GROUP 1

ASSIGNMENT
URINARY TRACT INFECTIONS & PYELONEPHRITIS
GROUP MEMBERS

1. EVANS WASWA BSN-1-5210-3/2020

2. IMBUGA SANDE BSN-1-8230-2/2019
3. IAN ADOGO BSN-1-5244-3/2020
4. HESBORN OGWANG’ BSN-1-5247-3/2020
5. JOSEPH IRUNGU BSN-1-5184-3/2020
6. MARTIN GACHIGWA BSN-1-5190-3/2020
INTRODUCTION

A urinary tract infection (UTI) refers to an infection that occurs in any part of the urinary system,
typically caused by bacteria. The most common type of UTI is a lower urinary tract infection, which
affects the bladder and urethra. UTIs are classsified into:
• Lower urinary tract infetions: bacterial cyctitis, prostatitis and urethritis.
• Upper UTIs: acute and chronic pyelonephritis, interstitial and renal nephritis.
• Uncomplicated UTI - most are community-acquired and are common in young women but not usually
recurrent.
• Complicated UTI - usually occur in people with urologic abnormalities or recent catheterization and
are often acquired during hospitalization.
CAUSES

• Inability or failure to empty the bladder completely. Stasis of urine inside the urinary bladder
attracts bacteria into entering the tract.
• Instrumentation of the urinary tract. Catheterization or cystoscopy procedures could introduce
bacteria into the urinary tract.
• Obstructed urinary flow. Abnormalities in the structure of the urinary tract could obstruct the flow
of the urine and result in inability to empty the bladder completely. Example: Uteropelvic junction
(UPJ) obstruction.
• Decreased natural host defenses. Immunosuppression or inability of the body to produce the
body’s defenses predisposes the patient to UTI.
PATHOPHYSIOLOGY

• Bacterial Entry. Bacteria gain access to the urinary tract through the urethra, which is the
tube that carries urine from the bladder to the outside of the body. In women, the urethra is
shorter, making it easier for bacteria to reach the bladder. Bacteria can enter the urinary tract
through various means, including improper hygiene,or the use of catheters.
• Adherence and Colonization. Once bacteria enter the urinary tract, they must adhere to the
epithelial cells lining the urinary system to establish infection. Bacterial adhesion is
facilitated by specific adhesins present on the bacterial surface, which bind to receptors on
the urinary tract cells. This adherence allows the bacteria to resist mechanical flushing and
immune clearance.
CONTD’

• Inflammatory Response. As the bacteria colonize the urinary tract, they initiate an
inflammatory response. The presence of bacteria and their toxic byproducts triggers the
release of pro-inflammatory substances, such as cytokines, chemokines, and prostaglandins.
This inflammatory response leads to localized tissue damage and the recruitment of immune
cells, particularly neutrophils, to the site of infection.
• Epithelial Invasion. In some cases, bacteria can invade the epithelial cells of the urinary
tract. Once inside the cells, bacteria can replicate and avoid immune detection and
clearance. Intracellular bacteria can form reservoirs and serve as a source of recurrent
infections.
CONTD’

• Urine Stagnation. Structural abnormalities or obstructions within the urinary tract, such as
urinary stones or anatomical defects, can lead to urine stagnation. Stagnant urine provides a
favorable environment for bacterial growth and can contribute to the persistence and
recurrence of UTIs.
• Ascending Infection. UTIs typically start in the lower urinary tract, primarily affecting the
bladder (cystitis). If left untreated, bacteria can ascend through the ureters to the upper
urinary tract, involving the kidneys (pyelonephritis). Kidney infections are generally more
severe and can lead to systemic symptoms and complications. The most common route of
infection in paediatrics.
RISK FACTORS

• Gender: Girls are at a higher risk of UTIs compared to boys. This is primarily because
girls have a shorter urethra, which allows bacteria to reach the bladder more easily.
• Age: Infants and young children, particularly those under the age of 2, have a higher risk
of UTIs. This may be due to factors such as incomplete bladder emptying, difficulty in
maintaining proper hygiene, or an immature immune system.
• Urinary tract abnormalities: Structural abnormalities in the urinary tract, such as
vesicoureteral reflux (VUR), ureteral obstruction, or congenital anomalies, can increase
the risk of UTIs. These abnormalities can interfere with the normal flow of urine and
create an environment favorable for bacterial growth.
CONTD’

• Urinary tract catheterization: Catheterization is a risk factor for UTIs in pediatric patients.
Inserting a urinary catheter can introduce bacteria into the urinary tract, increasing the
chances of infection.
• Constipation: Chronic constipation can contribute to UTIs in children. Stool retention can
put pressure on the bladder and interfere with normal urine flow, leading to urine stasis and
bacterial overgrowth.
• Poor hygiene: Insufficient or improper hygiene practices, such as inadequate wiping after
bowel movements or improper cleaning of the genital area, can increase the risk of UTIs.
CONTD’

