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Nursing management of urinary tract infections

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 Art & science | urologic system

Nursing management
of urinary tract infections
Sara Ribeiro looks at how nurses can assist older people through
the diagnosis, treatment and prevention of a common infection

The aetiology of UTIs explains their predominance

Abstract
Urinary tract infections (UTIs) are common in older people and can lead to serious
complications. Infections can worsen underlying medical conditions, adversely
affect recovery and be alarming to patients, their families and caregivers.
UTIs have a complex pathophysiology but the most common cause is the ascent
of bacteria from the periurethral area, which explains their prevalence in older
women. As a result of antibiotic resistance, an accurate diagnosis is imperative
and should be based on clinical history, presence of typical signs and symptoms
and test results. Nurses can assist patients through the diagnostic process,
treatment and prevention of UTIs, promoting their wellbeing and empowerment.
This article explores the pathophysiology of UTIs and diagnosis, prevention and
nursing management in a variety of care settings.
in women and increased risk of infection after
catheterisation (Rahn 2008, Grabe et al 2013).
UTIs can also develop as a result of lymphatic
or haematogenous spread of an existing infection
elsewhere in the body. The infection is restricted
to microorganisms such as S. aureus, Candida spp,
Salmonella spp and Mycobacterium tuberculosis,
which cause primary infections elsewhere in the
body (Grabe et al 2013). A prevalence of 16.5%
in women over 65 years of age increases to 30%
in women over 85, making it a common problem in
this group (Rowe and Juthani-Mehta 2014).

Keywords
Antibiotics, bacteria, diagnosis, nursing management, urinary tract infections
Correspondence URINARY TRACT infections (UTIs) are one of
saraiaribeiro@gmail.com the most common bacterial infections in older
Sara Ribeiro is a registered people and the second most common clinical
nurse, Mill House, Caring Homes indication for empirical antimicrobial treatment.
Group, Chipping Campden, Diagnosis is difficult in the older population
Gloucestershire
and requires a systematic approach (Scottish
Date of submission Intercollegiate Guidelines Network (SIGN) 2012a).
May 15 2015 Older people often present comorbidities with
Date of acceptance symptoms mistaken for UTIs (SIGN 2012b). Nurses
July 29 2015 can assistwith diagnosis and help prevent future
Peer review
infections by working closely with patients,
This article has been subject families and carers.
to double-blind review and
has been checked using
antiplagiarism software
Aetiology and epidemiology
UTIs are caused by inflammation of the urinary tract.
Author guidelines A series of interactions enable bacteria to colonise
journals.rcni.com/r/
nop-author-guidelines
the periurethral area, ascend into the bladder,
multiply in the urine and invade genitourinary tissue
causing an immune reaction (Monahan et al 2006).
Causative bacteria include Escherichia coli, Klebsiella,
Proteus and Enterobacter and Gram-positive bacteria
such as Staphylococcus and Streptococcus organisms.
Classification
UTIs may manifest as bacteriuria, bacteraemia
and urosepsis. Bacteriuria is the presence of
bacteria in urine revealed by a quantitative urine
culture or microscopy (Grabe et al 2013). It can
be asymptomatic or symptomatic, depending on
whether the patient presents with typical signs
and symptoms of lower or upper UTI (Box 1) (SIGN
2012a). Anatomically, UTIs can be classified as lower,
which includes urethritis (infection in the urethra)
and cystitis (infection in the bladder), or upper
when renal parenchyma and renal pelvis are affected
(pyelonephritis) (Monahan et al 2006).
Bacteraemia refers to the presence of pathogens
in blood culture. However, blood culture should
not be routinely collected except in patients
with urinary catheters, malignancies, those who
do not respond to antimicrobial treatment
(van Nieuwkoop et al 2010) and patients with
suspected urosepsis (Kalra and Raizada 2009,
Wagenlehner et al 2013).
Urosepsis relates to sepsis originating
in the genitourinary tract and is a complex
problem with treatment given in critical care
(Wagenlehner et al 2013).

