Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Urinary Tract Infection
N39.0 – Urinary tract infection, site not specified
I. DEFINITION
Infection of the urethra, bladder (cystitis), ureters, and/or kidneys
II. ETIOLOGY
A. Specific causes
1. Bacteria: Escherichia coli, 75% to 90% of all acute uncomplicated infections. Staphylococcus saprophyticus, second most commonly isolated organism; formerly thought to be a contaminant; now thought to be of causative significance, especially in women aged 16 to 25 years old. Others in descending order of implication: Klebsiella, Proteus mirabilis, Enterobacteriaceae, Citrobacter freundii, Enterococcus, and others, including Serratia, Providencia, Pseudomonas, group B Streptococcus, Staphylococcus aureus, Staphylococcus epidermidis, Mycoplasma, and Chlamydia.
2. Fungi, especially in those with diabetes and patients with catheters; immunocompromised persons
3. Viruses that cause viruria—measles, mumps, herpes simplex, cytomegalovirus, adenovirus, varicella zoster leading to hemorrhage in bladder, and cystitis
B. Mechanism: most commonly ascending infection
1. In females: gastrointestinal flora (E. coli)
2. In males: prostate plays a role in harboring infection, constricting urethra, causing urine retention
C. Other predisposing factors
1. Size of inoculum
2. Virulence of organism
3. Incomplete or infrequent bladder emptying
4. Urinary tract abnormalities: obstruction, calculi, congenital defects, prostatic hypertrophy
5. Use of catheters
6. Newly sexually active (honeymoon cystitis)
7. Chemical contamination secondary to spermicidal, barrier methods of contraception
8. Possibly being postmenopausal with estrogen deficiency
9. Family history of UTI
10. Pregnancy, menopause
11. Kidney stones
12. Bowel incontinence
13. Suppressed immune system
III. HISTORY
A. What the patient may present with
1. Dysuria
2. Frequency, urgency
3. Suprapubic pain, ache, pressure, scorched feeling after urination
4. Back pain, ache or pressure in genitals
5. No systemic symptoms except, occasionally, a low-grade fever of less than 101°F
6. Gross hematuria
7. Vague abdominal discomfort
B. Additional information to consider
1. Any previous cystitis or pyelonephritis; when was the last treatment, how it was treated, and response to treatment
2. Previous urologic workup
3. Any vaginal discharge: character and onset
4. Any chronic condition: diabetes, paraplegia, quadriplegia, cerebral palsy, meningomyelocele, and spina bifida
5. Duration of symptoms
6. Possible pregnancy with high-risk complications or use of contraindicated drugs
7. Sexual activity, especially 24 to 48 hours postvaginal intercourse
8. Method of contraception
IV. PHYSICAL EXAMINATION
A. Vital signs: temperature
B. Abdomen: any tenderness, masses
C. Back: any costovertebral angle tenderness or pain
D. Pelvic examination essential to rule out PID, vaginitis, vaginosis, STI
V. LABORATORY EXAMINATION
A. Urinalysis: clean catch midstream urine; pyuria with five or more white blood cells (WBCs) per high-power field
B. Culture alone is sufficient on first time ever with UTI with no risk factor; all others should have culture and sensitivities.
1. Culture and sensitivities: typically greater than 100,000 organisms felt to be diagnostic
2. If between 10,000 and 100,000, it would probably be significant if the clinical symptoms supported the diagnosis.
C. Note: Urine may be stored at room temperature for 1 hour or may be refrigerated for up to 72 hours.
D. In acute, uncomplicated cystitis (nonpregnant woman), use dipstick if the patient’s sample is positive for both nitrates and leukocyte esterase or if microscopic examination of urine shows an increase in WBCs (10 in high-power field), consider treating presumptively
VI. DIFFERENTIAL DIAGNOSIS
A. Upper tract disease: pyelonephritis
B. Urethritis caused by
1. Chlamydia
2. Bacteria from urethral manipulation causing irritation; thought to be early cystitis
C. Vaginitis
D. PID
E. STI
F. IC
G. No recognized pathology (honeymoon cystitis)
H. Pregnancy
I. Hormonal urethral changes: perior postmenopause
J. Urologic cancer
K. Overactive bladder
VII. TREATMENT
A. Antibiotics
1. For the first episode of UTI in women without risk factors, institute treatment with any of the following, provided that the woman is not allergic to the drug.
