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Understanding Urinary Tract Infections: Diagnosis, Asymptomatic Bacteriuria, and Treatment, Study notes of Nursing

Northern Oklahoma CollegeNursing

Comprehensive information on Urinary Tract Infections (UTIs), including the diagnosis process, asymptomatic bacteriuria, and treatment. It covers various types of UTIs, such as catheter-associated UTIs, and discusses the significance of white cells in the urine and bacteriuria. The document also highlights the importance of avoiding inappropriate antibiotic treatment and provides guidelines for urine culture collection.

What you will learn

  • How is asymptomatic bacteriuria treated?
  • What are the common reasons for inappropriate culture and treatment of asymptomatic bacteriuria?
  • What does it mean to have white cells in the urine?
  • What is asymptomatic bacteriuria and when should it be searched for?
  • What are the symptoms of a UTI?

Typology: Study notes

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Urinary Tract Infection 101
For Nurses
Nurses Take Antibiotic Stewardship Action Initiative
This material was supported in part by a U.S. Centers for Disease Control and
Prevention (CDC) contract to Johns Hopkins University.
Disclaimer: The conclusions in this presentation are those of the JHU authors and do not
necessarily represent the views of the Centers for Disease Control and Prevention.
The Department of Antimicrobial
Stewardship, The Johns Hopkins
Hospital:
•Valeria Fabre, MD
•Sara E. Cosgrove, MD, MS
•Ashley Pleiss, RN, BSN
The Office of Antibiotic Stewardship,
Centers for Disease Control and
Prevention:
•Arjun Srinivasan, MD
•Lauri Hicks, DO
•Melinda Neuhausser, PharmD
Proud to be a
NURSE
ANTIBIOTIC
STEWARD
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Download Understanding Urinary Tract Infections: Diagnosis, Asymptomatic Bacteriuria, and Treatment and more Study notes Nursing in PDF only on Docsity!

Urinary Tract Infection 101

For Nurses

Nurses Take Antibiotic Stewardship Action Initiative

This material was supported in part by a U.S. Centers for Disease Control and

Prevention (CDC) contract to Johns Hopkins University.

Disclaimer: The conclusions in this presentation are those of the JHU authors and do not

necessarily represent the views of the Centers for Disease Control and Prevention.

The Department of Antimicrobial

Stewardship, The Johns Hopkins

Hospital:

  • Valeria Fabre, MD
  • Sara E. Cosgrove, MD, MS
  • Ashley Pleiss, RN, BSN

The Office of Antibiotic Stewardship,

Centers for Disease Control and

Prevention:

  • Arjun Srinivasan, MD
  • Lauri Hicks, DO
  • Melinda Neuhausser, PharmD

NURSE

ANTIBIOTIC

STEWARD

Consists of an infection of:

  • Kidneys (Pyelonephritis, renal abscess) OR
  • Bladder (Cystitis) To make a diagnosis of UTI, the following 3 elements are needed: Symptoms (^) + White cells in the urine (except in neutropenic patients) + Positive urine culture (bacterial growth in urine culture) **1. CYSTITIS: Dysuria, frequency, urgency
  1. PYELONEPHRITIS: Fever and flank pain
  2. CATHETER-ASSOCIATED UTI: Fever and** suprapubic tenderness Urinary Tract Infections NURSE

ANTIBIOTIC

STEWARD

2

What Does It Mean To Have White Cells In The Urine?

  • White cells in the urine, or pyuria , is defined as:
    • ≥ 10 white cells/mm 3
    • ≥ 3 white cells/HPF of unspun urine
    • Positive leukocyte esterase
  • White cells may be present in the urine due to non-infectious causes - Examples of non-infectious cases of pyuria
  • Pyuria with or without bacteriuria is NOT an indication for a urine culture or antibiotic therapy if the patient is ASYMPTOMATIC (exceptions already discussed) - Presence of urinary catheter - Recent urologic procedure - NSAIDs (e.g., ibuprofen) - Steroids - Proton pump inhibitors - Antibiotics (e.g., vancomycin, penicillin) - Pelvic irradiation due to cancer - Urinary tract stones - Renal-vein thrombosis - Interstitial cystitis/nephritis - Systemic lupus erythematous NURSE

ANTIBIOTIC

STEWARD

Asymptomatic Bacteriuria And Pyuria Are Common In Certain Patient Populations

  • Patients with very high prevalence of ASB and pyuria (≥ 90%):
    • Dialysis patients
    • Patients with long-term indwelling catheters
  • Patients with moderate (30- 50 %) prevalence of ASB and high (90%) prevalence of pyuria: - Elderly women - Long-term care residents
  • Patients with lower (< 10%) prevalence of ASB and moderate (30-50%) prevalence of pyuria: - Short-term catheters (in place for < 30 days) - Pre-menopausal women NURSE

ANTIBIOTIC

STEWARD

Special Populations

  • Elderly patients
    • Bacteriuria and delirium are independently common in elderly patients.
    • Delirium or fall should not prompt a urine culture if there are no local

genitourinary symptoms (e.g., suprapubic pain) or other signs of infection

(e.g., fever or hemodynamic instability).