24 September 2015 | Volume 27 | Number 7 NURSING OLDER PEOPLE

 A UTI in a person with no structural or functional
abnormality of the urinary tract is considered
uncomplicated and responds well to antibiotics.
Complicated UTIs result from pathogens resistant
to commonly used antibiotics and if the person
has an anatomical or functional abnormality of
the genitourinary system, that interferes with host
defence mechanisms, increasing the risk of acquiring
infection or of failing therapy. Common abnormalities
include obstruction, urinary instrumentation (as
in invasive urological tests such as cystoscopy and
ureteroscopy, and urologic surgery) and foreign
bodies such as indwelling catheters, metabolic
disorders, urinary diversion, neurogenic bladder
and vesicoureteral reflux (Monahan et al 2006).
Pathophysiology
Bacteria can reach the urinary tract through
four main pathways (Grabe et al 2013):
■ Infection from the urethra, which explains
women’s increased susceptibility as a result of
a short urethra and rectal bacterial colonisation
of the perineum and vaginal vestibule.
■ Haematogenous and lymphatogenous spread
occur secondary to an infection elsewhere in the
body and are not common.
■ Bacteria reach the urinary tract in direct extension
via the lymphatic system from another organ
associated with intraperitoneal abscesses.
To colonise the urinary tract, bacteria adhere to the
urothelium and secrete toxins that promote their
survival. In a healthy urinary tract, a protective layer
in the bladder that interferes with this process and
efficient micturition decrease the number of bacteria
(Monahan et al 2006).
Pyelonephritis is caused either by ascent of
bacteria from the lower urinary tract to the kidneys
or haematologic spread. It is classified as acute or
chronic. Acute pyelonephritis temporarily affects
renal function and can eventually result in atrophy
and destruction of the tubules and glomeruli.
It manifests as enlarged kidneys and infiltration of
inflammatory cells with possible abscess formation.
Pyelonephritis is classified as chronic when repeated
inflammation and scarring permanently destroy renal
tissue, which becomes shrunken and non-functional.
Diagnostic workup often reveals previously unknown
urinary tract obstruction or another chronic kidney
disease (Hinkle and Cheever 2014).
The urinary tract is the cause of sepsis and
septic shock in 10% to 30% of cases and mortality
ranges from 30% to 40%, depending on how
quickly it is recognised and treated. Urosepsis is
mainly caused by obstructive disease in the upper
urinary tract with ureterolithiasis being the most
NURSING OLDER PEOPLE September 2015 | Volume 27 | Number 7 25
common (Wagenlehner et al 2013). It has a complex
pathology that starts when bacteria migrate to the
bloodstream from the genitourinary tract, releasing
endotoxins that damage cells. Damaged cells then
liberate pro-inflammatory cytokines and activate the
complement cascade, causing urosepsis. Widespread
inflammation alters metabolism and results in
multi-organ failure secondary to severe sepsis and
septic shock (Monahan et al 2006).
Risk factors
Risk factors for UTI usually involve a breakdown in the
body’s protective barrier: high osmolality and low pH
of urine and vagina; vaginal, periurethral and perineal
colonisation by Gram-positive bacteria, diphtheroids
and lactobacilli and a normal periodic voiding (the
production of 70 to 80ml/h of urine during waking
period and 30 to 40ml/h during sleep) (Rahn 2008).
Age-related changes such as increased vaginal pH,
weakened immune system and increased skin
colonisation with Gram-negative organisms associated
with possible cognitive deficits mean older women are
susceptible (Rahn 2008, Beveridge et al 2011).
Risk factors for the development of UTIs can be
divided into five groups (Box 2) (Grabe et al 2013).
The presence of a urinary catheter is a major
risk factor for UTIs and the most common source
of bacteraemia. A catheter provides a focus for the
formation of biofilm between itself and the urethral
mucosa, so bacteriuria occurs within three to four days
Box 1  Clinical manifestations of urinary tract infections
Lower UTI Bladder tenderness
Urinary frequency
Urinary urgency
Dysuria
Haematuria
Upper UTI Symptoms of lower UTI and:
Chills and fever
Malaise
Flank pain
Costovertebral angle tenderness
Leukocytosis
In chronic pyelonephritis, extensive scarring and atrophy result in renal failure
manifested by hypertension, increased blood urea and decreased creatinine clearance
Urosepsis Altered mental status
Fever or hypothermia
Tachycardia
Tachypnoea
Hypotension
Oliguria
Leukopenia
(Monahan et al 2006, Scottish Intercollegiate Guidelines Network 2012a, Hinkle and Cheever 2014)
 Art & science | urologic
acute care
system
of catheterisation (SIGN 2012a). Although intermittent
catheterisation has a lower risk of infection than
