Urinary Tract Infection Nursing Guide

Definition & Epidemiology

A UTI is infection of any part of the urinary tract (urethra, bladder, ureter, renal pelvis). It is one of the most common bacterial infections, particularly in women (50% experience at least one UTI in their lifetime). Most common pathogen: E. coli (80%).

Common Organisms

Organism	Setting	Notes
E. coli — 80%	Community-acquired	Most common; ascending from perineum
Klebsiella pneumoniae	Community + hospital	More resistant; common in diabetics
Staphylococcus saprophyticus	Young sexually active women	Second most common in young women
Proteus mirabilis	Male UTI, recurrent UTI	Urease-positive → struvite stones
Enterococcus faecalis	Hospital-acquired / CAUTI	Requires broader spectrum antibiotics
Pseudomonas aeruginosa	CAUTI, immunocompromised	Multi-drug resistant; difficult to treat

Risk Factors

Female sex (short urethra)
Sexual activity ("honeymoon cystitis")
Urinary catheter (CAUTI)
Diabetes mellitus
Urinary stasis (BPH, neurogenic bladder)

Urinary tract abnormalities (vesicoureteric reflux)
Pregnancy
Post-menopause (oestrogen loss → flora change)
Immunosuppression
Renal stones

Classification

Type	Location	Symptoms	Treatment
Cystitis (lower UTI)	Bladder	Dysuria, frequency, urgency, haematuria, suprapubic discomfort. NO fever typically.	3–7 days oral antibiotics; nitrofurantoin or trimethoprim
Pyelonephritis (upper UTI)	Kidney	Loin/flank pain, fever ≥38°C, rigors, nausea/vomiting; ± lower UTI symptoms	7–14 days; ciprofloxacin or co-amoxiclav; IV if severe
Urosepsis	Systemic	Pyelonephritis + sepsis criteria (HR >90, RR >20, altered consciousness, hypotension)	URGENT: IV antibiotics within 1 hour + fluid resuscitation (Sepsis 6)
Asymptomatic bacteriuria (ASB)	Any	Positive urine culture ≥10⁵ CFU/mL but NO symptoms	Treat ONLY in: pregnancy, before urological procedures. NOT routine elderly patients.
CAUTI	Any + catheter	UTI within 48 hours of catheterisation; catheter in situ	Remove/change catheter; urine MC&S; targeted antibiotics
Complicated UTI	Any	Male, pregnant, immunocompromised, structural abnormality, catheter, recent instrumentation	Longer course; broader spectrum; imaging

Asymptomatic bacteriuria in the elderly: Very common (20–50% of institutionalised elderly have positive urine cultures without symptoms). Treating ASB in elderly patients increases antimicrobial resistance and does NOT reduce morbidity. Do NOT culture urine in asymptomatic elderly unless going for urological surgery.

Antibiotic Treatment Guide

Condition	First-Line	Duration	Notes
Uncomplicated cystitis (women)	Nitrofurantoin 100mg MR BD (if eGFR ≥45) or Trimethoprim 200mg BD	3–7 days	Avoid nitrofurantoin if eGFR <45; GCC resistance patterns — check local guidelines
Uncomplicated cystitis (men)	Trimethoprim or ciprofloxacin	7 days	Exclude prostatitis; urine MC&S always in men
Mild pyelonephritis (oral)	Ciprofloxacin 500mg BD or Co-amoxiclav 625mg TDS	7–14 days	Adjust based on sensitivities; oral ciprofloxacin has excellent bioavailability
Severe pyelonephritis / urosepsis	IV piperacillin-tazobactam (Tazocin) 4.5g TDS or ceftriaxone 2g OD	Until afebrile 24–48h then oral step-down for 14 days total	Take blood cultures before antibiotics; urine MC&S
CAUTI	Based on culture sensitivity; empirical = ciprofloxacin or co-amoxiclav	7–14 days	Remove/change catheter; if stable, wait for sensitivities
Recurrent UTI (women, ≥2/6 months)	Antibiotic prophylaxis (trimethoprim 100mg nocte OR nitrofurantoin 50mg nocte) OR vaginal oestrogen (post-menopausal)	3–6 months	Self-start therapy option; cranberry juice (weak evidence)

Urosepsis — Sepsis 6 Bundle

Urosepsis = sepsis from urinary source. DELIVER SEPSIS 6 WITHIN 1 HOUR:

