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Urinary Tract Infections:

Contemporary Management
David D. Rahn

nfections of the upper and

lower urinary tract account
for more than 6 million
office visits per year in the
U.S., costing more than $2.5 billion annually (Griebling, 2005;
Karram & Siddighi, 2008; National Center for Health Statistics,
1977). Since 50% to 60% of
women report at least one urinary
tract infection (UTI) in their lifetime, UTIs have become a common condition diagnosed and
treated by gynecologists, urologists, and other health care
providers for women (Foxman,
2002). This article will review the
epidemiology of UTIs, the pathophysiology of this disease, the
appropriate clinical and laboratory investigation, current treatment recommendations and algorithms, and the management of
UTIs in different clinical scenarios, including catheter-associated
infections, infection during pregnancy, and acute pyelonephritis.
Definitions and Epidemiology
Cystitis refers to any inflammatory condition of the bladder.

David D. Rahn, MD, FACOG, is an

Assistant Professor, Department of
Obstetrics and Gynecology, Division of
Female Pelvic Medicine and Reconstructive
Surgery, University of Texas Southwestern
Medical Center, Dallas, TX.
Note: This review was presented at the
SUNA 2008 Annual Symposium in Tampa,
FL.

Urinary tract infections (UTIs) are an increasingly prevalent problem

for women. The diagnosis and management of uncomplicated acute
cystitis is relatively straightforward, while complicated and recurrent
infections require more specialized assessment and treatment. This
article will review the current management of UTIs.
Key Words: Urinary tract infections, cystitis, epidemiology, pathophysiology,

diagnosis, treatment, prophylaxis, management, bacteruria.

Objectives
1. Define cystitis.
2. Discuss the evaluation and diagnosis of UTIs.
3. Identify several treatments for patients with UTIs.
This definition may simply be a
clinical diagnosis in the setting of
irritative voiding symptoms and
dysuria. When infectious in etiology, cystitis will often refer to a
bacteriologic finding from a urine
culture, but cystitis may also be
based on histologic or cystoscopic findings. Non-bacterial cystitis
may occur after radiation exposure or in a disease known as
interstitial cystitis, which by definition, has sterile urine (Karram &
Siddighi, 2008). Complicated infections refer to those which occur
concomitant with the conditions
listed in Table 1, such as UTIs in
men, patients with diabetes mellitus, women who are pregnant,
relapsing or recurrent infections,

hospital-acquired infection, or
UTIs commensurate with indwelling catheters or recent urinary tract instrumentation. UTIs
not fitting into one of these scenarios are commonplace and are considered uncomplicated (Johnson
& Stamm, 1987).
Other definitions relevant to
the topic of UTI include urethritis, trigonitis, bacteriuria, and
urethral syndrome. Urethritis
indicates inflammation of the
urethra; in women, this is clinically indistinguishable from cystitis. Trigonitis refers to a localized hyperemia of the bladder
trigone. Bacteriuria denotes the
presence of bacteria in the urine.
A UTI may be diagnosed when as

Urologic Nursing Editorial Board Statements of Disclosure

Christine Bradway, PhD, RN, disclosed that she is on the Consulting Board for Boehringer
Ingelheim Pharmaceuticals, Inc.
Kaye K. Gaines, MS, ARNP, CUNP, disclosed that she is on the Speakers Bureau for Pfizer,
Inc., and Novartis Oncology.

Note: The author reported no actual or

potential conflict of interest in relation to this
continuing nursing education article.

Susanne A. Quallich, ANP,BC, NP-C, CUNP, disclosed that she is on the Consultants
Bureau for Coloplast.

Note: Objectives and CNE Evaluation Form

appear on page 342.

All other Urologic Nursing Editorial Board members reported no actual or potential conflict
of interest in relation to this continuing nursing education article.

UROLOGIC NURSING / October 2008 / Volume 28 Number 5

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Table 1.
Complicated Urinary Tract Infections
Men
Patients with diabetes mellitus
Pregnant women
History of UTI in childhood
History of acute pyelonephritis in past year
Documented relapsing UTI in past year
Greater than or equal to 3 UTIs in past year
Uropathogen with multiple drug resistance
Hospital-acquired UTI
Indwelling urethral catheter
Recent urinary tract instrumentation
Functional or anatomic abnormality of the urinary tract
Recent antimicrobial treatment (within past month)

few as 102 colony forming units

of bacteria per milliliter (cfu/mL)
are found in a symptomatic
patient. Asymptomatic bacteriuria refers to greater than 105
cfu/mL in a patient without complaints consistent with a UTI
(Norden & Kass, 1968; Stamm et
al., 1982). Finally, urethral syndrome is a term that has been
ascribed to patients with urinary
frequency, urgency, dysuria,
suprapubic discomfort, voiding
difficulties, and pyuria (white
blood cells in the urine) but in
the absence of organic pathology
(for example, negative urine cultures) (Maskell, 1974; Maskell,
Pead, & Allen, 1979).
UTIs are mostly found in
women, occurring in an 8:1 ratio
in women to men (Cox, Lacy, &
Hinman, 1968). Aside from being
common in the community, 2% of
hospitalized patients acquire
UTIs, accounting for more than
500,000 nosocomial infections
per year (Mayer, 1980; Turck &
Stamm 1981). There are at least
100,000 annual hospitalizations
for renal infections, which are
usually the result of ascending
infection from the lower urinary
tract. Beginning at about 1 year of
age, there is only about a 1%
infection rate until puberty.

