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 urethral meatus. Because it is usually difficult to determine the exact location of the infection, the term UTI is used to explain microorganisms anywhere within the urinary tract. The greatest incidence 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 the first year of life and steadily declines through adolescence, but remains higher than the incidence for males at a rate of 10:1. DEFINITIONS A urinary tract infection (UTI) is defined as a bacterium that exists anywhere between the 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% in girls(1). The incidence varies with age. During the first year of life, the male to female ratio is 3-5:1. Beyond 1-2 years, there is female preponderance with male to female ratio of 1:10. <1 year M : F, 2.85.4 : 1 >1 year M : F, 1 : 10 st In girls, 1 episode of UTI occurs during infancy and 2nd after 18 months In boys, 1st episode of UTI occurs during infancy and more in uncircumcised males

ETIOLOGY - E. Coli (75-90% ) , (female) - Klebsiella - Proteus, ( male) - Pseudomonas - Enterobacter

- 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 in a host without underlying renal, metabolic, or neurologic diseases. Cystitis represents bladder mucosal 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 the development 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 of urea, and the presence of organic acids derived from a diet that includes fruits and protein. Organic acids enhance acidification of the urine.

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 present are removed by the mucosal cell production of organic acids. If the defense mechanisms of the lower urinary tract fail, upper tract or kidney involvement occurs and is termed pyelonephritis. Host defenses at this level include local leukocyte phagocytosis and renal production of antibodies that kill bacteria in the presence of complement. 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, poor feeding, irritability and weight loss Pyelitis / Pyelonephritis (2) Cystitis Dysuria, urgency, frequency, suprapubic pain, incontinence, and malodorous urine. No fever 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 tract infections( 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 urinary infection

(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 AGES NEONATAL 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

 DIAGNOSIS

Growth failure Excessive thirst Enuresis Painful urination Swelling of face Seizures Pallor Fatigue Blood in the urine Abdominal or back pain Edema Hypertension Tetany

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 indicative o 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 o o o o X-ray KUB Normal kidney length total width of L1 L4 vertebrae USG Details of kidney, ureter, bladder, major blood vessels - Hydronephrosis, perirenal abscess, pyonephrosis, renal scar(30%) - Insensitive in identifying reflux ( 40% )

VCUG < 5 yrs with UTI All children

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

1. 2. 3. 4.

To eliminate the current infection To identify the contributing factors to reduce the risk of recurrence To prevent symptomatic spread of infection To preserve the renal function

Antibiotic therapy should be initiated on the basis of identification of the pathogen,childs history 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 Tract Infection DRUG ADVERSE EFFECTS NURSING CONSIDERATIONS Amoxicillin Occasional nausea, Readily absorbed. (Amoxil) vomiting, diarrhea May be taken with food. Hypersensitivity reactions of skin Ampicillin (Omnipen)

Diarrhea, urticaria Anaphylactic reaction

Contraindicated in penicillin-sensitive children. Package insert should be consulted regarding reconstitution, administration, and storage of I.M. and I.V. preparations. Absorption of oral preparations may be decreased with food. Dose must be repeated q6h to ensure therapeutic blood levels. May be taken with food. Dose should be reduced if renal function is impaired. Toxic effects can be minimized by slow I.V. infusion (over 1 hour).

Cephalexin (Keflex) Gentamicin (Garamycin)

Diarrhea, nausea, vomiting Renal and auditory toxicity; respiratory paralysis Fever, nausea, vomiting, peripheral neuropathy

Nitrofurantoin (Macrodantin, Furadantin)

Recommended for prolonged use. Give with food or milk to decrease GI adverse effects. May cause urine to be amber or brown in color. Contraindicated in renal failure and in infants younger than age 3 months. Commonly used if bacterial resistance is

Co-trimoxazole

Nausea, vomiting,

(Bactrim, Septra)

fever, rash, photosensitivity

anticipated or the child fails to respond to initial 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 identify those with an underlying urinary tract anomaly. If anatomical defects such as primary reflux 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 all children with recurrent UTI.

NURSING MANAGEMENT NURSING ASSESSMENT

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

Focus assessment on identifying clinical manifestations and determining location of infection, such as presence and appearance of urethral discharge, high-grade fever (more common 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 of additional 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 been obtained for culture). o Antibiotic therapy is generally determined by the results of the urine cultures and sensitivities 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 child regularly for any of the signs and symptoms.

2.Acute Pain related to inflammatory changes and feveras evidenced by feacial expression and 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 is the best clear fluid.) Administer I.V. fluids if necessary.

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

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 temperature is 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 concerns about the functioning of the urinary tract and sexual function. Reassure the child that he or 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 in female 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.

PROGNOSIS Even with effective antibiotic treatment, the average duration of severe symptoms in women with 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, urinary frequency, and more severe symptoms at baseline.[10] . Although simple lower UTI (cystitis) may resolve spontaneously, effective treatment lessens the duration of symptoms and reduces the incidence of progression to upper UTI. Even with effective 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,6th edition,saunders publications,page no.923-924 Datta Parul(2009),pediatric nursing ,2nd edition,Jaypee brothers medical publishers,365 Hockenberry J Marlin,Wongs essentials of pediatric nursing,7th edition,Elsevir publishers,page no:989-992 Chowdhary Balram(2008),Pediatric lecture Notes ,Peepee publications,page no 405-409

PRESENTATION ON URINARY TRACT INFECTION

Submitted 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