urinary tract infection (2)

8/13/2019 Urinary Tract Infection (2)

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URINARY TRACT INFECTION

INTRODUCTION

Infection of the urinary tract is identified by growth of a significant number of

organisms of a single species in the urine, in the presence of symptoms.A urinary tract infection(UTI) is defined as bacteria that exists anywhere between the renal cortex and the urethralmeatus. Because it is usually difficult to determine the exact location of the infection, the termUTI is used to explain microorganisms anywhere within the urinary tract. The greatestincidence of UTI in males occurs in the first year of life, after which it rapidly declines,remaining low through childhood and adolescence. Incidence in females is also highest in thefirst year of life and steadily declines through adolescence, but remains higher than theincidence for males at a rate of 10:1.

DEFINITIONS

A urinary tract infection (UTI) is defined as a bacterium that exists anywhere betweenthe renal cortex and the urethral meatus.

Lippincott Manual Of Nursing

INCIDENCE

Urinary tract infections (UTI) are a common bacterial infection in infants and children.The risk of developing UTI before the age of 14 years is approximately 1% in boys and 3-5% ingirls(1). The incidence varies with age. During the first year of life, the male to female ratio is3-5:1. Beyond 1-2 years, there is female preponderance with male to female ratio of 1:10.

1 year M : F, 1 : 10 In girls, 1 st episode of UTI occurs during infancy and 2 nd after 18 months In boys, 1 st episode of UTI occurs during infancy and more in uncircumcised males

ETIOLOGY

- E. Coli (75-90% ) , (female)

- Klebsiella

- Proteus, ( male)

- Pseudomonas

- Enterobacter


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- Candida

- Adenovirus

- Staphylococcus saprophyticus

RISK FACTORS

- Female

- Uncircumcised male

- Vesicoureteral reflux

- Voiding dysfunctions

- Obstructive uropathy

- Urethral instrumentation

- Wiping from back to front

- Tight clothing

- Pinworm infestation

- Constipation

- P fimbriated bacteria

- Labial adhesion

- Neurogenic bladder

PATHOPHYSIOLOGY

The urinary tract is normally sterile. Uncomplicated UTI involves the urinary bladder ina host without underlying renal, metabolic, or neurologic diseases. Cystitis represents bladdermucosal invasion, most often by enteric coliform bacteria (eg, Escherichia coli ) that inhabit the

periurethral vaginal introitus and ascend into the bladder via the urethra.

In recurrent E coli UTIs, peak colonization rates of the periurethral area 2-3 days prior to thedevelopment of the symptoms of acute cystitis range from 46-90%. During this same period,asymptomatic bacteriuria rates increase from 7% to 70%.

Factors unfavorable to bacterial growth include a low pH (5.5 or less), a high concentration ofurea, and the presence of organic acids derived from a diet that includes fruits and protein.Organic acids enhance acidification of the urine.


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Frequent and complete voiding has been associated with a reduction in the incidence of UTI. Normally, a thin film of urine remains in the bladder after emptying, and any bacteria presentare removed by the mucosal cell production of organic acids.

If the defense mechanisms of the lower urinary tract fail, upper tract or kidney involvementoccurs and is termed pyelonephritis. Host defenses at this level include local leukocyte

phagocytosis and renal production of antibodies that kill bacteria in the presence ofcomplement.

In general, there are 3 main mechanisms responsible for UTIs:

Colonization with ascending spread Hematogenous spread Periurogenital spread

CLASSIFICATION

UTI is classified into -

(1) Pyelonephritis

Abdominal pain or flank pain, fever, malaise, nausia, vomiting, diarrhea. Jaundice, poorfeeding, irritability and weight loss

Pyelitis / Pyelonephritis

(2) Cystitis

Dysuria, urgency, frequency, suprapubic pain, incontinence, and malodorous urine. Nofever and parenchymal injury

(3) Asymptomatic bacteriuria

Positive urine culture without any symptoms, occurs almost exclusively in girls, benign,no renal injury.

(4)Bacteriuria-presence of bacteria in the urine.

(5)Symptomatic bacteriuria-bacteriuria accompanied by physical signs of urinary tractinfections( dysuria, suprapubic discomfort,hematuria ,fever)

(6)Recurrent UTI- Recurrent episode of bacteriuria or symptomatic bacteriuria

(7)Persistant bacteriuria-persistance of bacteriuria despite of antibiotic treatment

(8)Febrile uti-bacteriuria accompanied by fever and other physical symptomsof urinaryinfection


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(9)Urethritis-inflammation of the urethra

(10)Urosepsis-Febrile urinary tract infection co-existing with systemic signs of bacterial illness,blood culture reveals the presence of urinary pathogen

SIGNS AND SYMPTOMS OF UTI AT DIFFERENT AGESNEONATAL PERIOD

Poor feeding Vomiting Failure to gain weight Rapid respirations Respiratory distress Spontaneous pnemothorax

Frequent urination Screaming on urination Poor urinf stream Jaundice Seizures Dehydration Other anomalies or stigmata Enlarged kidneys or bladder