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Table 2.
Most Common Urinary Isolates from Outpatient
Urinary Tract Infections North American Urinary
Tract Infection Collaborative Alliance (NAUTICA)
Escherichia coli (57.5%)
Klebsiella pneumoniae (12.4%)
Enterococcus spp. (6.6%)
Proteus mirabilis (5.4%)
Pseudomonas aeruginosa (2.9%)
Citrobacter spp. (2.7%)
Staphylococcus aureus (2.2%)
Enterobacter cloacae (1.9%)
Coagulase-negative staphylococci (1.3%)
S. saprophyticus (1.2%)
Other Klebsiella spp. (1.2%)
Enterobacter aerogenes (1.1%)
Streptococcus agalactiae (1.0%)

Bacteriuria is found in 2% to 3%
of women 15 to 24 years of
age, 20% in women 65 to 80
years, and 25% to 50% in
women greater than 80 years
(Mulholland, 1986). The U.S.
population of women greater than
65 years of age is projected to double between 2000 and 2030,
increasing to more than 40 million women (U.S. Census Bureau,
2008). Therefore, one may anticipate that UTI diagnoses will
increase in coming years.
Pathophysiology
Approximately 80% of the
bacteria isolated in UTIs are
gram-negative bacilli from the
large family Enterobacteriaceae.
These include Escherichia coli,
Klebsiella, Enterobacter, Proteus,
and Serratia. Another gram-negative bacteria, Pseudomonas, and
many gram-positive bacteria
(Staphylococcus epidermidis, S.
aureus, S. agalactiae, S. saprophyticus, and Enterococcus) are
other common pathogens (Echols,
Tosiello, Haverstock, & Tice, 1999;
Hooton, Besser, Foxman, Fritsche,
& Nicolle, 2004). Less common
pathogens include anaerobic bacteria as well as yeast, trematodes,
and tapeworms (Nash, Cheever,

Ottesen, & Cook, 1982). A recent

study of nearly 2,000 outpatient
urinary isolates sampled from 41
centers from various geographic
regions in the U.S. and Canada
presented the most common urinary pathogens (see Table 2)
(Zhanel et al., 2005).
Urinary tract infections may
rarely result from hematogenous
or lymphatic spread of an existing
infection elsewhere in the body,
but the most common route is an
infection ascending from vaginal/perineal or perianal areas.
This likely explains the markedly
higher rate of infection in women
compared with men (Cox et al.,
1968).
There are many host defenses
to the development of a UTI. First,
urine is high in osmolality and
low in pH due to high concentrations of urea and organic acids
(Kaye, 1968). Second, vaginal,
periurethral, and perineal colonization by gram-positive bacteria, diphtheroids, and lactobacilli,
and the normally acidic vaginal
pH (4.0 in healthy premenopausal
women) inhibit migration of
microorganisms from the rectum
to the bladder (Stamey, 1980).
Third, normal periodic voiding
limits the ability of bacteria to
reach concentrations that are high

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enough in the bladder to establish
a significant infection, and glycosaminoglycans of the bladder
lining and Tamm-Horsfall proteins of the loop of Henle further
decrease bacterial adherence (Cox
& Hinman, 1961; Orskov, Ferencz,
& Orskov, 1980). The known risk
factors for the development of
UTIs generally involve a breakdown in these protective barriers.
The physiologic changes
associated with menopause result in decreased vaginal glycogen and an increase in pH. It has
been found that intravaginal
estrogen replacement in postmenopausal women results in
reappearance of normal lactobacilli and a reacidification,
with a decrease in uropathogen
growth and decreased incidence
of UTIs (Jackson et al., 2004; Raz
& Stamm, 1993).
Any condition that results in
inefficient bladder emptying and
stagnant urine in the bladder
increases the likelihood of infection, including uterovaginal prolapse or cystocele with obstructive voiding; neurogenic bladder
as in patients with diabetes mellitus, multiple sclerosis, and
spinal cord injuries; and anticholinergic medications, which
are frequently prescribed for
symptoms of overactive bladder.
Other risk factors include
decreased functional ability, as
found in patients with dementia,
cardiovascular accidents, neurologic deficits, and fecal incontinence (Karram & Siddighi, 2008).
Systemic factors may also
include diabetes mellitus, severe
vascular disease, gouty nephropathy, sickle cell trait, and cystic
renal disease (Jackson et al.,
2004). Sexual intercourse, especially when in combination with
diaphragm and spermicide use,
increases the likelihood of infection (Fihn et al., 1996, 1998;
Hooton, Fennell, Clark, & Stamm,
1991; Hooton et al., 1996).
Interestingly, some women appear
to be more genetically predisposed to infection; there is a
greater risk of infection in

women with type B or AB blood,

and recurrent UTIs correlate with
women bearing the human
leukocyte antigen A3 subtype
(Lomberg et al., 1986; Stapleton,
Nudelman, Clausen, Hakomori,
& Stamm, 1992).
Bacteria have developed different means by which to overcome host defenses. The best
studied of the bacterial virulence
mechanisms are adhesins on
bacterial surfaces and fimbriae,
also known as pili. These
adhesins enhance the ability of
bacteria to adhere to mucosal
cells of the bladder lining while
bacterial motility is enhanced via
flagellae (Bryan, Sutcliffe, &
McGee, 1973; Lane & Mobley,
2007; Servin, 2005; Vaisanen et
al., 1981). Other virulence factors
include the ability of some bacteria to produce hemolysins and
colicin V, while Proteus produces
urease, which can ultimately contribute to the formation of struvite
stones (Mobley, Island, & Massad,
1994). Multiple drug resistant
bacteria are increasingly being
observed in urinary isolates
from community-dwelling women
across North America (Zhanel et
al., 2005).
Evaluation
Clinical Presentation
A UTI may present with
diverse symptoms and signs. The
most common complaints are
acute painful voiding (dysuria),
urinary frequency and urgency,
nocturia, and suprapubic discomfort. Mild incontinence, hematuria, and systemic symptoms
may be reported. On average, a
UTI results in 6.1 days of symptoms, 2.4 days of decreased activity, 1.2 days of lost time at work or
school, and 0.4 days in bed
(Foxman, 2002). A progression to
upper tract infection should be
suspected when the patient also
reports fever, chills, malaise,
nausea and vomiting, and flank
pain. On examination, it is
important to note the patients