• Voiding dysfunction: Abnormal voiding patterns, such as infrequent urination, incomplete

bladder emptying, or holding urine for extended periods, can contribute to UTIs. These patterns
can lead to urine stagnation and bacterial growth.
• Previous UTIs: Children who have had UTIs in the past are more prone to recurrent infections.
Recurrent UTIs may indicate underlying urinary tract abnormalities or incomplete resolution of
the initial infection.
• Immunodeficiency: Certain medical conditions that weaken the immune system, such as
congenital immunodeficiency disorders or conditions requiring immunosuppressive therapy,
can increase the susceptibility to UTIs.
SIGNS AND SYMPTOMS.

• Fever: Unexplained fever may be the only noticeable symptom in infants.

• Irritability or fussiness.
• Poor feeding or decreased appetite.
• Vomiting or diarrhea.
• Failure to thrive or inadequate weight gain.
• Strong-smelling or cloudy urine.
• Jaundice (in severe cases).
• Abdominal pain or discomfort.
• Blood in the urine (hematuria) may sometimes be present.
CONTD’ - OLDER CHILDREN

• Frequent urination or urgency.

• Pain or burning sensation during urination (dysuria).
• Lower abdominal pain or discomfort.
• Bedwetting or urinary accidents in previously toilet-trained children.
• Strong-smelling or cloudy urine.
• Hematuria.
• Fever and chills.
• Back pain (in cases of upper urinary tract involvement).
• Fatigue or malaise.
• Urinary incontinence.
DIAGNOSIS

• Medical History and Physical Examination.

• Urinalysis.
• Urine culture. - If the urinalysis suggests a possible UTI, a urine culture is typically performed to identify
the specific causative bacteria and determine their susceptibility to antibiotics.
• Complete blood count. WBC - >5 polymorphonuclear leukocytes/field indicates inflammatory process.
• Renal function studies; serum creatinine and BUN levels (normal; Newborn: 4 to 18mg/dl. Infant, child: 5
to 18mg/dl)
• Renal U/S.- to help identify structural abnormalities, such as kidney stones or urinary tract obstructions.
MEDICAL MANAGEMENT

The medical management is based on empirical antibiotic therapy - the choice of antibiotics
is based on common pathogens and local resistance patterns.
• Amoxi-clav
• Septrin
• Cephalosporins: cifixime and ceftriaxone.
Culture-Directed Therapy. If the urine culture results become available, the antibiotic
regimen can be adjusted based on the identified bacteria and their sensitivity patterns. This
allows for more targeted treatment and helps prevent the emergence of antibiotic resistance.
NURSING MANAGEMENT

• Monitor vital signs 2 hourly.

• Health Education. Provide information about the condition, treatment options, and potential complications to
the caregiver/paediatric.
• Pain management. PCM 10mg/kg QiD.
• Hygiene. Daily change of linen, garment, and takes a bath. Advice the caregiver to change the diaper at
appropriate time, for young children. For girls, they should be advised to wipe from front to back.
• Nutrition. Plenty of vitamin rich foods to improve the clients immune system.
• Bed rest to promote healing.
• Drug regimen compliance to attain effective management.
CONTD’

• Monitor the input and output daily.

• Weigh daily.
• Monitor and assess for signs of complications.
• Emotional support.
• If surgery is suggested, in case of UPJ, then prepare the patient pre-operatively and provide post-op
care.
• Encourage fluid intake.
• Catheter care.
COMPLICATIONS

• Kidney Infection (Pyelonephritis).

• Renal Scarring. The recurrence of UTI can cause scarring. The inflammation and tissue
damage caused by the infection can result in fibrosis and loss of normal renal architecture.
Renal scarring can potentially lead to long-term complications, such as hypertension, renal
insufficiency, and chronic kidney disease.
• Sepsis.
• Renal Dysfunction.
• Renal Abscess.
PYELONEPHRITIS

Pyelonephritis involves the inflammation and infection of the kidneys. It is typically caused
by bacteria ascending from the lower urinary tract, a complication of lower UTI.
It is mainly caused by E.coli.
It is classified into: based on acuteness; acute - sudden onset, and chronic - recurrent or
persistent kidney infections over a prolonged period.
based on location of infection; unilateral - one kidney is infected, and bilateral - infection
of both kidneys.
PATHOPHYSIOLOGY

• Bacterial Entry from lower urinary tract.

