests a non-infectious cause with ed to intercourse, estrogen defi- rest and hydration (Pollen, 1995). the caveat that in pregnancy, the ciency, interstitial cystitis, or an Short-term use of urinary anal- presence of pyuria is less sensi- irritant urethritis. Irritation may gesics is often helpful with agents tive for infection. In the setting of commonly occur with the use of such as phenazopyridine (Pyri- an infection with less than 104 a new contraceptive gel, condom, dium®) and urised (Urisept®). cfu/mL, observing one or more or tampon (Bergman, Karram, & Pyridium should be avoided in bacteria on a gram-stained speci- Bhatia, 1989; Karram & Siddighi, patients who are allergic to sulfa. men correlates highly with the 2008). (Amit & Halkin, 1997). There is presence of a UTI, having a sensi- some evidence that cranberry tivity of 80%, specificity of 90%, Imaging juice or its extract may be protec- and positive predictive value of To a limited extent, certain tive in developing cystitis via 85% (Fihn & Stamm, 1983). imaging modalities may be useful decreasing bacterial adherence The urine culture is often not in the diagnosis and assessment of (Schmidt & Sobota, 1988; Sobota necessary in the treatment of an UTIs. For patients with recurrent 1984). uncomplicated infection. It may or persistent UTIs or in patients Ultimately, antibiotics will be be collected as a screening tool if with asymptomatic microscopic required. The ideal medication the dipstick and urinalysis are hematuria, cystourethroscopy is would have a higher concentra- inconclusive, in settings of recur- used to evaluate the lower urinary tion in the bladder than in other rent infection, prior infection tract for pathology, such as stones, tissues, in particular, the vagina unresolved with antibiotics, or if diverticulae, polyps, cancer, or and bowel. Some commonly pre- there are signs or symptoms of an anatomical abnormalities. Cystitis scribed medications do adversely upper tract infection. The tradi- may appear as diffuse inflamma- affect the normal vaginal flora. tional interpretation of urine cul- tion throughout the bladder with Ampicillin results in 25% of tures is that it is positive for an erythematous, non-raised lesions, patients developing a yeast vagini- infection when greater than 105 or multiple small clear cysts after tis; tetracycline results in 80% cfu/mL are present. However, a resolved UTI known as “cystitis yeast vaginitis. However, nitrofu- 46% of women with symptomatic cystica” (Engel, Schaeffer, Gray- rantoin (Macrobid®) has no signif- UTIs have just 102 to 104 cfu/mL; hack, & Wendel, 1980). icant serum level and excellent therefore, a newer interpretation Evaluation of the upper uri- activity against E. coli. Trimetho- would be to deem a symptomatic nary tract via intravenous pyelo- prim/sulfamethoxazole (TMP- woman with greater than 102 gram or computed tomography is SMX) (Bactrim®, Septra®) has only cfu/mL as positive (Kunin, White, indicated when there has been a a moderate effect on bowel and & Hua, 1993). This distinction is history of prior upper tract infec- vaginal flora, and has the benefit not made by all laboratories, so it tions, a history of childhood of BID dosing, but up to 39% of E. is important to know the local infections, or when there is coli are resistant to the medication reporting practice of one’s diag- recurrent infection caused by the in community-acquired UTIs nostic laboratory. same organism. For instance, (Gupta, Sahm, Mayfield, & Stamm, urea-splitting organisms, such as 2001; Kahlmeter, 2000). Differential Diagnosis Proteus, are often associated with With respect to specific med- Most patients presenting with infected stones. These studies are ications, nitrofurantoin has been acute dysuria will have a UTI, but also appropriate in the evalua- well studied. It has been used for other diagnoses should be enter- tion of painless hematuria, with a several decades and is generally tained. The presence of pyuria is history of prior stones or ureteral well tolerated. There is a low not entirely specific for a UTI. obstruction, and in rapidly recur- level of resistance among E. coli White blood cells in the urine rent infections. When one specif- and gram-positive cocci and may also be noted in women with ically wants to assess for the many gram-negative bacteria. It vaginitis, urethritis, or with cer- presence of a urethral diverticu- is inactive against most Proteus, tain sexually transmitted diseases. lum, most authors recommend some Enterobacter, and some Patients need to be asked about magnetic resonance imaging Klebsiella. This medication still vaginal discharge, odor, and asso- or a voiding cystourethrogram requires a 7-day treatment ciated dyspareunia. Appropriate (Karram & Siddighi, 2008). course; when comparing the 3- testing should be undertaken to day regimens, TMP-SMX is more