UROLOGIC NURSING / October 2008 / Volume 28 Number 5

temperature and to document the

abdominal examination and
presence or absence of costovertebral angle tenderness. Depending on the patients complaints, a pelvic examination is
required to evaluate for vaginitis
or cervicitis.
Laboratory Diagnosis
When a UTI is suspected by
history, the initial laboratory
evaluation is often an office urine
kit, a dipstick. The gold standard for urine specimen collection is suprapubic aspiration, but
this typically is not necessary nor
well-tolerated by patients for the
assessment of most UTIs (Stamm
et al., 1980). The next most preferred method of urine collection
is a midstream clean catch; this
requires local disinfection followed by spreading the labia or
holding back the foreskin and
then collecting a midstream
urine specimen in a sterile cup.
In patients unable to negotiate a
clean midstream collection,
transurethral catheterization is
permissible. For most office dipsticks, the presence of nitrites
provides the most useful information. In order to have nitrites
in the urine, bacteria with nitrate
reductase must be present (for
example, some E. coli and
Proteus), and there must be
dietary nitrate to convert. This
test is very specific (92% to
100%) but not too sensitive (only
25%). False positives may occur
when the urine is turned red, as
with beets or phenazopyridine.
Leukocyte esterase is an enzyme
present in neutrophil granules.
The sensitivity of this test is
directly related to bacterial load
(75% to 96%) and is very specific (94% to 98%) (Pappas, 1991;
Rahn, Boreham, Allen, Nihira, &
Schaffer, 2005).
Urine microscopy is then
generally performed on an uncentrifuged specimen. In an
uncontaminated specimen, there
are few epithelial cells. Pyuria
(literally, pus in the urine) means
there are more than 10 white

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blood cells per microliter (or
10,000 per milliliter); the presence of pyuria is 80% to 95%
sensitive and 50% to 75% specific for an infection (Stamm, 1983;
Wilson & Gaido, 2004). The
absence of pyuria strongly suggests a non-infectious cause with
the caveat that in pregnancy, the
presence of pyuria is less sensitive for infection. In the setting of
an infection with less than 104
cfu/mL, observing one or more
bacteria on a gram-stained specimen correlates highly with the
presence of a UTI, having a sensitivity of 80%, specificity of 90%,
and positive predictive value of
85% (Fihn & Stamm, 1983).
The urine culture is often not
necessary in the treatment of an
uncomplicated infection. It may
be collected as a screening tool if
the dipstick and urinalysis are
inconclusive, in settings of recurrent infection, prior infection
unresolved with antibiotics, or if
there are signs or symptoms of an
upper tract infection. The traditional interpretation of urine cultures is that it is positive for an
infection when greater than 105
cfu/mL are present. However,
46% of women with symptomatic
UTIs have just 102 to 104 cfu/mL;
therefore, a newer interpretation
would be to deem a symptomatic
woman with greater than 102
cfu/mL as positive (Kunin, White,
& Hua, 1993). This distinction is
not made by all laboratories, so it
is important to know the local
reporting practice of ones diagnostic laboratory.
Differential Diagnosis
Most patients presenting with
acute dysuria will have a UTI, but
other diagnoses should be entertained. The presence of pyuria is
not entirely specific for a UTI.
White blood cells in the urine
may also be noted in women with
vaginitis, urethritis, or with certain sexually transmitted diseases.
Patients need to be asked about
vaginal discharge, odor, and associated dyspareunia. Appropriate
testing should be undertaken to

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diagnose Trichomonas, candidiasis, Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus.
In patients with dysuria but
without pyuria, the differential
diagnosis includes trauma related to intercourse, estrogen deficiency, interstitial cystitis, or an
irritant urethritis. Irritation may
commonly occur with the use of
a new contraceptive gel, condom,
or tampon (Bergman, Karram, &
Bhatia, 1989; Karram & Siddighi,
2008).
Imaging
To a limited extent, certain
imaging modalities may be useful
in the diagnosis and assessment of
UTIs. For patients with recurrent
or persistent UTIs or in patients
with asymptomatic microscopic
hematuria, cystourethroscopy is
used to evaluate the lower urinary
tract for pathology, such as stones,
diverticulae, polyps, cancer, or
anatomical abnormalities. Cystitis
may appear as diffuse inflammation throughout the bladder with
erythematous, non-raised lesions,
or multiple small clear cysts after
a resolved UTI known as cystitis
cystica (Engel, Schaeffer, Grayhack, & Wendel, 1980).
Evaluation of the upper urinary tract via intravenous pyelogram or computed tomography is
indicated when there has been a
history of prior upper tract infections, a history of childhood
infections, or when there is
recurrent infection caused by the
same organism. For instance,
urea-splitting organisms, such as
Proteus, are often associated with
infected stones. These studies are
also appropriate in the evaluation of painless hematuria, with a
history of prior stones or ureteral
obstruction, and in rapidly recurrent infections. When one specifically wants to assess for the
presence of a urethral diverticulum, most authors recommend
magnetic resonance imaging
or a voiding cystourethrogram
(Karram & Siddighi, 2008).

Treatment
General Measures, Initial or
Uncomplicated Infections
For the patient with an
uncomplicated acute UTI, preliminary interventions may include
rest and hydration (Pollen, 1995).
Short-term use of urinary analgesics is often helpful with agents
such as phenazopyridine (Pyridium) and urised (Urisept).
Pyridium should be avoided in
patients who are allergic to sulfa.
(Amit & Halkin, 1997). There is
some evidence that cranberry
juice or its extract may be protective in developing cystitis via
decreasing bacterial adherence
(Schmidt & Sobota, 1988; Sobota
1984).
Ultimately, antibiotics will be
required. The ideal medication
would have a higher concentration in the bladder than in other
tissues, in particular, the vagina
and bowel. Some commonly prescribed medications do adversely
affect the normal vaginal flora.
Ampicillin results in 25% of
patients developing a yeast vaginitis; tetracycline results in 80%
yeast vaginitis. However, nitrofurantoin (Macrobid) has no significant serum level and excellent
activity against E. coli. Trimethoprim/sulfamethoxazole (TMPSMX) (Bactrim, Septra) has only
a moderate effect on bowel and
vaginal flora, and has the benefit
of BID dosing, but up to 39% of E.
coli are resistant to the medication
in community-acquired UTIs
(Gupta, Sahm, Mayfield, & Stamm,
2001; Kahlmeter, 2000).
With respect to specific medications, nitrofurantoin has been
well studied. It has been used for
several decades and is generally
well tolerated. There is a low
level of resistance among E. coli
and gram-positive cocci and
many gram-negative bacteria. It
is inactive against most Proteus,
some Enterobacter, and some
Klebsiella. This medication still
requires a 7-day treatment
course; when comparing the 3day regimens, TMP-SMX is more