indwelling, UTIs are the most common complication,
especially in patients who perform intermittent
self-catheterisation. The causes of intermittent
catheterisation-related UTI include inadequate
frequency of emptying, inadequate emptying at time
of catheterisation, inadequate or excessive fluid
intake, poor catheterisation technique and catheter
care, traumatic catheterisation and nocturnal polyuria
(Newman and Willson 2011).
Diagnosis
According to SIGN (2012a), diagnosis of UTI is
difficult, especially in older people, as they are
more likely to have asymptomatic bacteriuria.
Diagnosis is made based on signs and symptoms
and by excluding other possible causes (SIGN
2012b) (Figure 1). When patients exhibit signs
and symptoms of UTI, presence and duration of
symptoms, predisposing factors and history of
previous UTIs should be determined. Physical
examination should include assessment of vital
signs, abdominal or costovertebral tenderness
and the need for a urine culture (Monahan et al
2006). Results of urine culture take between 24 and
Box 2  Risk factors for the development of urinary tract infections
Group of risk factors Risk factor
Risk factors for recurrent UTI, but no Sexual behaviour and
risk of severe outcome contraceptive devices
Hormonal deficiency in
post-menopausal women
Secretory type of certain blood groups
Controlled diabetes mellitus
Extra-urogenital risk factors, with risk of Poorly controlled diabetes mellitus
more severe outcome Relevant immunosuppression*
Connective tissue diseases
Nephropathy, with risk of more Relevant renal insufficiency*
severe outcome Polycystic nephropathy
Urological risk factors, with risk of more Urethral obstruction
severe outcome, which can be resolved Transient short-term urinary catheter
during therapy Asymptomatic bacteriuria when
associated with other risk factors
Controlled neurogenic
bladder dysfunction
Urological surgery
Permanent urinary catheter and Long-term urinary catheter treatment
non-resolvable urological risk factors, Non-resolvable urinary obstruction
with risk of more severe outcome Poorly controlled neurogenic bladder
NB Some risk factors have not been included as they are not applicable to older patients
*Risk factor not well defined
(Grabe et al 2013)
26 September 2015 | Volume 27 | Number 7
48 hours so patients should be reassured that
antibiotics might be prescribed without knowing
the result (National Institute for Health and Care
Excellence (NICE) 2013). In older patients, urinalysis
has poor diagnostic value and should not be
used (SIGN 2012b).
If urosepsis is suspected, a blood culture is also
required as well as initial imaging tests. Further
sonographic and radiographic investigation will
be needed to determine underlying abnormalities
if patients do not respond to therapy within the
first 48 to 72 hours (Kalra and Raizada 2009,
Wagenlehner et al 2013).
The presence of a catheter is associated with
a greater incidence of fever of urinary tract
origin and it is commonly present without any
localising signs. Due to the presence of bacteriuria
and common occurrence of fever, classical
symptoms should not be relied on to diagnose
UTI in a catheterised patient. New costovertebral
tenderness, rigors, new onset of delirium
and fever (>37.9°C or 1.5°C above baseline on
two occasions over 12 hours) are indications
to start antibiotic therapy. Other symptoms
to consider are lethargy if no other cause is
identified, flank pain, acute haematuria and pelvic
discomfort (SIGN 2012a).
Nursing management
Nurses can reassure patients, address concerns and
reinforce knowledge of the urinary tract (Newman
and Willson 2011). Information should be provided
about medication regimen. Patients should complete
the full course of antibiotics even after resolution
of symptoms to prevent antibiotic resistance
(Monahan et al 2006) and use over-the-counter
analgesics to control pain (SIGN 2012a). Increased
fluid intake so that urine is pale in colour reduces
irritation and provides a continual flow of urine
(NICE 2013). Patients should avoid bladder irritants,
such as coffee, alcohol, spicy food and tomatoes
(Monahan et al 2006).
In chronic pyelonephritis, the cause of
recurrent infection should be determined and
reversed if possible. Nurses should advise patients
to monitor urinary output and weight daily,
and report if urine volume is inferior to fluid intake
and if weight suddenly increases. NICE (2013)
recommended hospital admission for patients with
pyelonephritis who do not improve in the 24 hours
after treatment, are unable to take oral medications
and those who respond to medications only available
by intravenous administration.
A follow-up appointment is important seven to
14 days after initial infection. This provides an
NURSING OLDER PEOPLE
Figure 1  Diagnosis and management of suspected UTI in older people