INFANCY(1-24 MONTHS ) Poor feeding Vomiting Failure to gain weight Excessive thirst Frequent urination Straining or screaming on urination Foul-smelling urine Pallor Fever Persistant diapher rash Seizures Dehydration Enlarged kidneys or bladder

CHILDHOOD (2-14 YEARS) Poor appetite Vomitting


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Growth failure Excessive thirst Enuresis Painful urination

Swelling of face Seizures Pallor Fatigue Blood in the urine Abdominal or back pain Edema Hypertension Tetany

DIAGNOSIS

Urine culture:o Documentation of pathogenic organisms in the urine is the only means of

definitive diagnosis.o A urine culture demonstrating more than 100,000 bacteria per mL indicates

significant bacteriuria.o A catheterized urine specimen, with growth greater than 10,000 colonies of

bacteria per mL is considered significant. Urinalysis:

o Leukocytes, nitrites, suggestive but not indicativeo Casts, especially WBC casts, may be present and are indicative of intrarenal

infection.o Hematuria occurs occasionally.o Renal concentrating ability decreased.

Imaging studies

o X-ray KUB Normal kidney length total width of L1 L4 vertebrae

o USG Details of kidney, ureter, bladder, major blood vessels

o - Hydronephrosis, perirenal abscess, pyonephrosis, renal

o scar(30%)

o - Insensitive in identifying reflux ( 40% )

VCUG

< 5 yrs with UTI All children


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Febrile UTI

School age girls > 2 episodes of UTI

School age boys Any male with UTI

Timing

2 - 6 wks after treatment

Contrast VCUG - IVP, MCU, angiography

Radionuclide VCUG Non invasive,

Highly sensitive,

Less radiation exposure

Radionuclide VCUG > Contrast VCUG

Radionuclide imaging

DTPA ( Diethylenetriamine penta acetic acid )

- Filtered at glomerulus with no tubular reabsorption or

excretion.

- Renal perfusion and function

DMSA ( Dimercapto succinic acid )

- Parenchymal involvement

- More sensitive for renal scarring

COMPLICATIONS

A tendency for recurrent infection exists. Children with obstructive lesions of the urinary tract and those with severe

vesicoureteral reflux are at highest risk for kidney damage. These patients may need prophylactic oral antibacterial therapy

MANAGEMENT

The objective of treatment of children with UTI are


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1. To eliminate the current infection2. To identify the contributing factors to reduce the risk of recurrence3. To prevent symptomatic spread of infection4. To preserve the renal function

Antibiotic therapy should be initiated on the basis of identification of the pathogen,childshistory of antibiotics use and the location of the infection.

Severe symptoms Treatment started immediately

Mild symptoms Treatment started after culture report

A.PHARMACOLOGICAL MANAGEMENT

Antimicrobial Agents Commonly Used in the Management of Childhood Urinary TractInfection

DRUG ADVERSE EFFECTS NURSING CONSIDERATIONS Amoxicillin(Amoxil)

Occasional nausea,vomiting, diarrhea

Hypersensitivityreactions of skin

Readily absorbed. May be taken with food.

Ampicillin(Omnipen)

Diarrhea, urticaria Anaphylactic reaction

Contraindicated in penicillin-sensitivechildren. Package insert should beconsulted regarding reconstitution,administration, and storage of I.M. andI.V. preparations. Absorption of oral

preparations may be decreased with food.Dose must be repeated q6h to ensuretherapeutic blood levels.

Cephalexin(Keflex)

Diarrhea, nausea,vomiting

May be taken with food. Dose should bereduced if renal function is impaired.

Gentamicin(Garamycin)

Renal and auditorytoxicity; respiratory

paralysis

Toxic effects can be minimized by slowI.V. infusion (over 1 hour).

Nitrofurantoin(Macrodantin,Furadantin)

Fever, nausea,vomiting, peripheralneuropathy

Recommended for prolonged use. Givewith food or milk to decrease GI adverseeffects. May cause urine to be amber or

brown in color. Contraindicated in renalfailure and in infants younger than age 3months.

Co-trimoxazole Nausea, vomiting, Commonly used if bacterial resistance is


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(Bactrim,Septra)

fever, rash, photosensitivity

anticipated or the child fails to respond toinitial therapy.

Oral antibiotic therapy for uncomplicated UTI.

Repeat culture may be necessary before treatment is discontinued.

All children with the first UTI should be promptly investigated to identifythose with an underlying urinary tract anomaly. If anatomical defects such as primaryreflux or bladder neck obstruction are present surgical correction are necessary to

prevent recurrent infection.

Guidelines for evaluation of patients vary. Recommendations of the Expert Group are

Evaluation following initial UTI. MCU: Micturating cystourethrogram; DMSA:dimercaptosuccinic acid scan.

Detailed evaluation with ulrasound, MCU and renal scan is recommended for allchildren with recurrent UTI.

NURSING MANAGEMENT

NURSING ASSESSMENT

Obtain history to determine if UTI is initial or recurrent and to determine if there may beother disease processes contributing to this infection.