  • Spinal cord injury patients
    • Clinical signs and symptoms of a UTI may differ from persons with normal

sensation (presenting symptoms may include increased spasticity, leaking

around the catheter, malaise).

  • Both of these patient groups are at a higher risk of inappropriate antibiotic treatment as their urine is frequently cultured for non-specific symptoms. NURSE

ANTIBIOTIC

STEWARD

The Color Does NOT Tell

  • Many non-infectious causes may alter the appearance of the urine. - Pale yellow/clear : good hydration - Bright yellow : B vitamins - Red : blood, beets, blackberries - Orange : dehydration, carrots, rifampin - Green : phenol drugs, antidepressants, dyes in food, bile - Brown : anti-psychotics, laxatives, muscle relaxants, muscle injury - Purple : porphyria
  • Isolated urine color changes (“dark”, “murky”, “cloudy”) do not correlate well with UTI and should not prompt urine cultures in the absence of other signs and symptoms of infection. NURSE ANTIBIOTIC STEWARD

Common Reasons For Inappropriate Culture/Decision To Treat ASB

  • Pyuria
  • Foul smelling urine
  • Dark urine
  • Sediment in urine
  • Prior UTI diagnosis
  • Test of cure
  • Resistant organisms in urine
  • Vague malaise/weakness
  • Fall
    • Admission or transfer to a new unit/hospital
    • Leukocytosis (increased white blood cell count in blood) NURSE

ANTIBIOTIC

STEWARD

Treatment

  • If a patient is able to take oral medications, oral options are preferred for cystitis and recommended for pyelonephritis once the patient has improved (to avoid complications of intravenous access such as phlebitis, bacteremia, and thrombosis).
  • Duration: o Cystitis: 3 - 7 days depending on antibiotics o Pyelonephritis: 5 - 14 days depending on antibiotics o CAUTI: Remove catheter (this alone may resolve the infection). Duration depends on location and severity of illness ( 3 - 14 days). o Longer courses for cases with urinary obstruction
  • If an antibiotic was started for a suspected UTI and subsequently an alternative diagnosis is identified, antibiotics should be stopped. NURSE

ANTIBIOTIC

STEWARD

Urine Collection DO’s Indwelling catheter urine:

1. Clean the catheter with an alcohol pad.

2. Use a sterile needle and syringe to puncture the tubing or

use the urine vacutainer.

3. Aspirate the urine directly from the tubing.

4. Transfer the urine to a sterile specimen

container or appropriate transport media.

Midstream urine (instructions to patients):

1. Wash hands.

2. Clean area with towelette.

3. Void ~20 mL into toilet and catch portion of the remaining urine in

cup without stopping the stream.

NURSE

ANTIBIOTIC

STEWARD

(^13)

When To Order A UA Versus A UA With A Urine Culture?

  • If a UTI is suspected based on signs and symptoms of UTI (not a fall, not fatigue) either a UA with reflex or a UA plus a urine culture can be ordered
  • If a UA with reflex is ordered, the clinical laboratory will set the urine culture if predefined criteria are met (usually based on pyuria, nitrite [comes from some urinary bacteria], or leukocyte esterase [comes from white cells]) NURSE

ANTIBIOTIC

STEWARD

References 16 Slide 3

  • IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria, Clin Infect Dis 2019.
  • Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from IDSA, Clin Infect Dis 2010. Slide 4
  • Wise and Schlegel. Sterile Pyuria, NEJM 2015;372:1048-54.
  • Glen, Peter et al. “Sterile pyuria: a practical management guide.” The British journal of general practice : the journal of the Royal College of General Practitioners vol. 66,644 (2016): e225-7. doi:10.3399/bjgp16X Slide 5
  • IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria, Clin Infect Dis 2019. Slide 6
  • Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat?. Clin Infect Dis. 2012 Sep;55(6): 771 - 7.
  • Harding GK, Zhanel GG, Nicolle LE, et al. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med. 2002 Nov 14;347(20): 1576 -
  • Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987 Jul;83(1):27-33.
  • Cai T, Nesi G, Mazzoli S, et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis. 2015 Dec 1;61(11):1655- 61. Slide 7
  • McKenzie R, Stewart MT, Bellantoni MF, et al. Bacteriuria in individuals who become delirious. Am J Med. 2014.
  • Boscia JA, Kobasa WD, Abrutyn E, et al. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986.
  • Nicolle LE, Bentley DW, Garibaldi R, et al. Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee. Infect Control Hosp Epidemiol.
  • IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria, Clin Infect Dis 2019. Slide 9
  • Midthun and Lindseth J Gerontol Nurs. 2004 Jun;30(6):4-9. Slide 10
  • Trautner et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Medical Informatics and Decision Making , 2013. Slide 11
  • Lai KK, Arch Intern Med. 1996;156(22):2579.
  • Hooton TM, Bradley SF, Cardenas DD, et al. Clin Infect Dis. 2010 Mar;50(5):625-63.
  • Harding GK, Nicolle LE, Ronald AR, et al.. Ann Intern Med. 1991 May 1;114(9):713-9.