336 UROLOGIC NURSING / October 2008 / Volume 28 Number 5 SERIES effective than 3-day nitrofuran- Table 3. for instance, spermicides and toin (Hooton, Winter, Tiu, & Sources of Bacterial diaphragms should be discontin- Stamm, 1995; Katchman et al., Persistence and Relapsing ued in favor of alternative contra- 2005; Norrby, 1990). Infection ception. Patients should also void Quinolone derivatives (such after coitus, try liberal fluid intake, Urethral diverticulum as ciprofloxacin [Cipro®]) are and perhaps initiate drinking cran- very effective for gram-negative Infected stone berry juice (Schmidt & Sobota, bacteria, with expanded coverage Significant cystocele 1988; Sobota, 1984). Thereafter, against P. aeruginosa and gram- Foreign body three options exist for antibiotic positive bacteria. Some of the Papillary necrosis prophylaxis; these are continuous antibiotics in this family are Duplicated or ectopic ureter prophylaxis, postcoital prophylax- available in intravenous form. is, or self-start (patient-initiated) High cost often limits routine use Atrophic pyelonephritis (unilateral) therapy (Foxman, 1990; Nicolle & of this class, and bacterial resist- Medullary sponge kidney Ronald, 1987). ance is increasing (Andriole, 1991). Quinolones are inappro- Prophylaxis priate in women who are preg- moderate to severe symptoms. nant, nursing mothers, and in Finally, nitrofurantoin (7-day) Continuous prophylaxis is adolescents less than 18 years may be used as a fluoroquinolone the recommended initial therapy old. Women who may become sparing agent for patients with for recurrent UTIs (Nicolle & pregnant should consider contra- mild to moderate symptoms who Ronald, 1987). The most com- ceptive use concomitant with are allergic to TMP-SMX, or if mon options are for nitrofuran- quinolone antibiotics. the community is at risk for sig- toin 100 mg, cephalexin (Keflex®) When treating a first UTI or nificant TMP-SMX resistance 250 mg, or TMP-SMX 1 tablet infrequent reinfection, 3-day (Hooton et al., 2004). every night for 6 months. These antibiotic regimens have been therapies are cost effective. After shown to be superior to single- 6 months of therapy, patients Recurrent Infection dose regimens and are usually may be frequently re-cultured as equally as effective as 7-day regi- Recurrent infection refers to necessary. Postcoital prophylaxis mens with fewer side effects and women with three or more cul- involves the administration of a better compliance (Hooton et al., ture-documented infections in a single antimicrobial tablet before 1995; Katchman et al., 2005). year, or two or more in six or after intercourse (Stapleton, Single-dose regimens have a months (Schaffer, 2004). Of Latham, Johnson, & Stamm, higher treatment failure rate and women who develop UTIs, 22% 1990). In 135 sexually active per- are less likely to be effective if have recurrent infections. The imenopausal women, post-coital there is an undiagnosed compli- urine culture and sensitivity is therapy was as effective as daily cating factor, such as diabetes helpful for documenting whether prophylaxis but required only mellitus, pregnancy, or an the recurrence is a relapse of the one-third the amount of drug anatomical abnormality. This same bacteria versus a reinfec- (Melekos et al., 1997). As noted single dose type of treatment is tion with a different strain. above, patients using diaphragms also suboptimal in the setting of Relapse occurring after an appro- and spermicides should be an occult upper tract UTI. priate course of antibiotics, espe- encouraged to try alternative Ideally, one will have knowledge cially if the relapse occurs within means of contraception. Finally, of the local susceptibility profile 2 weeks, warrants a more thor- self-start therapy may be consid- of the community’s common ough investigation of the upper ered for motivated, compliant pathogens and use this to tailor and lower urinary tracts. For patients who have good relation- empiric treatment decisions. An example, one may rule out an ships with their providers. initial treatment of TMP-SMX for infected stone. Other sources Patients generally submit a urine 3 days is recommended for contributing to relapse are listed culture at the outset of symptoms patients with an uncomplicated in Table 3 (Karram & Siddighi, and then start an empiric 3-day UTI if there is no allergy to sulfa 2008). Re-infection with a new or antibiotic regimen. Patients medications and if local E. coli different strain of bacteria almost should be notified to call their resistance is not greater than always indicates a new ascend- provider if symptoms have not 20% (Hooton et al., 2004). Next, a ing infection. The appropriate improved within 48 hours fluoroquinolone is used for management of recurrent infec- (Gupta, Hooton, Roberts, & patients allergic to TMP-SMX, if tions is to first obtain sterile Stamm 2001). there is significant TMP-SMX urine. Then, the patient is As a final caveat, infections in resistance, in cases of complicat- encouraged to change behaviors post-menopausal women with ed cystitis, or if patients have that may contribute to reinfection; recurrent UTIs should be treated,