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Focus assessment on identifying clinical manifestations and determining location ofinfection, such as presence and appearance of urethral discharge, high-grade fever (morecommon with upper UTI), or low-grade fever (more common with lower UTI).

Determine urinary pattern (ie, amount and frequency) and associated discomfort.

NURSING DIAGNOSES

1.Impaired Urinary Elimination related to infection as evidenced by dysuria

GOAL:Promoting Urinary Elimination

Nursing Interventions

Obtain a clean urine specimen for urinalysis or culture.o Obtain freshly voided early morning specimen, if possible (most accurate). This

urine is usually acid and concentrated, which tends to preserve the formed

elements.o Provide fluids to help the child void.o Perform catheterization, if necessary, to obtain a sterile specimen; however, this

procedure may cause emotional trauma and the accidental introduction ofadditional bacteria.

o Send urine to the laboratory immediately or refrigerate to avoid a falsely high bacterial count.

Administer antibiotics as ordered by the health care provider (after specimen has beenobtained for culture).

o Antibiotic therapy is generally determined by the results of the urine cultures andsensitivities and by the child's response to therapy; however, empirical therapy

may be started before culture results are back.o Become familiar with toxic effects of antimicrobial agents and assess the childregularly for any of the signs and symptoms.

2.Acute Pain related to inflammatory changes and feveras evidenced by feacial expressionand pain score of seven.

GOAL:Maintaining Comfort and Providing Symptomatic Relief

Nursing interventions

Administer analgesics and antipyretics as ordered. Maintain child on bed rest while febrile.

Encourage fluids to reduce the fever and dilute the concentration of the urine. (Water isthe best clear fluid.)

Administer I.V. fluids if necessary.

3.Hyperpyrexia related to the infection as evidenced by the increased body temperature.


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Goal : maintain normal body temperature

Nursing interventions:

Note conditions promoting fevers.

Measure/monitor childs temperature, using properly functioning thermometer. Discuss variables in temperature measurements for age of child and where temperatureis measured.

Administer antipyretics as per the order.

4.Anxiety related to exposure and manipulation of the genitourinary tract

GOAL :Promoting Self-Esteem

Reinforce medical explanations of the disease and its therapy. Explain all diagnostic tests and procedures to the child, allowing time for questions and

answers. Encourage verbalizing. Correct any misconceptions and particularly address concernsabout the functioning of the urinary tract and sexual function. Reassure the child that heor she did not cause the problem.

Maintain privacy for the child as much as possible. Provide an environment that is as close to normal as possible during hospitalization.

Include opportunities for the child to play. Prepare the child and family for discharge and begin discussions of rest, fluids, and

medications.

HEALTH EDUCATION

Review long-term antibiotic therapy, if prescribed, to prevent recurrence of UTI.Schedules for prolonged therapy vary from several months to continuous prophylaxis.

Encourage scheduled follow-up visits because of the possibility of disease recurrence.o Emphasize that even though this disease may have few symptoms, it can lead to

serious, permanent disability.o Advise family that subsequent suspected UTIs should be assessed and followed

by health care provider. Teach measures of prevention:

o Minimize spread of bacteria from the anal and vaginal areas to the urethra infemale children by cleansing the perianal area from the urethra back toward the

anus.o Avoid bubble baths because of the bladder-irritant effect of these solutions.o Encourage adequate fluid intake, especially water.o Avoid carbonated and caffeinated beverages because of their irritative effect on

bladder mucosa.o Encourage the child to void frequently and to empty the bladder completely with

each voiding (double voiding).o Encourage a high-fiber diet to avoid constipation.


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PROGNOSISEven with effective antibiotic treatment, the average duration of severe symptoms in womenwith cystitis is somewhat longer than 3 days. Features that have been associated with a more

prolonged course than average include a history of somatization, previous cystitis, urinaryfrequency, and more severe symptoms at baseline .[10] .

Although simple lower UTI (cystitis) may resolve spontaneously, effective treatment lessens theduration of symptoms and reduces the incidence of progression to upper UTI. Even witheffective treatment, however, about 25% of women with cystitis will experience a recurrence.

Younger patients have the lowest rates of morbidity and mortality

BIBLIOGRAPHY

Marlow R. Dorothy and Redding A Barbara(2006) ,Textbook of pediatric nursing,6 th edition,saunder s publications,page no.923-924

Datta Parul(2009),pediatric nursing ,2 nd edition,Jaypee brothers medical publishers,365 Hockenberry J Marlin,Wongs essentials of pediatric nursing,7 th edition,Elsevir

publishers,page no:989-992 Chowdhary Balram(2008),Pediatric lecture Notes ,Peepee publications,page no 405-409


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PRESENT TION

ON

URIN RY TR CT INFECTIONSubmitted to,Mrs . Nisha

Associate Professor,

R.V.S. College Of N ursing ,

Sulur

Submitted on : 02-01-2013 Submitted by,

Angela Sebastian

Second year MSc Nursing Student,

R.V.S. College Of Nursing

Sulur

urinary tract infection (2)

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