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effective than 3-day nitrofurantoin (Hooton, Winter, Tiu, &
Stamm, 1995; Katchman et al.,
2005; Norrby, 1990).
Quinolone derivatives (such
as ciprofloxacin [Cipro]) are
very effective for gram-negative
bacteria, with expanded coverage
against P. aeruginosa and grampositive bacteria. Some of the
antibiotics in this family are
available in intravenous form.
High cost often limits routine use
of this class, and bacterial resistance is increasing (Andriole,
1991). Quinolones are inappropriate in women who are pregnant, nursing mothers, and in
adolescents less than 18 years
old. Women who may become
pregnant should consider contraceptive use concomitant with
quinolone antibiotics.
When treating a first UTI or
infrequent reinfection, 3-day
antibiotic regimens have been
shown to be superior to singledose regimens and are usually
equally as effective as 7-day regimens with fewer side effects and
better compliance (Hooton et al.,
1995; Katchman et al., 2005).
Single-dose regimens have a
higher treatment failure rate and
are less likely to be effective if
there is an undiagnosed complicating factor, such as diabetes
mellitus, pregnancy, or an
anatomical abnormality. This
single dose type of treatment is
also suboptimal in the setting of
an occult upper tract UTI.
Ideally, one will have knowledge
of the local susceptibility profile
of the communitys common
pathogens and use this to tailor
empiric treatment decisions. An
initial treatment of TMP-SMX for
3 days is recommended for
patients with an uncomplicated
UTI if there is no allergy to sulfa
medications and if local E. coli
resistance is not greater than
20% (Hooton et al., 2004). Next, a
fluoroquinolone is used for
patients allergic to TMP-SMX, if
there is significant TMP-SMX
resistance, in cases of complicated cystitis, or if patients have

Table 3.
Sources of Bacterial
Persistence and Relapsing
Infection
Urethral diverticulum
Infected stone
Significant cystocele
Foreign body
Papillary necrosis
Duplicated or ectopic ureter
Atrophic pyelonephritis (unilateral)
Medullary sponge kidney

moderate to severe symptoms.

Finally, nitrofurantoin (7-day)
may be used as a fluoroquinolone
sparing agent for patients with
mild to moderate symptoms who
are allergic to TMP-SMX, or if
the community is at risk for significant TMP-SMX resistance
(Hooton et al., 2004).
Recurrent Infection
Recurrent infection refers to
women with three or more culture-documented infections in a
year, or two or more in six
months (Schaffer, 2004). Of
women who develop UTIs, 22%
have recurrent infections. The
urine culture and sensitivity is
helpful for documenting whether
the recurrence is a relapse of the
same bacteria versus a reinfection with a different strain.
Relapse occurring after an appropriate course of antibiotics, especially if the relapse occurs within
2 weeks, warrants a more thorough investigation of the upper
and lower urinary tracts. For
example, one may rule out an
infected stone. Other sources
contributing to relapse are listed
in Table 3 (Karram & Siddighi,
2008). Re-infection with a new or
different strain of bacteria almost
always indicates a new ascending infection. The appropriate
management of recurrent infections is to first obtain sterile
urine. Then, the patient is
encouraged to change behaviors
that may contribute to reinfection;

UROLOGIC NURSING / October 2008 / Volume 28 Number 5

for instance, spermicides and

diaphragms should be discontinued in favor of alternative contraception. Patients should also void
after coitus, try liberal fluid intake,
and perhaps initiate drinking cranberry juice (Schmidt & Sobota,
1988; Sobota, 1984). Thereafter,
three options exist for antibiotic
prophylaxis; these are continuous
prophylaxis, postcoital prophylaxis, or self-start (patient-initiated)
therapy (Foxman, 1990; Nicolle &
Ronald, 1987).
Prophylaxis
Continuous prophylaxis is
the recommended initial therapy
for recurrent UTIs (Nicolle &
Ronald, 1987). The most common options are for nitrofurantoin 100 mg, cephalexin (Keflex)
250 mg, or TMP-SMX 1 tablet
every night for 6 months. These
therapies are cost effective. After
6 months of therapy, patients
may be frequently re-cultured as
necessary. Postcoital prophylaxis
involves the administration of a
single antimicrobial tablet before
or after intercourse (Stapleton,
Latham, Johnson, & Stamm,
1990). In 135 sexually active perimenopausal women, post-coital
therapy was as effective as daily
prophylaxis but required only
one-third the amount of drug
(Melekos et al., 1997). As noted
above, patients using diaphragms
and spermicides should be
encouraged to try alternative
means of contraception. Finally,
self-start therapy may be considered for motivated, compliant
patients who have good relationships with their providers.
Patients generally submit a urine
culture at the outset of symptoms
and then start an empiric 3-day
antibiotic regimen. Patients
should be notified to call their
provider if symptoms have not
improved within 48 hours
(Gupta, Hooton, Roberts, &
Stamm 2001).
As a final caveat, infections in
post-menopausal women with
recurrent UTIs should be treated,

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but appropriate patients should
also be started on vaginal estrogen
replacement. A randomized controlled trial of 93 women with
recurrent infections demonstrated
that those women who received
topical intravaginal estrogen significantly reduced the incidence
of UTI compared to women using
a placebo (0.5 versus 5.9 episodes
per patient year, respectively)
(Raz & Stamm,1993).
Other Clinical Scenarios
Asymptomatic Bacteriuria
Asymptomatic bacteriuria
(ASB) is diagnosed when two
consecutive urine cultures grow
greater than 105 cfu/mL in
patients without the symptoms
of an acute UTI. Studies have
demonstrated that treatment is
generally not required in these
patients, and there is no
increased risk of permanent renal
injury or sepsis. There are exceptions, however. Women who are
pregnant, patients with infections involving Proteus, patients
with severe diabetes mellitus,
and men about to undergo
transurethral resection of the
prostate all require treatment in
the setting of ASB. ASB treatment is controversial but possibly indicated in the elderly and
before urodynamic testing, or
before other urologic procedures
during which mucosal bleeding
is anticipated (Nicolle et al.,
2005).
Catheter Associated Infections
UTIs related to indwelling
transurethral catheters are the
most common cause of hospitalacquired infection. The first priority in catheter care and management should be aseptic technique in an attempt to avoid subsequent infection. Table 4 lists
these guidelines; they include
avoiding unnecessary catheterization, removing the catheter as
soon as possible, and anchoring
the catheter to the thigh to avoid
traction against the urethra

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Table 4.
Guidelines for Aseptic Care of a Urinary Catheter
Avoid unnecessary catheterization and remove catheter as soon as possible.
After sterile insertion, anchor catheter to prevent urethral traction.
Monitor urine level in bag q 4 hour; exchange catheter if cessation of flow for > 4 hours
Fluid intake of 1.5 L or more per day.
Avoid catheter manipulation.
Exchange catheter if infection suspected.

