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/
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/
So first let's talk about urethritis. This is inflammation of the urethra. It can be caused by substances like soap. It can be caused by bacteria. Most commonly it's in those who are ages 20 to 24 and the most common cause is sexually transmitted infections. The symptoms of urethritis can be the same symptoms as cystitis, vaginitis or cervicitis, so basically it's going to have a lot of the same symptoms we see with our patients who have urinary tract infections. Additional symptoms could be purulent discharge, dysuria or that burning or discomfort during urination, itching and just general discomfort in the area. Now let's talk about cystitis. Cystitis is inflammation of the bladder. Cyst C-Y-S-T should make you think. Bladder Cystitis can be caused by a lot of different things. Most of the time we think about it in conjunction with an infection, usually a bacterial infection, but it can also be caused by medications, chemicals If the patient needed to have local radiation to the area irritants like feminine hygiene spray, some of the spermacidal jellies, or long-term use of a catheter. Today I'm going to focus on urinary tract infections.
Speaker 0:Urinary tract infections can affect 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 be classified by upper, meaning it's pylonephritis or infection of the kidneys, or lower, which would be the bladder or the urethra. They're also classified by acute or recurring. An acute urinary tract infection is an invasion by an infectious pathogen or organism. A recurrent UTI is defined as having two or more infections in six months, or three or more infections in a year. We also classify them by complicated and uncomplicated urinary tract infections. A complicated urinary tract infection typically involves a functional or anatomic abnormality. What would cause a complicated urinary tract infection, you ask? Chronic disease such as diabetes, an obstruction from, maybe, urinal calculi or kidney stones and having male genitalia. Now, where do these germs come from? Where do these bacteria come from? Guess what? Most of them come from the bowel.
Speaker 0:As far as hospital-acquired urinary tract infections, the most common factor associated with that is going to be a urinary catheter. The risk of infection when a patient has a catheter inserted into their urinary tract goes up by somewhere between 3 and 10% per day that the catheter is actually in place. As a good nurse, I want to make sure that I minimize my patient's potential for developing that hospital-acquired urinary tract infection, and I do that by knowing when it's appropriate to insert a urinary catheter and when it's not. I also will assess my patient every day that I'm there, so every shift the patient should be assessed by an RN whether or not that catheter is still needed. The American Nurses Association has created a streamlined, evidence-based RN tool for preventing catheter associated urinary tract infections. I'll include the link in the show notes. The tool is just a basic algorithm. This tool is really easy to use to help you determine if it's appropriate to put in a urinary catheter and, if your patient already has one, if it's appropriate for them to continue to have that catheter in place.
Speaker 0:According to this algorithm, the reasons for putting in a catheter or the criteria for indwelling urinary catheter insertion are acute urinary retention to improve comfort for end-of-life care. Critically ill and patients who need accurate measurements of eyes and o's basically hourly monitoring of output. Selected surgical procedures such as genital urinary surgery, colorectal surgery, to assist healing of an open sacral or perineal wound in an incontinent patient, if we need to monitor urinary output intraoperatively or large volumes of fluid or diuretics are anticipated and in prolonged immobilization with a potentially unstable thoracic or lumbar spine, multiple traumatic injuries like pelvic fractures those kinds of things. Preventing urinary tract infections in patients at home is something that we also want to think about. We can teach our patients to ensure they're drinking enough fluid so that they're urinating throughout the day. Their urine should be a light yellow color, of course. Maintaining a healthy lifestyle, so a healthy diet, exercise.
Speaker 0:For those with female genitalia, wiping front to back because you don't want to pull bacteria from the backside to the front side the recommendation is to urinate before and after intercourse, and I'm not really sure how long that's going on. Don't hold your urine. Go to the bathroom when you feel like you need to go to the bathroom. I think the recommendation is somewhere around every three to four hours. You should be urinating, and there's been conflicting research about whether or not cranberry juice can actually help prevent a urinary tract infection.
Speaker 0:I think most people are familiar with the symptoms of a urinary tract infection. They include urinary frequency having to go very often. Urgency you have to go right now. Dysuria or discomfort, maybe burning sensation when you urinate. Super pubic just above that pubic bone pain. Tenderness I've had patients complain of pressure there needing to get up at night to urinate. Having new onset incontinence.
Speaker 0:Hematuria, meaning blood in the urine. Pyuria, which means there's white blood cells in the urine bacteriauria, meaning you have bacteria in your urine. Now something to take note of there. A person can have bacteria in their urine without having a urinary tract infection. In that case we would say they're colonized. You may have been told that altered mental status or changes in mental status can be a symptom of urinary tract infection, especially in the elderly. However, we have to be super careful with that, because a lot of different things can cause those symptoms and you can't just assume it's a urinary tract infection. Those symptoms have to be investigated. Often if the provider feels that it's an uncomplicated urinary tract infection the patient hasn't had one before, they haven't had one in a long time, they don't have any structural abnormalities or other conditions that could be contributing to a complicated urinary tract infection. They may go ahead and prescribe an antibiotic without doing a urinalysis or culture insensitivity. In that case, the important thing to teach your patient is going to be if they don't have a resolution of their symptoms, then they need to come back, because they may need to have that culture insensitivity done to determine which antibiotic is going to be the one that's going to take care of this infection.