Decision aid to guide management of patients/residents with fever defined as temperature >37.9°C or 1.5°C increase above baseline
occurring on at least two occasions in last 12 hours.
Hypothermia (low temperature of <36°C) may also indicate infection, especially those with comorbidities.
Be alert to non-specific symptoms of infection such as abdominal pain, alteration of behaviour or loss of diabetes control.

Are there any symptoms suggestive of non-urinary infection?

Manage
following local Respiratory – shortness of breath, cough or sputum production, new pleuritic chest pain
antibiotic YES Gastrointestinal – nausea/vomiting, new abdominal pain,
policy new onset diarrhoea
Skin/soft tissue – new redness, warmth, swelling, purulent drainage

NO

YES Does the patient/resident have a urinary catheter? NO

Does patient/resident Does patient/resident have two or more

have one or more of of following symptoms?
following symptoms?
NO YES YES NO
• Dysuria
• Shaking chills (rigors) • Urgency
• New costovertebral • Frequency
tenderness • Urinary incontinence
• New onset delirium • Shaking chills (rigors)
UTI unlikely • Flank or suprapubic pain UTI unlikely
but continue • Frank haematuria but continue
to monitor • New onset or worsening of pre-existing to monitor
symptoms confusion/agitation symptoms
UTI likely

• Assess if retention or sub-acute retention of urine is likely (eg blocked catheter or distended bladder)
• DO NOT use dipstick test in diagnosis of UTI in older people
• Obtain a sample for urine culture and send to Microbiology
• Start antibiotic therapy following local policy or as advised by Microbiology
• If patient has a urinary catheter, remove and replace it. Consider the ongoing need for a long term catheter in consultation with specialists
• Consider use of analgesia (paracetamol or ibuprofen) to relieve pain
• Consider admission to hospital if patient has fever with chills or new onset hypotension (low blood pressure)
• Review response to treatment daily and if no improvement of symptoms or deterioration, consider hospital admission or raised level of care

Developed by the Scottish Antimicrobial Prescribing Group (www.scottishmedicines.org.uk/SAPG)

(Scottish Intercollegiate Guidelines Network 2012b)

NURSING OLDER PEOPLE September 2015 | Volume 27 | Number 7 27

 Art & science | urologic
acute care
system

opportunity to obtain a new urine culture and
discuss further treatment and preventive measures.
At this point, a self-reported pain level less
than three on a scale of one to ten, a completed
antibiotic course and resolution of symptoms mean
the main nursing objectives have been achieved
(Monahan et al 2006).
A patient with urosepsis should be treated in the
critical care environment where aggressive antibiotic
therapy, adjunctive therapies and life-support
measures are available. This includes measures
to maintain euglycaemia, inotropic and ventilator
support (Kalra and Raizada 2009). Treatment plans
and end-of-life care should be discussed within the
first 72 hours (Wagenlehner et al 2013). Nurses’
presence and support are particularly valuable
during this time. As a result of concerns over
antimicrobial resistance and healthcare-associated
infections, avoiding broad-spectrum antibiotics is
important. Empirical treatment should be chosen
according to symptoms and local antibiotic policies.
Choice of antibiotic considers spectrum
and susceptibility patterns of the aetiological
microorganism, efficacy, tolerability, adverse effects,
cost and availability (SIGN 2012a, Grabe et al 2013).
Public Health England (2015) stated that
asymptomatic bacteriuria should not be treated,
as it is common in people over 65 years old and
not associated with increased morbidity. Treating
asymptomatic bacteriuria can lead to increased
antibiotic resistance, making future infections
more difficult to treat. Antibiotics are also not
recommended for patients with indwelling catheters
unless symptomatic (Cove-Smith and Almond 2007).
Antibiotic therapy
Lower UTIs are treated with trimethoprim or
nitrofurantoin or as an alternative, amoxicillin or
an oral cephalosporin. A seven-day course is the
ideal treatment, but shorter is usually adequate
for uncomplicated UTIs in women. To treat acute
pyelonephritis, a broad-spectrum cephalosporin

Table 1  Prevention of catheter-associated urinary tract infections (CAUTIs)

Indwelling catheters should only be used if alternative management methods have been considered, need for catheterisation is reviewed
regularly and catheter is removed as soon as possible (National Institute for Health and Care Excellence (NICE) 2012, Loveday et al 2014)
Hand hygiene and standard precautions are needed immediately before and after insertion or manipulation of catheter device or site
(Gould et al 2009, Loveday et al 2014)
The nurse should be aware of catheterisation procedure, educate on technique and maintenance of catheter and offer follow-up training and
ongoing support throughout catheterisation (NICE 2012)
Antibiotic prophylaxis should not be routinely prescribed when changing catheters, unless the patient has a history of CAUTI after catheter
change or in a hospital setting, where a narrow-spectrum antibiotic should be considered (Loveday et al 2014)

Catheter insertion Catheter maintenance (Loveday Intermittent catheterisation and intermittent

et al 2014) self-catheterisation (Newman and Willson 2011)