(Cravens & Zweig, 2000). For

patients who require long-term
indwelling catheters, bacteriuria
is virtually inevitable. As in other
patients with ASB, if these
catheterized patients have no
local or systemic signs or symptoms of infection, antibiotic treatment is not required. In patients
with symptoms of infection,
urine culture is the best means of
diagnosing a UTI. Ideally, the
urine specimen should be
retrieved using a fresh catheter. If
this is not possible, urine should
be aspirated directly from the
catheter and never from the collection bag. The treatment regimen should be a 10 to 14-day
course of antibiotics based on the
culture and sensitivity results,
and a fresh catheter (or intermittent self catheterization) should
be used while the infection is
clearing (Niel-Weise & van den
Broek, 2005; Tenney & Warren,
1988; Trautner & Darouiche,
2004; Shah, Cannon, Sullivan,
Nemchausky, & Pachucki, 2005).
Some authors argue for a routine
exchange of the catheter every 8
to 12 weeks in an attempt to prevent infection.
Pregnancy
During pregnancy, there are
many physiologic changes that
occur that predispose a woman
to UTI and to progression of a
UTI or ASB to pyelonephritis.
Hormonal effects, largely due to
progesterone, of pregnancy include ureteral dilation, and sluggish peristalsis. Vesicoureteral
reflux may also occur, and the
enlarging uterus causes external
compression of the ureters with

particularly the right ureter being

affected due to dextro-rotation of
the uterus. During pregnancy, the
bladder mucosa is hyperemic
and edematous. All of these
changes contribute to common
urinary complaints during pregnancy, such as frequency, nocturia, and incontinence (Beydoun,
1985; Francis, 1960; Heidrick,
Mattingly, & Amberg, 1967;
Mattingly & Borkowf, 1978; Thorp
et al., 1999).
Bacteriuria develops in 2%
to 7% of pregnancies; if left
untreated, women who are pregnant have a greater propensity to
progress to pyelonephritis (40%).
These infections are associated
with increased risk of preterm
birth, low birth weight, and perinatal mortality (Naeye, 1979).
Cystitis treatment requires a 7day course of either penicillin/
cephalosporin or nitrofurantoin.
TMP-SMX is avoided in the first
trimester because TMP is a folic
acid antagonist, and it should also
be avoided at term because sulfonamides can displace bilirubin
causing kernicterus in the newborn. TMP-SMX is acceptable and
effective in the second trimester.
Quinolones and tetracyclines are
contraindicated in pregnancy. If a
pregnant woman with cystitis
develops a fever or flank pain,
pyelonephritis should be presumed. Most authors recommend
admission for intravenous antibiotic therapy followed by antibiotic suppression for the remainder
of the pregnancy (Kass, 1960;
Patterson & Andriole, 1997;
Sweet, 1977; Vazquez & Villar,
2000).

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Acute Pyelonephritis
The diagnosis of pyelonephritis is suspected when
patients present with flank pain,
nausea and vomiting, fever
greater than 38 degrees Celsius,
and/or costovertebral angle tenderness. Patients may or may not
also have classic cystitis symptoms (Fairley et al., 1971). Acute
pyelonephritis accounts for
greater than 250,000 annual hospitalizations per year in the U.S.
(Stamm et al., 1989). In the diagnostic evaluation, urinalysis
reveals pyuria in virtually all
cases; blood cultures will be positive in 10% to 20% of cases. The
same pathogens observed in cystitis patients are responsible for
pyelonephritis.
The initial treatment decision is often whether these
patients require inpatient versus
outpatient management. Appropriate patients for hospital
admission include severely ill or
markedly debilitated patients,
patients with an uncertain diagnosis, women who are pregnant,
those unable to tolerate oral
intake, and those for whom there
is concern about compliance
with the prescribed antibiotic
regimen. Patients treated as outpatients must be available for
contact in 2 to 3 days to assure
symptoms are improving.
The empiric antibiotic choice
is typically an aminoglycoside or
a fluroquinolone (such as
ciprofloxacin 500 mg PO BID)
because these achieve high tissue
levels in the kidneys. Ampicillin
and sulfonamides should be
avoided because the level of
resistance is too high in most
communities. Patients need to
complete a 14-day regimen in
total, and antibiotics may be tailored once urine culture and sensitivity results are available
(Stamm, McKevitt, & Counts,
1987). A spiral-computed tomography scan or renal sonogram
should be considered to radiographically evaluate the upper
urinary tract in patients after 2
recurrences of pyelonephritis or

if the patient has any complicating factor (Warren et al., 1999;

Wyatt, Urban, & Fishman, 1995).
Summary
UTIs are a very prevalent
problem for women from puberty
through their postmenopausal
years, and the diagnosis will only
become more common as the
U.S. population ages. Acute cystitis is generally easily diagnosed
by a consistent constellation of
symptoms, including dysuria,
frequency, urgency, and suprapubic pain. In uncomplicated infections, urine culture (the gold
standard for diagnosing bacteriuria and cystitis) is often not
required because these UTIs
respond well to multiple available antibiotic regimens. Microscopic urinalysis with assessment for pyuria is often helpful
in narrowing the differential
diagnosis. For patients with complicated or recurrent infections,
however, urine culture is necessary because a relapsing infection of the same bacterial strain
may prompt further imaging of
the upper and lower urinary
tracts to detect other abnormalities. These patients often require
more rigorous regimens of antibiotic treatment, including longterm prophylaxis, postcoital therapy, or self-start therapy. Infections associated with transurethral catheterization or pregnancy require special attention
and management in order to prevent progression to pyelonephritis, which may be associated with significant morbidity.
References
Amit, G., & Halkin, A. (1997). Lemon-yellow nails and long-term phenazopyridine use. Annals of Internal
Medicine, 127, 1137.
Andriole, V.T. (1991). Use of quinolones
in treatment of prostatitis and lower
urinary tract infections. European
Journal of Clinical Microbiology &
Infectious Diseases, 10(4), 342-350.
Bergman, A., Karram, M.M., & Bhatia,
N.N. (1989). Urethral syndrome: A
comparison of different treatment
modalities. Journal of Reproductive
Medicine, 34(2), 157-160.