UROLOGIC NURSING / October 2008 / Volume 28 Number 5 337 SERIES but appropriate patients should Table 4. also be started on vaginal estrogen Guidelines for Aseptic Care of a Urinary Catheter replacement. A randomized controlled trial of 93 women with Avoid unnecessary catheterization and remove catheter as soon as possible. recurrent infections demonstrated After sterile insertion, anchor catheter to prevent urethral traction. that those women who received Monitor urine level in bag q 4 hour; exchange catheter if cessation of flow for > 4 hours topical intravaginal estrogen sig- Fluid intake of 1.5 L or more per day. nificantly reduced the incidence of UTI compared to women using Avoid catheter manipulation. a placebo (0.5 versus 5.9 episodes Exchange catheter if infection suspected. per patient year, respectively) (Raz & Stamm,1993). (Cravens & Zweig, 2000). For particularly the right ureter being patients who require long-term affected due to dextro-rotation of Other Clinical Scenarios indwelling catheters, bacteriuria the uterus. During pregnancy, the is virtually inevitable. As in other bladder mucosa is hyperemic Asymptomatic Bacteriuria patients with ASB, if these and edematous. All of these Asymptomatic bacteriuria catheterized patients have no changes contribute to common (ASB) is diagnosed when two local or systemic signs or symp- urinary complaints during preg- consecutive urine cultures grow toms of infection, antibiotic treat- nancy, such as frequency, noc- greater than 105 cfu/mL in ment is not required. In patients turia, and incontinence (Beydoun, patients without the symptoms with symptoms of infection, 1985; Francis, 1960; Heidrick, of an acute UTI. Studies have urine culture is the best means of Mattingly, & Amberg, 1967; demonstrated that treatment is diagnosing a UTI. Ideally, the Mattingly & Borkowf, 1978; Thorp generally not required in these urine specimen should be et al., 1999). patients, and there is no retrieved using a fresh catheter. If Bacteriuria develops in 2% increased risk of permanent renal this is not possible, urine should to 7% of pregnancies; if left injury or sepsis. There are excep- be aspirated directly from the untreated, women who are preg- tions, however. Women who are catheter and never from the col- nant have a greater propensity to pregnant, patients with infec- lection bag. The treatment regi- progress to pyelonephritis (40%). tions involving Proteus, patients men should be a 10 to 14-day These infections are associated with severe diabetes mellitus, course of antibiotics based on the with increased risk of preterm and men about to undergo culture and sensitivity results, birth, low birth weight, and peri- transurethral resection of the and a fresh catheter (or intermit- natal mortality (Naeye, 1979). prostate all require treatment in tent self catheterization) should Cystitis treatment requires a 7- the setting of ASB. ASB treat- be used while the infection is day course of either penicillin/ ment is controversial but possi- clearing (Niel-Weise & van den cephalosporin or nitrofurantoin. bly indicated in the elderly and Broek, 2005; Tenney & Warren, TMP-SMX is avoided in the first before urodynamic testing, or 1988; Trautner & Darouiche, trimester because TMP is a folic before other urologic procedures 2004; Shah, Cannon, Sullivan, acid antagonist, and it should also during which mucosal bleeding Nemchausky, & Pachucki, 2005). be avoided at term because sul- is anticipated (Nicolle et al., Some authors argue for a routine fonamides can displace bilirubin 2005). exchange of the catheter every 8 causing kernicterus in the new- to 12 weeks in an attempt to pre- born. TMP-SMX is acceptable and Catheter Associated Infections vent infection. effective in the second trimester. UTIs related to indwelling Quinolones and tetracyclines are transurethral catheters are the Pregnancy contraindicated in pregnancy. If a most common cause of hospital- During pregnancy, there are pregnant woman with cystitis acquired infection. The first pri- many physiologic changes that develops a fever or flank pain, ority in catheter care and man- occur that predispose a woman pyelonephritis should be pre- agement