■ Nurses should always use
aseptic technique to prevent
cross-infection (Newman
and Willson 2011)
■ Catheterise before bowel
movement to decrease risk of
contamination with Escherichia
coli (Newman and Willson 2011)
■ Clean meatus before insertion
of catheter using sterile normal
saline (Loveday et al 2014)
■ Use lubricant from a sterile
single-use container and ensure
catheter is properly secured to
minimise trauma (Newman and
Willson 2011)
■ Connect the catheter to a sterile, closed
drainage system with sampling port and
avoid breaking this connection
■ Change short-term indwelling
catheter and drainage bags when
clinically indicated and in line with
manufacturer’s recommendations
■ Position drainage system below
the level of bladder on a stand that
prevents floor contact
■ To empty drainage bag use a separate
clean container for each patient
■ Do not allow the drainage bag to
fill more than ¾
■ Routine daily personal hygiene is
sufficient for meatal cleansing
■ Assess technique of the person who performs
catheterisation
■ Consider alternative catheter designs to ease insertion
■ Consider use of a sterile, closed system or single-use
catheters based on medical necessity
■ Drain urine regularly, between four and six times a day,
and perform Credé’s manoeuvre as the catheter is
removed to ensure adequate emptying (a technique
for manual expression of urine from the bladder by
holding the hands flat against the abdomen just below
the umbilicus and performing a firm downward stroke
towards the bladder. This is repeated six to seven
times followed by pressure from both hands placed
directly over the bladder)
■ Encourage regular fluid intake in small volumes spaced
hourly reducing intake to sips in the evening
■ Manage nocturnal polyuria by avoiding large volumes
of fluid in the evening and catheterising several times
during the night

28 September 2015 | Volume 27 | Number 7 NURSING OLDER PEOPLE

or a quinolone is recommended in a course of ten
to 14 days, which can be longer in complicated
pyelonephritis (British National Formulary 2015).
Complicated UTIs are more difficult to treat and
hospitalisation is often required. The spectrum of
bacteria in complicated UTIs is much larger than in
uncomplicated UTIs, and bacteria more likely to be
resistant to antimicrobials.
Catheter-associated UTIs are treated with
a seven-day antibiotic course or a ten to 14-day
course if there is a delayed response to treatment.
The catheter should be replaced before starting
antibiotic therapy as this increases likelihood
of cure or improvement after three days,
and decreases duration of fever and reoccurrence
of acute symptoms within one month of
treatment (SIGN 2012a).
Patients with urosepsis are started on an
empirical antimicrobial therapy until results from
urine cultures are available, avoiding previously used
antibiotics (Wagenlehner et al 2013). Commonly used
antibiotics include third-generation cephalosporin,
piperacillin in combination with beta-lactamase
inhibitor and fluoroquinolone in a course of 14 to
21 days. Patients who show no clinical improvement
within 48 to 72 hours should be reassessed (Kalra
and Raizada 2009, Wagenlehner et al 2013).
Prevention
The most important prevention measures are
adequate education and patient concordance
(Newman and Willson 2011). Recurrent
uncomplicated UTIs can be prevented with the
use of a prophylactic dose of antibiotics, if all
non-antimicrobial therapies have failed. Antibiotic
choice is based on susceptibility pattern of the
causative agent and patient history of drug allergies
(Grabe et al 2013).
According to the Alzheimer’s Society (2015a),
850,000 people live with dementia in the UK, a figure
set to rise to over two million by 2051. Of this
group, 95% are aged over 65. Dementia leads to
immobility, difficulty with basic hygiene practices
and continence issues (Cove-Smith and Almond
2007). The Alzheimer’s Society (2015b) recommends
good fluid intake, regular voiding, good hygiene and
avoidance of constipation for those with dementia.
Good fluid intake can be promoted by ensuring
patients’ preferred drinks are available and visible,
using brightly coloured cups and glasses. Regular
voiding can be encouraged by using signs or pictures
on toilet doors and seats. If someone is not drinking
enough and/or has difficulty with swallowing,
an assessment by a speech and language therapist
should be considered. Constipation should be
avoided by promoting exercise and a diet high in
fibre and fluids. Patients should wash their genitals
using unperfumed soap, avoid talcum powder
and wipe ‘front to back’ after using the toilet.
Preventive measures for catheterised patients are
outlined in Table 1.
Conclusion
UTIs are common and can have a significant adverse
effect on patients’ quality of life. Of the healthcare
team, nurses have the most patient contact and Online archive
the opportunity to identify UTIs sooner and
For related information, visit
prevent escalation of the infection. Nurses should our online archive and search
use the best available evidence and their clinical using the keywords
judgement to assist in the selection of appropriate
treatment and relevant care measures that prioritise Conflict of interest
patients’ wellbeing. None declared

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