Speaker 0:Speaking of urinalysis and culture insensitivity. If you have orders for urinalysis and the patient is able to get it on their own, you need to get a midstream clean catch specimen. You get that by instructing the patient to take usually castile towelettes. Clean the area just like we would clean right before we do a urinary catheter. They're going to clean around the urethral meatus and then they'll urinate a little bit into the toilet and then a little bit into the cup and the rest into the toilet. We only need 10 milliliters for urinalysis. We don't need a whole cup full of urine.
Speaker 0:Once we take a look at that urinalysis, a combination of positive leukocyte, esterase and nitrate is about 68 to 88% sensitive to the diagnosis of UTI. We might also see white blood cells, which is called pyuria, red blood cells, which is called hematuria, or CAS, which are clumps of material or cells. These can also be indicative of UTI. If this is a complicated UTI where the patient didn't resolve their symptoms or there's some other mechanism of action affecting this urinary tract infection, they'll do a culture insensitivity and what that will do is it will allow us to identify the organism and it will also allow us to see what antibiotic is going to work the best for this organism.
Speaker 0:In the end, the diagnosis of a urinary tract infection needs to be left to a provider, because these tests that I have mentioned aren't necessarily indicative 100% of a urinary tract infection. If the provider suspects a complicated urinary tract infection, they may do a CT scan, which is going to help us to see more soft tissue than an X-ray would. A CT scan is going to be used to look for the presence of renal calculi or kidney stones or to identify if there's another kind of obstruction. Another procedure that may be done is called cystoscopy and there's that CYST again Cystoscopy. We're going to take an endoscope and go into the bladder to look around. That's really going to be reserved for a complicated urinary tract infection, where it's a recurrent, and they're looking to see what kind of structural or other abnormalities may be present.
Speaker 0:The most common antibiotics that are going to be given for an uncomplicated urinary tract infection are nitrofurentine, a combination medication called trimethoprim, sulfamethoxazole or Bactrim and Phosomycin. Now, these are given for uncomplicated urinary tract infections with a low risk for resistant bacteria. The big thing to know about sulfamethoxazole trimethoprim is that it should be stopped if there's any kind of a skin rash and the patient should notify their provider. To help your patient with their symptoms, especially if they're having dysuria, you can educate them to use a Sitzbath, or I've even had patients, if they're very uncomfortable, to sit in a Sitzbath or in a little bit of water and urinate there, because it helps to dilute the urine as it comes out and it's less burning. Make sure they're drinking plenty of fluids, unless it's contraindicated, and there is a medication called venasopydidine that can help with the symptoms, but make sure your patient understands that it can change their urine to an orange color.
Speaker 0:The last thing on this topic for us to talk about is pylonephritis, which refers to an infection that's in the kidneys. Pylonephritis can be acute, meaning it is a single episode, sudden onset, or it can be chronic, which is something that occurs often over time. The chronic pylonephritis usually is associated with structural deformities, urinary stasis obstruction or urinary reflux. Depending on the severity of the disease, the patient may be able to be treated at home or they may be treated in the hospital. Some things that may necessitate a hospitalization is bacteremia or the bacteria leaving the kidney and escaping into the bloodstream, or when the patient becomes hemodynamically unstable and they can't take oral medication. This is where you might see cost over tibial angle tenderness. You may even notice that there's some enlargement there, some asymmetry, edema or erythema, which is redness.
Speaker 0:Other symptoms that usually come along with acute pylonephritis are fever chills they're also called rigors where you have the shivering, tachycardia, tachypnea, general malaise or not feeling well, fatigue, nausea, vomiting, and they may have the other symptoms of an uncomplicated urinary tract infection. We might also see an elevation in their serum white blood cells, so the amount of white blood cells that are in their bloodstream, and some nonspecific markers for inflammation, like C-reactive protein or erythrocyte sedimentation rate. We're going to make sure that we're also monitoring our patient's blood, urea nitrogen or BUN and their creatinine to make sure that we have the baseline and that we can trend for recovery or deterioration. We're also going to get an estimate of the glomerular filtration rate because that can be used to trend kidney function as well. The provider may order a CT scan or an x-ray of the kidney's ureters and bladder, which is often called a KUB, and this is just to look at the anatomy, looking for inflammation, fluid accumulation, abscess formation and if there's any defects in the kidneys or the urinary tract. We can also identify stones, tumors, cysts and prostate enlargement with these imaging tests.
Speaker 0:Treatment for these patients is going to probably include a pseudomenophen, which is preferred over an NSAID because it doesn't interfere with kidney auto-regulation of blood flow like NSAIDs do. It's also going to help reduce any fever or pain. We typically will do a urine culture insensitivity, but we'll also probably get blood cultures to see if there's any bacteria remia going on. In the hospital, patients are typically given IV antibiotics and our big goal is preventing chronic kidney disease. And of course, our last big goal is to educate our patients to take all of their antibiotics, no matter how they feel. Two or three days in, they feel much better. They feel great. Please keep taking your antibiotics. That's all I've got for today on urinary tract infections. Join me next time on Nursing with Dr Hobbock and we'll talk about acute kidney injury and chronic kidney disease.