Urinary Tract Infections (UTIs): Nursing Study Guide

Urinary tract infections (UTIs) are among the most common infections nurses manage across all care settings. This guide reviews the major types, causative organisms, clinical presentation, diagnostics, treatment, and nursing priorities — with attention to populations (pregnant women, older adults, catheterized patients) where management differs.

Types of UTIs

Risk Factors

• Female anatomy — shorter urethra and proximity to anus
• Sexual activity — introduces bacteria into the urethra
• Indwelling catheters — bypass natural defenses
• Menopause — decreased estrogen alters vaginal flora
• Obstruction — kidney stones or BPH prevent complete bladder emptying
• Diabetes — impaired immunity and glycosuria support bacterial growth

Causative Organisms

• Escherichia coli causes 80–90% of uncomplicated UTIs
• Other gram-negatives: Klebsiella, Proteus, Pseudomonas
• Proteus is associated with struvite kidney stones

Clinical Presentation

Cystitis

• Dysuria — burning with urination
• Frequency and urgency
• Suprapubic pain
• Urine may be cloudy, foul-smelling, or bloody

Pyelonephritis

• High fever (often >101°F) with chills
• Flank pain — unilateral or bilateral, below the ribs
• Nausea and vomiting
• Costovertebral angle (CVA) tenderness on percussion

Diagnostic Tests

• Leukocyte esterase indicates WBCs in urine
• Nitrites indicate bacteria that convert nitrates to nitrites
• A clean-catch midstream specimen is essential to avoid contamination

Treatment

Uncomplicated Cystitis

• Nitrofurantoin 100 mg PO BID × 5 days — first-line
• TMP-SMX × 3 days if local resistance is low
• Fosfomycin 3 g single dose — alternative
• Phenazopyridine — symptomatic relief only; does not treat infection

Pyelonephritis

• Outpatient: oral fluoroquinolone or TMP-SMX for 7–14 days
• Inpatient: IV ceftriaxone until afebrile, then switch to oral
• Hospitalize for severe illness, pregnancy, or inability to tolerate oral meds

Complicated and Catheter-Associated UTI

• Complicated UTI — occurs with structural abnormalities, pregnancy, or immunosuppression; requires longer course (7–14 days)
• Catheter-associated UTI (CAUTI) is the most common healthcare-associated infection
• Avoid unnecessary catheters; remove as soon as possible
• Maintain a closed drainage system; keep the bag below bladder level
• Do NOT routinely change catheters — only for obstruction or infection

Asymptomatic Bacteriuria

• Positive culture without symptoms
• Treat only in:
  • Pregnant women
  • Patients undergoing urologic procedures
• Treating in elderly or catheterized patients does not improve outcomes

Special Populations

• Pregnant women: screen at first prenatal visit; treat with amoxicillin or nitrofurantoin
• Avoid fluoroquinolones and TMP-SMX in the first trimester
• Older adults may present with confusion, falls, or decreased appetite rather than urinary symptoms — confirm with culture before treating

Nursing Assessment

• Assess for dysuria, frequency, urgency, suprapubic pain
• Monitor temperature and assess for chills
• Palpate for CVA tenderness
• Assess mental status in older adults
• Obtain a clean-catch urine specimen

Nursing Interventions

• Encourage fluid intake 2–3 L/day to flush bacteria
• Administer antibiotics on time; complete the full course
• Provide phenazopyridine for symptom relief as ordered (warn: turns urine orange)
• For catheterized patients: maintain closed drainage, bag below bladder
• Offer warm sitz baths for suprapubic discomfort

Prevention Teaching

• Drink adequate fluids daily
• Urinate when the urge is felt — do not hold urine
• Wipe front to back after toileting
• Urinate after sexual intercourse
• Wear cotton underwear and loose-fitting clothing
• Cranberry products may help prevent recurrence but do not treat active infection

Common Exam Traps

• Pyelonephritis causes fever and flank pain; cystitis does not
• Always use a clean-catch midstream specimen
• Treat asymptomatic bacteriuria only in pregnancy or before urologic procedures
• Nitrofurantoin is NOT used for pyelonephritis — it does not reach therapeutic levels in renal tissue
• Fluoroquinolones are avoided in pregnancy
• Phenazopyridine turns urine orange and does not treat infection
• Older adults with UTI may present with confusion rather than urinary symptoms

Key takeaways

• Cystitis = bladder symptoms (dysuria, frequency, suprapubic pain); pyelonephritis = fever, flank pain, and CVA tenderness.
• E. coli causes 80–90% of uncomplicated UTIs; diagnosis is confirmed by urine culture showing >100,000 CFU/mL.
• First-line therapy: nitrofurantoin or TMP-SMX for cystitis; fluoroquinolones or IV ceftriaxone for pyelonephritis.
• Prevent CAUTIs by avoiding unnecessary catheters, maintaining closed drainage, and keeping the bag below the bladder.
• Treat asymptomatic bacteriuria only in pregnancy or before urologic procedures.
• In older adults, suspect UTI when new confusion, falls, or appetite changes appear — confirm with culture before treating.