UROLOGIC NURSING / October 2008 / Volume 28 Number 5

Beydoun, S.N. (1985). Morphologic

changes in the renal tract in pregnancy. Clinical Obstetrics &
Gynecology, 28(2), 249-256.
Bryan, R.E., Sutcliffe, M.C., & McGee, F.E.
(1973). Human polymorphonuclear
leukocyte function in urine. Yale
Journal of Medicine, 46(2), 113-124.
Cox, C.E., & Hinman, F. (1961). Experiments
with induced bacteriuria, vesical emptying, and bacterial growth on the
mechanism of bladder defense to
infection. The Journal of Urology, 86,
739-748.
Cox, C.E., Lacy, S.S., & Hinman, F. (1968).
The urethra and its relationship to
urinary tract infection, II. The urethral flora of the female with recurrent urinary tract infection. The
Journal of Urology, 99, 632-638.
Cravens, D.D., & Zweig, S. (2000). Urinary
catheter management. American
Family Physician, 61(2), 369-376.
Echols, R.M., Tosiello, R.L., Haverstock, D.C.,
& Tice, A.D. (1999). Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis.
Clinical Infectious Diseases, 29(1), 113119.
Engel, G., Schaeffer, A.J., Grayhack, J.T., &
Wendel, E.F. (1980). The role of
excretory urography and cystoscopy
in the evaluation and management
of women with recurrent urinary
tract infection. The Journal of
Urology, 123, 190-198.
Fairley, K.F., Carson, N.E., Gutch, R.C.,
Leighton, P., Grounds, A.D., McCallum,
P.H., et al. (1971). Site of infection in
acute urinary tract infection in general
practice. The Lancet, 2, 615-618.
Fihn, S.D., Boyko, E.J., Chen, C.L.,
Normand, E.H., Yarbro, P., &
Scholes, D. (1998). Use of spermicide-coated condoms and other risk
factors for urinary tract infection
caused by Staphylococcus saprophyticus. Archives of Internal
Medicine, 158(3), 281-287.
Fihn, S.D., Boyko, E.J., & Normand, E.H.,
Chen, C.L., Grafton, J.R., Hunt, M., et
al. (1996). Association between use
of spermicide-coated condoms and
Escherichia coli urinary tract infection in young women. American
Journal of Epidemiology, 144, 512520.
Fihn, S.D., & Stamm, W.E. (1983).
Management of women with acute
dysuria. In D. Rund & B.W. Wolcott
(Eds.), Emergency medical annual
(pp. 2-225). Norwalk, CT: AppletonCentury-Crofts.
Foxman, B. (1990). Recurring urinary
tract infection: Incidence and risk
factors. American Journal of Public
Health, 80, 331-333.
Foxman, B. (2002). Epidemiology of urinary tract infections: Incidence,
morbidity, and economic costs.
American Journal of Medicine,
113(Suppl 1A), 5S-13S.

339

SERIES
Francis, W.J.A. (1960). Disturbances of
bladder function in relation to pregnancy. British Journal of Obstetrics
and Gynaecology, 67, 353-366.
Griebling, T.L. (2005). Urologic diseases in
America project: Trends in resource
use for urinary tract infections in
women. The Journal of Urology, 173,
1281-1287.
Gupta, K., Hooton, T.M., Roberts, P.L., &
Stamm, W.E. (2001). Patient-initiated
treatment of uncomplicated recurrent
urinary tract infections in young
women. Annals of Internal Medicine,
135(1), 9-16.
Gupta, K., Sahm, D.F., Mayfield, D., &
Stamm, W.E. (2001). Antimicrobial
resistance among uropathogens that
cause community-acquired urinary
tract infections in women: A nationwide analysis. Clinical Infectious
Diseases, 33(1), 89-94.
Heidrick, W.P., Mattingly, R.F., & Amberg,
J.R. (1967). Vesicoureteral reflux in
pregnancy. Obstetrics & Gynecology,
29(4), 571-578.
Hooton, T.M., Besser, R., Foxman, B., Fritsche,
T.R., & Nicolle, L.E. (2004). Acute
uncomplicated cystitis in an era of
increasing antibiotic resistance: A proposed approach to empirical therapy.
Clinical Infectious Diseases, 39(1), 75-80.
Hooton, T.M., Fennell, C.L., Clark, A.M., &
Stamm, W.E. (1991). Nonoxynol-9:
Differential antibacterial activity and
enhancement of bacterial adherence
to vaginal epithelial cells. The Journal
of Infectious Diseases, 164(6), 12161219.
Hooton, T.M., Scholes, D., Hughes, J.P.,
Winter, C., Roberts, P.L., Stapleton,
A.E., et al. (1996). A prospective study
of risk factors for symptomatic urinary tract infection in young women.
New England Journal of Medicine,
335(7), 468-474.
Hooton, T.M., Winter, C., Tiu, F., & Stamm,
W.E. (1995). Randomized comparative trial and cost analysis of 3-day
antimicrobial regimens for treatment
of acute cystitis in women. Journal of
the American Medical Association,
273(1), 41-45.
Jackson, S.L., Boyko, E.J., Scholes, D.,
Abraham, L., Gupta, K., & Fihn, S.D.
(2004). Predictors of urinary tract
infection after menopause: A prospective study. The American Journal of
Medicine, 117(12), 903-911.
Johnson, J.R., & Stamm, W.E. (1987).
Diagnosis and treatment of acute urinary tract infections. Infectious
Disease Clinics of North America,
1(4), 773-791.
Kahlmeter, G. (2000). The ECO.SENS
Project: A prospective, multinational, multicentre epidemiological survey of the prevalence and antimicrobial susceptibility of urinary tract
pathogens Interim report. Journal
of Antimicrobical Chemotherpy,
46(Suppl 1), 15-22.