a. Nitrofurantoin monohydrate/macrocrystals, trimethoprimsulfamethoxazole (TMP-SMX) (Macrodantin)—50 mg four times a day for 7 days and, depending on repeat culture results, possibly 25 mg four times a day for 7 more days or Macrobid 100 mg twice a day for 7 days
b. Beta-lactam antibiotics (including but not limited to penicillin, cephalosporin, monobactams, and carbapenems) may be used when other recommended agents cannot be used. Fosfomycin and nitrofurantoin monohydrate/macrocrystals should be avoided in patients with possible early pyelonephritis. Fluoroquinolones are typically reserved for complicated cystitis.
c. For uncomplicated first or second episodes, trimethoprim (160 mg) and sulfamethoxazole (800 mg); take two Septra DS or Bactrim DS STAT or one twice a day for 3 days; or trimethoprim 100 mg twice a day for 3 days
d. Cipro (ciprofloxacin HCl) 100 to 250 mg twice a day for 3 days; or ciprofloxacin extended release 500 mg once a day for 3 days; or Floxin (ofloxacin) 200 mg twice a day for 3 days; or gatifloxacin
400 mg once a day for 3 days or a single 400-mg dose; or Augmentum (amoxicillin 400 mg/clavulanic acid 125 mg) one twice a day for 3 days; or Noroxin (norfloxacin) 400 mg twice a day for 3 days; or Maxaquin (lomefloxacin) 400 mg once a day for 3 days (these drugs should be reserved for complicated UTIs and in areas where local resistance rates to TMP-SMX are high)
e. Monurol (fosfomycin) 3 g in a single dose mixed in 3 to 4 ounces of cold water (not recommended for patients younger than 18 years of age)
2. For reinfection or UTI in women without risk factors, treatment is the same as for the first episode. It is important to distinguish reinfection from relapse. Reinfection occurs within weeks to months of preceding episode and is often caused by a new organism. Relapse is a recurrence of symptoms and infection after finishing a medication course and is caused by the same organism as the original infection.
3. For relapse in women
a. Consider retreatment with same medication, with a test of cure 24 to 48 hours after the completion of medication
b. Consider change of medication with a test of cure 24 to 48 hours after the completion of medication
c. For second relapse, consult with a physician
4. For patients with risk factors (past history of pyelonephritis, known urinary tract abnormality, use of catheter, diabetes), consider referral to a physician
B. For pregnant women
1. The causative pathogen in pregnant women is usually E. coli. Do culture before treatment; do sensitivity only if no improvement from medication.
a. First choice: ampicillin 250 mg four times a day for 10 days (caution of increasing antibacterial resistance among urinary E. coli)
b. Second choice: nitrofurantoin (Macrodantin) or Macrobid (pregnancy category B); note caution for use near time of labor and delivery
c. In areas with high resistance of E. coli, consider fosfomycin (pregnancy category B)
d. Do not use sulfa, Septra, or Bactrim (trimethoprim), or ciprofloxacin (pregnancy category C)
C. Pain relief: phenazopyridine hydrochloride (Pyridium, AZO Standard, Baridium, diazo, Phenazo, Urodine) 200 mg three times a day for 24 hours; Uristat (phenazopyridine HCl 95 mg) two tablets three times a day for no more than 2 days (available over the counter; not recommended in pregnancy)
D. General measures
1. Advise voiding before and after sex
2. Advise adequate lubrication for sex
3. Teach about hygiene, contamination
4. Treat as mentioned previously (see Urinary Tract Infection, Treatment, VII.A) if bacteria are present
5. Consider treatment with Pyridium, AZO Standard, Uristat, or other such product only if the patient is symptomatic in the absence of pathogenic organism
6. Cranberry juice; 6 to 8 glasses of water a day; cranberry juice capsules; AZO 450 mg cranberry juice concentrate one to four capsules per day with meals; CranXact urinary formula (tannins in cranberries prevent E. coli from attaching to urinary tract)
7. Decrease bladder irritants such as caffeine, smoking, and artificial sweeteners
8. Wear cotton underwear; avoid tight-fitting garments
9. Consider topical or vaginal estrogen as adjunct therapy in postmenopausal woman with recurrent cystitis
VIII. COMPLICATIONS
A. Pyelonephritis
IX. CONSULTATION/REFERRAL
A. Consider physician consult for
1. Women with relapsed infections
2. Women who are symptomatic after 3 days of treatment
3. Women who have more than three episodes in a year
4. Complicated UTIs
5. Pregnant women, especially those who are close to term
X. FOLLOW-UP
A. Follow-up culture if symptoms do not resolve after treatment
B. Consider test of cure up to 1 week after completion of medication
Appendix I, Cystitis, may be photocopied or adapted for your patients. See Bibliographies.