High-flow O₂
Blood cultures (before antibiotics)
IV broad-spectrum antibiotics
IV fluid challenge (500 mL crystalloid bolus)
Urinary catheter + strict fluid balance
Serum lactate

Special Populations

UTI in Pregnancy

Asymptomatic bacteriuria in pregnancy: MUST be treated (risk of pyelonephritis 20–40% if untreated, premature labour)
Screen with urine culture at booking visit (12 weeks)
Safe antibiotics: nitrofurantoin (avoid at term — neonatal haemolysis), cefalexin, amoxicillin (if sensitive)
Avoid: trimethoprim (folate antagonist in 1st trimester), ciprofloxacin (cartilage development), nitrofurantoin at >36 weeks

UTI in GCC Context

Diabetes mellitus — extremely high prevalence of T2DM in GCC. Diabetic patients have higher risk of complicated UTI, pyelonephritis, emphysematous cystitis/pyelonephritis (gas in bladder/kidney wall on CT — urgent surgery). Fungal UTI (Candida) also more common in diabetics with catheters.
Dehydration in GCC heat — inadequate fluid intake in summer increases UTI risk (concentrated urine, reduced flushing). Encourage ≥2.5 litres/day fluid intake for UTI prevention, especially outdoor workers.
Antibiotic resistance — E. coli resistance to trimethoprim and ampicillin exceeds 30–40% in many GCC countries. Fluoroquinolone resistance is also rising. Local microbiology guidance and antibiotic stewardship are critical. Always send urine culture and adjust to sensitivities.
Schistosomiasis — Schistosoma haematobium causes chronic bladder inflammation, haematuria, and increased UTI risk in patients from endemic areas (Egypt, Sudan, sub-Saharan Africa). Consider in patients with persistent haematuria not responding to conventional UTI treatment.

MCQ Practice — UTI

Q1. A 28-year-old woman has dysuria, frequency, and suprapubic discomfort but no fever or flank pain. Urine dipstick is positive for nitrites and leukocytes. What is the diagnosis and treatment?

A) Pyelonephritis — 14 days ciprofloxacin

B) Uncomplicated cystitis — 3–7 days nitrofurantoin or trimethoprim

C) Asymptomatic bacteriuria — no treatment needed

D) Urosepsis — IV piperacillin-tazobactam

✅ B — Lower UTI (cystitis): dysuria, frequency, suprapubic pain, NO fever, NO flank pain. Treat with 3–7 days nitrofurantoin (if eGFR ≥45) or trimethoprim. Pyelonephritis would include fever and loin pain. Urosepsis requires systemic signs.

Q2. An 80-year-old nursing home resident has a urine culture positive for E. coli >10⁵ CFU/mL but is completely asymptomatic. What is the appropriate management?

A) Treat with trimethoprim 7-day course

B) IV antibiotics as elderly are high risk

C) No treatment — asymptomatic bacteriuria in elderly does not require antibiotics

D) Repeat culture in 48 hours; treat if still positive

✅ C — Asymptomatic bacteriuria (ASB) in elderly patients should NOT be treated. Treatment increases antibiotic resistance without reducing symptoms, morbidity, or mortality. Treat ASB only in pregnancy or pre-urological procedure. Do not culture urine in asymptomatic elderly.

Q3. A patient with a urethral catheter develops fever 39°C, rigors, and hypotension. Urine is cloudy and offensive. Sepsis 6 is initiated. What specific action regarding the catheter should be taken?

A) Leave catheter in place — removal risks further bacteraemia

B) Irrigate the catheter with antibiotics

C) Remove or change the urinary catheter and send urine from the catheter tip for culture

D) Clamp the catheter to prevent further infection spread

✅ C — In CAUTI with urosepsis, the catheter should be removed or changed (it harbours biofilm and perpetuates infection). Urine and catheter tip should be sent for MC&S to guide antibiotic therapy. Never irrigate with antibiotics — promotes resistance.

Q4. Which antibiotic for uncomplicated UTI is CONTRAINDICATED at 36+ weeks of pregnancy due to risk of neonatal haemolytic anaemia?

A) Cefalexin

B) Amoxicillin

C) Nitrofurantoin

D) Fosfomycin

✅ C — Nitrofurantoin should be avoided at term (≥36 weeks) and during labour due to risk of neonatal haemolytic anaemia (glutathione instability in neonates). It is safe in 1st and 2nd trimesters. Trimethoprim is avoided in 1st trimester (folate antagonist). Cefalexin and amoxicillin are safe throughout pregnancy.

Urinary Tract Infection — Nursing Guide