340

Karram, M., & Siddighi, S. (2008). Lower

urinary tract infection. In A.E. Bent,
G.W. Cundiff, & S.E. Swift (Eds.),
Ostergardss urogynecology and
pelvic floor dysfunction (pp. 148169). Philadelphia: Lippincottt,
Williams and Wilkins.
Kass, E.H. (1960). Bacteriuria and
pyelonephritis of pregnancy. Archives
of Internal Medicine, 105, 194-198.
Katchman, E.A., Milo, G., Paul, M.,
Christiaens, T., Baerheim, A., &
Leibovici L. (2005). Three-day vs.
longer duration of antibiotic treatment for cystitis in women:
Systematic review and meta-analysis. American Journal of Medicine,
118(11), 1196-1207.
Kaye, D. (1968). Anitbacterial activity of
human urine. Journal of Clinical
Investigation, 47, 2374-2390.
Kunin, C.M., White, L.V., & Hua, T.H.
(1993). A reassessment of the importance of low-count bacteriuria in
young women with acute urinary
symptoms. Annals of Internal
Medicine, 119(6), 454-460.
Lane, M.C., & Mobley, H.L. (2007). Role of
P-fimbrial-mediated adherence in
pyelonephritis and persistence of
uropathogenic Escherichia coli
(UPEC) in the mammalian kidney.
Kidney International, 72(1), 19-25.
Lomberg, H., Cedergren, B., Leffler, H.,
Nilsson, B., Carlstrm, A.S., &
Svanborg-Edn, C. (1986). Influence
of blood group on the availability of
receptors for attachment of uropathogenic Escherichia coli. Infection &
Immunity, 51(3), 919-926.
Maskell, R. (1974). Importance of coagulase-negative Staphylococci as
pathogens in the urinary tract. The
Lancet, 1, 1155-1159.
Maskell, R., Pead, L., & Allen, J. (1979).
The puzzle of urethral syndrome: A
possible answer? The Lancet,
1(8125), 1058-1059.
Mattingly, R.F., & Borkowf, H.I. (1978).
Clinical implications of ureteral
reflux in pregnancy. Clinical
Obstetrics & Gynecology, 2193), 863873.
Mayer, T.R. (1980). UTI in the elderly:
How to select treatment. Geriatrics,
35, 67-77.
Melekos, M.D., Asbach, H.W., Gerharz, E.,
Zarakovitis, I.E., Weingaertner, K., &
Naber, K.G. (1997). Post-intercourse
versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women. The
Journal of Urology, 157, 935-939.
Mobley, H.L., Island, M.D., & Massad, G.
(1994). Virulence determinants of
uropathogenic Escherichia coli and
Proteus mirabilis. Kidney International,
47(Suppl.), S129-S136.
Mulholland, S.G. (1986). Controversies in
management of urinary tract infection. Urology, 27(Suppl), 3-8.

Naeye, R.L. (1979). Causes of the excessive rates of perinatal mortality and
prematurity in pregnancies complicated by maternal urinary-tract
infections. New England Journal of
Medicine, 300, 819-823.
Nash, T.E., Cheever, A.W., Ottesen, E.A.,
& Cook, J.A. (1982). Schistosome
infections in humans: perspectives
and recent findings. NIH conference.
Annals of Internal Medicine, 97(5),
740-754.
National Center for Health Statistics.
(1977). Ambulatory medical care
rendered in physicians offices.
United States 1975. Advanced Data,
12, 1-8.
Nicolle, L.E., Bradley, S., Colgan, R., Rice,
J.C., Schaeffer, A., Hooton, T.M., et
al. (2005). Infectious Diseases
Society of America guidelines for
the diagnosis and treatment of
asymptomatic bacteriuria in adults.
Clinical Infectious Diseases, 40(5),
643-654.
Nicolle, L.E., & Ronald, A.R. (1987).
Recurrent urinary tract infection in
adult women: Diagnosis and treatment. Infectious Disease Clinics of
North America, 1(4), 793-806.
Niel-Weise, B.S., & van den Broek, P.J.
(2005). Antibiotic policies for shortterm catheter bladder drainage in
adults. Cochrane Database Systematic
Review, 3, CD005428.
Norden, C.W., & Kass, E.H. (1968).
Bacteriuria of pregnancy A critical
appraisal. Annual Review of
Medicine, 19, 431-470.
Norrby, S.R. (1990). Short-term treatment
of uncomplicated lower urinary
tract infections in women. Review of
Infectious Disease, 12(3), 458-467.
Orskov, I., Ferencz, A., & Orskov, F.
(1980). Tamm-Horsfall protein or
uromucoid is the normal urinary
slime that traps type I fimbricated
Escherichia coli. The Lancet,
1(8173), 887-893.
Pappas, P.G. (1991). Laboratory in the
diagnosis and management of urinary tract infections. Medicine
Clinics of North America, 75(2), 313325.
Patterson, T.F., & Andriole, V.T. (1997).
Detection, significance, and therapy
of bacteriuria in pregnancy. Update
in the managed health care era.
Infectious Disease Clinics of North
America, 11, 593-608.
Pollen, J.J. (1995). Short-term course for
uncomplicated cystitis. Contemporary
Nurse Practitioner, 1, 21.
Rahn, D.D., Boreham, M.K., Allen, K.E.,
Nihira, M.A., & Schaffer, J.I. (2005).
Predicting bacteriuria in urogynecology patients. The American Journal
of Obstetrics & Gynecology, 192(5),
1376-1378.
Raz, R., & Stamm, W.E. (1993). A controlled trial of intravaginal estriol in
postmenopausal women with recur-