• Adherence and Colonization. Bacteria adhere to the urothelium, the lining of the urinary tract. They may
use fimbriae (hair-like structures) or other adhesins to attach to the urothelial cells, enabling colonization and
subsequent infection.
• Inflammatory Response: Bacterial invasion triggers an immune response, resulting in the release of pro-
inflammatory cytokines. These cytokines initiate an inflammatory cascade, attracting immune cells,
particularly neutrophils, to the site of infection.
• Renal Inflammation: The immune cells migrate from the blood vessels into the renal parenchyma, causing
inflammation and tissue damage. The infiltrating neutrophils release enzymes and reactive oxygen species,
leading to further injury to the renal tissue.
CONTD’

• Tubulointerstitial Damage: Pyelonephritis primarily affects the tubulointerstitial region

of the kidneys, where the renal tubules and surrounding connective tissue are located. The
infection and inflammation can damage the renal tubules, leading to impaired tubular
function.
• Parenchymal Involvement: As the infection progresses, it can involve the renal
parenchyma, including the renal cortex and medulla. The bacteria can invade the renal
tissue, leading to abscess formation and further destruction of the renal structures.
SIGNS AND SYMPTOMS

• High fever and chills.

• Flank pain (pain in the lower back or side, where the kidneys are located)
• Abdominal pain or discomfort
• Frequent urination
• Painful urination
• Blood in the urine (hematuria)
• Cloudy or foul-smelling urine
• Fatigue and general malaise
DIAGNOSIS

• Clinical evaluation. A detailed medical history and physical examination.

• Urinalysis: Examination of a urine sample to look for the presence of bacteria, white blood cells, red blood cells,
and other indicators of infection.
• Urine culture: to identify the specific bacteria causing the infection and determine their susceptibility to
antibiotics.
• Blood tests: To evaluate kidney function, assess inflammatory markers, and check for signs of systemic
infection. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may be elevated. CBC levels will
be elevated in presence of infection.
• Imaging studies: In some cases, imaging tests like ultrasound, CT scan, or MRI may be performed to assess the
kidneys and look for any structural abnormalities or complications.
MEDICAL MANAGEMENT

• The primary treatment is antibiotic therapy.

• Amoxicillin 15mg/kg TDS per oral
• Ceftriaxone 50mg/kg BD
• Paracetamol 10mg/kg TDS
• Nitrofurantoin 12.5mg/kg QID
NURSING MANAGEMENT

• Monitor vital signs ie temperature 4 hourly.

• Health Education. Provide information about the condition, treatment options, and potential complications to
the caregiver/paediatric.
• Hygiene. Daily change of linen, garment, and takes a bath. Advice the caregiver to change the diaper at
appropriate time, for young children. For girls, they should be advised to wipe from front to back.
• Nutrition. Plenty of vitamin rich foods to improve the clients immune system.
• Bed rest to promote healing.
• Drug regimen compliance to attain effective management.
• hydration with fluids and monitoring input/output
COMPLICATIONS

Renal Abscess: Pyelonephritis can sometimes lead to the formation of a pus-filled cavity within the kidney
known as a renal abscess. This occurs when the infection progresses and the bacteria cause tissue damage
and abscess formation.
2. Sepsis: In severe cases of pyelonephritis, the infection can spread from the kidneys into the bloodstream,
leading to a condition called sepsis. Sepsis is a life-threatening condition that causes a systemic
inflammatory response throughout the body. It requires immediate medical attention.
3. Kidney Scarring: Repeated episodes of pyelonephritis or inadequate treatment can result in kidney
scarring. Scar tissue replaces healthy kidney tissue, impairing the kidney's ability to function properly.
Kidney scarring can lead to long-term complications, such as chronic kidney disease and reduced kidney
function.
• 4. Chronic Pyelonephritis: If pyelonephritis becomes a recurrent or persistent condition, it can progress to
chronic pyelonephritis. This is characterized by persistent inflammation and kidney damage, leading to
ongoing symptoms and potential complications.
• 5. Kidney Failure: Severe or untreated pyelonephritis can ultimately result in kidney failure, where the
kidneys lose their ability to function adequately. Kidney failure requires dialysis or a kidney transplant for
survival.
• 6. Hypertension (High Blood Pressure): Chronic pyelonephritis or kidney damage from pyelonephritis can
contribute to the development of hypertension. The kidneys play a crucial role in regulating blood
pressure, and when they are compromised, it can lead to hypertension.
• 7. Pregnancy Complications: Pyelonephritis during pregnancy can pose risks to both the mother and the
developing fetus. It can increase the risk of preterm labor, low birth weight, and other pregnancy-related
complications
PREVENTION MEANS

• Hygine – changing of diaper when soiled appropriatley

• Treatment – ensure on time treatment when infection occurs as this prevent regular
occurrence of the uti and prevention of complications
• Catheter care- insert the catheter using the aseptic technique and ensure it is always clean
without blood stain.
• Adequate hydration- this helps in flushing out the bacteria present in the urinary tract.
REFERENCES

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2020). Brunner &
Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.
• WONG’s essential of paediatric nursing. 10th edition.
• DAVIS’s drug guide. 13th edition.
• Basic Paediatric protocol. 5th edition.