should be aseptic tech- to UTI and to progression of a sumed. Most authors recommend nique in an attempt to avoid sub- UTI or ASB to pyelonephritis. admission for intravenous antibi- sequent infection. Table 4 lists Hormonal effects, largely due to otic therapy followed by antibiot- these guidelines; they include progesterone, of pregnancy in- ic suppression for the remainder avoiding unnecessary catheteri- clude ureteral dilation, and slug- of the pregnancy (Kass, 1960; zation, removing the catheter as gish peristalsis. Vesicoureteral Patterson & Andriole, 1997; soon as possible, and anchoring reflux may also occur, and the Sweet, 1977; Vazquez & Villar, the catheter to the thigh to avoid enlarging uterus causes external 2000). traction against the urethra compression of the ureters with

338 UROLOGIC NURSING / October 2008 / Volume 28 Number 5 SERIES

Acute Pyelonephritis if the patient has any complicat- Beydoun, S.N. (1985). Morphologic ing factor (Warren et al., 1999; changes in the renal tract in preg- The diagnosis of pyelo- nancy. Clinical Obstetrics & nephritis is suspected when Wyatt, Urban, & Fishman, 1995). Gynecology, 28(2), 249-256. patients present with flank pain, Bryan, R.E., Sutcliffe, M.C., & McGee, F.E. (1973). Human polymorphonuclear nausea and vomiting, fever Summary greater than 38 degrees Celsius, leukocyte function in urine. Yale UTIs are a very prevalent Journal of Medicine, 46(2), 113-124. and/or costovertebral angle ten- Cox, C.E., & Hinman, F. (1961). Experiments derness. Patients may or may not problem for women from puberty with induced bacteriuria, vesical emp- also have classic cystitis symp- through their postmenopausal tying, and bacterial growth on the toms (Fairley et al., 1971). Acute years, and the diagnosis will only mechanism of bladder defense to become more common as the infection. The Journal of Urology, 86, pyelonephritis accounts for 739-748. greater than 250,000 annual hos- U.S. population ages. Acute cys- Cox, C.E., Lacy, S.S., & Hinman, F. (1968). pitalizations per year in the U.S. titis is generally easily diagnosed The urethra and its relationship to (Stamm et al., 1989). In the diag- by a consistent constellation of urinary tract infection, II. The ure- nostic evaluation, urinalysis symptoms, including dysuria, thral flora of the female with recur- frequency, urgency, and suprapu- rent urinary tract infection. The reveals pyuria in virtually all Journal of Urology, 99, 632-638. cases; blood cultures will be pos- bic pain. In uncomplicated infec- Cravens, D.D., & Zweig, S. (2000). Urinary itive in 10% to 20% of cases. The tions, urine culture (the gold catheter management. American same pathogens observed in cys- standard for diagnosing bacteri- Family Physician, 61(2), 369-376. uria and cystitis) is often not Echols, R.M., Tosiello, R.L., Haverstock, D.C., titis patients are responsible for & Tice, A.D. (1999). Demographic, clin- pyelonephritis. required because these UTIs ical, and treatment parameters influ- The initial treatment deci- respond well to multiple avail- encing the outcome of acute cystitis. sion is often whether these able antibiotic regimens. Micro- Clinical Infectious Diseases, 29(1), 113- patients require inpatient versus scopic urinalysis with assess- 119. ment for pyuria is often helpful Engel, G., Schaeffer, A.J., Grayhack, J.T., & outpatient management. Ap- Wendel, E.F. (1980). The role of propriate patients for hospital in narrowing the differential excretory urography and cystoscopy admission include severely ill or diagnosis. For patients with com- in the evaluation and management markedly debilitated patients, plicated or recurrent infections, of women with recurrent urinary however, urine culture is neces- tract infection. The Journal of patients with an uncertain diag- Urology, 123, 190-198. nosis, women who are pregnant, sary because a relapsing infec- Fairley, K.F., Carson, N.E., Gutch, R.C., those unable to tolerate oral tion of the same bacterial strain Leighton, P., Grounds, A.D., McCallum, intake, and those for whom there may prompt further imaging of P.H., et al. (1971). Site of infection in is concern about compliance the upper and lower urinary acute urinary tract infection in general tracts to detect other abnormali- practice. The Lancet, 2, 615-618. with the prescribed antibiotic Fihn, S.D., Boyko, E.J., Chen, C.L., regimen. Patients treated as out- ties. These patients often require Normand, E.H., Yarbro, P., & patients must be available for more rigorous regimens of antibi- Scholes, D. (1998). Use of spermi- contact in 2 to 3 days to assure otic treatment, including long- cide-coated condoms and other risk term prophylaxis, postcoital ther- factors for urinary tract infection symptoms