Urinary Tract Infection
The new Illinois Medicaid Reimbursement System will reimburse facilities for the care
they give related to infectious disease. One of the disease processes reimbursed in this
category is Urinary Tract Infections (UTI). The Resident Assessment Instrument User’s
Manual gives a very specific definition of a UTI: "Urinary Tract Infection (I2j) includes
chronic and acute symptomatic infections in the last 30 days. Check this item only if there
is current supporting documentation and significant laboratory findings in the clinical
record." This month’s Clinical Capsule will look at UTI, the diagnosis and treatment.
Definition - A urinary tract infection (UTI) is a bacterial invasion of the bladder or
kidney. UTIs are the second most common infection next to respiratory infections and the
most common bacterial infection in nursing home residents. Urine is usually sterile; that
is, it contains no microorganisms. With a urinary tract infection, there are bacteria and
pus cells present in the urine. If there is also inflammation of the bladder, it is called
cystitis. If one or both kidneys are involved then it is called nephritis.
Cause - Most infections are caused by one type of bacteria, Escherichia Coli (E.Coli),
which is normally a part of the individual’s own intestinal organisms. An infection occurs
when these bacteria cling to the opening of the urethra (tube carrying urine from the
bladder to the outside) and begin to multiply. Frequent use of antibiotics for UTIs has
caused other bacteria to start emerging as the cause of UTI but E.Coli is still the most
common cause responsible for 70% of infections.
Risk: Some people are more prone to getting a UTI than others. Any abnormality of the
urinary tract that obstructs the flow of urine makes a person prone to infection. The
following are some of the risk factors:
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Women are more prone to infection because of the shorter urethra, which allows
bacteria to be transported easily to the bladder. In the younger population, women
have a higher incidence of UTI, but as people age the ratio of women to men with
UTIs falls. This is due to the decreased sexual activity in elderly women and the
increased prevalence of bladder outlet obstruction due to prostatic enlargement in
men.
Many, otherwise healthy, elderly have between 2-20 ml of urine left in the
bladder after voiding. This retention of stagnant urine allows bacteria to grow.
Urinary retention can also be caused by neurological disorders.
Foreign bodies such as catheters promote bacterial growth. With time, indwelling
catheters often lead to bacteriuria (presence of bacteria in the urine).
Diabetics have increased urine glucose, which provides an environment for
bacteria.
Residents with poor hygiene and poor diet were not found at higher risk for
developing UTIs.
Asymptomatic Bacteriuria or UTI – The Association for Professionals in Infection
Control and Epidemiology (APIC) define a positive urine culture as a laboratory
confirmation of > 100,000 colony-forming units. This positive culture, however, does not
indicate whether a resident has a UTI or asymptomatic bacteriuria. A positive urine
culture without any symptoms for the week prior to obtaining the urine does not indicate
a UTI, but asymptomatic bacteriuria. Asymptomatic bacteriuria is not a UTI and should
not be treated unless accompanied by symptoms. The prevalence of asymptomatic
bacteriuria among residents in long term care facilities is estimated to be 10-50%.
Urinary catheters frequently cause bacteriuria in residents. A simple in and out
catheterization may cause bacteriuria in 20% of residents.
Symptoms-The elderly resident with a UTI may be asymptomatic or exhibit vague
symptoms. Some of the symptoms may include:
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The frequent need to urinate
Painful, burning sensation in the area of the bladder or urethra during urination*
Cloudy, foul smelling urine*, +
Having the feeling of having to pass urine, but unable to do so or passing only a
small amount
Chills
Fever (>38oC) – may mean that the infection has reached the kidneys *, +
Lower abdominal pain or pain in the back (flank) below the ribs *, +
The need to hurry to get to the bathroom in time to urinate (Sometimes recent
onset incontinence may occur)
Blood or pus in the urine
Not feeling well
Confusion, agitation, and delirium *, +
Change in appetite
Functional decline
Some practitioners use the above symptom list for diagnosis. If a resident without an
indwelling catheter has three of the symptoms above marked with a *, they meet the
criteria for a UTI. If the resident has an indwelling catheter and have only two of the
symptoms above marked with a +, they meet the criteria for a UTI.
Diagnosis- Urine culture is the usual method for diagnosis. This will confirm the
infection and check the sensitivity of the bacteria to different antibiotics so that
appropriate treatment can be prescribed. It is very important to get a clean specimen in
order to avoid bacteria from around the genital area getting into the specimen and
confusing the test results. Washing the genital area before collecting the specimen will
help to get a clean specimen. A urine culture revealing a bacterial count of 100,000/ml or
more ,with symptoms, confirms diagnosis. A follow up culture is usually performed after
10 days, to determine the effectiveness of antibiotic treatment.
Treatment – Asymptomatic bacteriuria should not be treated. Treatment of symptomatic
UTI should not be delayed while waiting for culture and sensitivity results. Look at the
past patterns of cultures in the facility and resident, to determine the starting antibiotic. It
can be changed later if needed, after the results of the culture and sensitivity are obtained.
UTIs rapidly respond to antibacterial drugs. The choice of drug and length of treatment
depend on the history and the urine tests that identify the bacteria. The treatment of
asymptomatic bacteriuria (no symptoms of UTI during the week prior to urine sample
collection) is generally not warranted, although neither the benefit of treating nor the risk
of withholding treatment has been demonstrated. Many clinicians feel that urinary
leakage, in the absence of other symptoms, may be indicative of a UTI. They feel that
testing and treatment should be done to see if the leakage stops.
Nursing Implications - Since many elderly residents will not exhibit the usual symptoms
of UTI, staff must be alert for any change in cognition, appetite or decline in the function
of residents. These may be the only signs of a UTI. These must be recognized and
investigated further before the infection progresses. Prevention involves proper catheter
care and catheterizing only when necessary. The Centers for Disease Control and
Prevention has Recommendations for prevention of Catheter-Associated Urinary Tract
Infections available at www.cdc.gov/ncidod/dhgp/gl_catheter_assoc.html .
UTI PRE-TEST
1. Elderly men are prone to UTI.
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2. All patients have the same symptoms with a UTI.
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3. Foley Catheters play no role in UTI's.
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4. Wiping back to front greatly reduces
the risk of UTI.
5. E-COLI is the number 1 type of bacteria associated with
UTI's.
UTI POST TEST
1.UTI can be captured on the MDS Section I2 if the resident had an
abnormal Urinalysis, and was asymptomatic.
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2. Constipation contributes to risk of UTI.
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3. Asymptomatic bacteriuria should always be treated with
antibiotics.
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4. UTI's are a simple problem that cause no actual harm.
5. Change in cognition, appetite could be a sign of UTI.