UROLOGIC NURSING / October 2008 / Volume 28 Number 5

SERIES
rent urinary tract infections. New
England Journal of Medicine,
329(11), 753-756.
Schaffer, J. (2004). Urinary tract infection.
In A.M. Weber, L. Brubaker, J.
Schaffer, & M.R. Toglia (Eds.), Office
urogynecology: Practical pathways
in obstetrics and gynecology (pp.
134-156). New York: McGraw-Hill.
Schmidt, D.R., & Sobota, A.E. (1988). An
examination of the anti-adherence
activity of cranberry juice on urinary
and nonurinary bacterial isolates.
International Microbiology, 55, 173181.
Servin, A.L. (2005). Pathogenesis of Afa/Dr
diffusely adhering Escherichia coli.
Clinical Microbiology Reviews, 18(2),
264-292.
Shah, P.S., Cannon, J.P., Sullivan, C.L.,
Nemchausky, B., & Pachucki, C.T.
(2005). Controlling antimicrobial
use and decreasing microbiological
laboratory tests for urinary tract
infections in spinal-cord-injury
patients with chronic indwelling
catheters. American Journal of
Health-System Pharmacy, 62(1), 7477.
Sobota, A.E. (1984). Inhibition of bacterial adherence by cranberry juice:
Potential use for the treatment of urinary tract infections. The Journal of
Urology, 131(5), 1013-1016.
Stamey, T.A. (1980). Urinary tract infections in women. In T.A. Stamey
(Ed.), Pathogenesis and treatment of
urinary tract infections (pp. 122209). Baltimore: Williams and
Wilkins.
Stamm, W.E. (1983). Measurement of
pyuria and its relation to bacteriuria.
The American Journal of Medicine,
75(18), 53-58.
Stamm, W.E., Counts, G.W., Running,
K.R., Fihn, S., Turck, M., & Holmes,
K.K. (1982). Diagnosis of coliform
infection in acutely dysuric women.

New England Journal of Medicine,

307(8), 463-468.
Stamm, W.E., Hooton, T.M., Johnson, J.R.,
Johnson, C., Stapleton, A., Roberts,
P.L., et al. (1989). Urinary tract infections: From pathogenesis to treatment. Journal of Infectious Diseases,
159(3), 400-406.
Stamm, W.E., McKevitt, M., & Counts,
G.W. (1987). Acute renal infection in
women: Treatment with trimethoprim-sulfamethoxazole or ampicillin for two or six weeks. A randomized trial. Annals of Internal
Medicine, 106(3), 341-345.
Stamm, W.E., Wagner, K.F., Amsel, R.,
Alexander, E.R., Turck, M., Counts,
G.W., et al. (1980). Causes of acute
urethral syndrome in women. New
England Journal of Medicine, 303(8),
409-415.
Stapleton, A., Latham, R.H., Johnson, C.,
& Stamm, W.E. (1990). Postcoital
antimicrobial prophylaxis for recurrent urinary tract infection. A randomized, double-blind, placebocontrolled trial. Journal of the
American Medical Association, 264,
703-706.
Stapleton, A., Nudelman, E., Clausen, H.,
Hakomori, S., & Stamm, W.E. (1992).
Binding of uropathogenic Escherichia
coli R45 to glycolipids extracted from
vaginal epithelial cells is dependent
on histo-blood group secretor status.
Journal of Clinical Investigation,
90(3), 965-972.
Sweet, R.L. (1977). Bacteriuria and
pyelonephritis during pregnancy.
Seminars in Perinatology, 1(1), 2540.
Tenney, J.H., & Warren, J.W. (1988).
Bacteriuria in women with longterm catheters: Paired comparison of
indwelling and replacement catheters.
Journal of Infectious Diseases, 157(1),
199-202.

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Thorp, J.M. Jr, Norton, P.A., Wall, L.L.,

Kuller, J.A., Eucker, B., & Wells, E.
(1999). Urinary incontinence in
pregnancy and the puerperium: A
prospective study. American Journal
of Obstetrics & Gynecology, 181(2),
266-273.
Trautner, B.W., & Darouiche, R.O. (2004).
Role of biofilm in catheter-associated urinary tract infection. American
Journal of Infection Control, 32(3),
177-183.
Turck, M., & Stamm, W. (1981).
Nosocomial infection of the urinary
tract. The American Journal of
Medicine, 70, 651-654.
U.S. Census Bureau. (2008). U.S. interim projections by age, sex, race, and Hispanic
origin. Retrieved August 1, 2008, from
http://www.census.gov/population/ww
w/projections/usinterimproj/
Vaisanen, V., Elo, J., Tallgreen, L.G.,
Siitonen, A., Mkel, P.H., SvanborgEdn, C., et al. (1981). Mannoseresistant haemagglutination and P
antigen recognition are characteristic of Escherichia coli causing primary pyelonephritis. The Lancet,
2(8260-61), 1366-1369.
Vazquez, J.C., & Villar, J. (2000).
Treatments for symptomatic urinary
tract infections during pregnancy.
Cochrane Database Systematic
Review, 4, CD002256.
Warren, J.W., Abrutyn, E., Hebel, J.R.,
Johnson, J.R., Schaeffer, A.J., &
Stamm, W.E. (1999). Guidelines for
antimicrobial treatment of uncomplicated acute bacterial cystitis and
acute pyelonephritis in women.
Clinical Infectious Diseases, 29(4),
745-758.
Wilson, M.L., & Gaido, L. (2004).
Laboratory diagnosis of urinary tract
infections in adult patients. Clinical
Infectious Diseases, 38(8), 11501158.
Wyatt, S.H., Urban, B.A., & Fishman, E.K.
(1995). Spiral CT of the kidneys:
Role in characterization of renal disease. Part I: Nonneoplastic disease.
Critical Reviews of Diagnostic
Imaging, 36(1), 1-37.
Zhanel, G.G., Hisanaga, T.L., Laing, N.M.,
DeCorby, M.R., Nichol, K.A., Palatnik,
L.P., et al. (2005). Antibiotic resistance in outpatient urinary isolates:
Final results from North American
Urinary Tract Infection Collaborative
Alliance (NAUTICA). International
Journal of Antimicrobical Agents,
26(5), 380-388.

341

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