are improving. caused by Staphylococcus sapro- The empiric antibiotic choice apy, or self-start therapy. In- phyticus. Archives of Internal is typically an aminoglycoside or fections associated with trans- Medicine, 158(3), 281-287. a fluroquinolone (such as urethral catheterization or preg- Fihn, S.D., Boyko, E.J., & Normand, E.H., ciprofloxacin 500 mg PO BID) nancy require special attention Chen, C.L., Grafton, J.R., Hunt, M., et and management in order to pre- al. (1996). Association between use because these achieve high tissue of spermicide-coated condoms and levels in the kidneys. Ampicillin vent progression to pyelo- Escherichia coli urinary tract infec- and sulfonamides should be nephritis, which may be associat- tion in young women. American avoided because the level of ed with significant morbidity. Journal of Epidemiology, 144, 512- 520. resistance is too high in most Fihn, S.D., & Stamm, W.E. (1983). communities. Patients need to References Amit, G., & Halkin, A. (1997). Lemon-yel- Management of women with acute complete a 14-day regimen in low nails and long-term phenazopy- dysuria. In D. Rund & B.W. Wolcott total, and antibiotics may be tai- ridine use. Annals of Internal (Eds.), Emergency medical annual lored once urine culture and sen- Medicine, 127, 1137. (pp. 2-225). Norwalk, CT: Appleton- Century-Crofts. sitivity results are available Andriole, V.T. (1991). Use of quinolones in treatment of prostatitis and lower Foxman, B. (1990). Recurring urinary (Stamm, McKevitt, & Counts, urinary tract infections. European tract infection: Incidence and risk 1987). A spiral-computed tomog- Journal of Clinical Microbiology & factors. American Journal of Public raphy scan or renal sonogram Infectious Diseases, 10(4), 342-350. Health, 80, 331-333. Bergman, A., Karram, M.M., & Bhatia, Foxman, B. (2002). Epidemiology of uri- should be considered to radi- nary tract infections: Incidence, ographically evaluate the upper N.N. (1989). Urethral syndrome: A comparison of different treatment morbidity, and economic costs. urinary tract in patients after 2 modalities. Journal of Reproductive American Journal of Medicine, recurrences of pyelonephritis or Medicine, 34(2), 157-160. 113(Suppl 1A), 5S-13S.

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rent urinary tract infections. New New England Journal of Medicine, Thorp, J.M. Jr, Norton, P.A., Wall, L.L., England Journal of Medicine, 307(8), 463-468. Kuller, J.A., Eucker, B., & Wells, E. 329(11), 753-756. Stamm, W.E., Hooton, T.M., Johnson, J.R., (1999). Urinary incontinence in Schaffer, J. (2004). Urinary tract infection. Johnson, C., Stapleton, A., Roberts, pregnancy and the puerperium: A In A.M. Weber, L. Brubaker, J. P.L., et al. (1989). Urinary tract infec- prospective study. American Journal Schaffer, & M.R. Toglia (Eds.), Office tions: From pathogenesis to treat- of Obstetrics & Gynecology, 181(2), urogynecology: Practical pathways ment. Journal of Infectious Diseases, 266-273. in obstetrics and gynecology (pp. 159(3), 400-406. Trautner, B.W., & Darouiche, R.O. (2004). 134-156). New York: McGraw-Hill. Stamm, W.E., McKevitt, M., & Counts, Role of biofilm in catheter-associat- Schmidt, D.R., & Sobota, A.E. (1988). An G.W. (1987). 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Baltimore: Williams and pyelonephritis during pregnancy. plicated acute bacterial cystitis and Wilkins. Seminars in Perinatology, 1(1), 25- acute pyelonephritis in women. Stamm, W.E. (1983). Measurement of 40. Clinical Infectious Diseases, 29(4), pyuria and its relation to bacteriuria. Tenney, J.H., & Warren, J.W. (1988). 745-758. The American Journal of Medicine, Bacteriuria in women with long- Wilson, M.L., & Gaido, L. (2004). 75(18), 53-58. term catheters: Paired comparison of Laboratory diagnosis of urinary tract Stamm, W.E., Counts, G.W., Running, indwelling and replacement catheters. infections in adult patients. Clinical K.R., Fihn, S., Turck, M., & Holmes, Journal of Infectious Diseases, 157(1), Infectious Diseases, 38(8), 1150- K.K. (1982). Diagnosis of coliform 199-202. 1158. infection in acutely dysuric women. Wyatt, S.H., Urban, B.A., & Fishman, E.K. (1995). Spiral CT of the kidneys: Role in characterization of renal disease. Part I: Nonneoplastic disease. Critical Reviews of Diagnostic Imaging, 36(1), 1-37. Need CNE Credit? Zhanel, G.G., Hisanaga, T.L., Laing, N.M., DeCorby, M.R., Nichol, K.A., Palatnik, Visit the “Education” section at www.suna.org L.P., et al. (2005). Antibiotic resistance in outpatient urinary isolates: Final results from North American Urinary Tract Infection Collaborative Alliance (NAUTICA). International Journal of Antimicrobical Agents, 26(5), 380-388.

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