Urinary Tract Infections

dr Putra Hendra SpPD

UNIBA
 Definition
 Adanya bacteriuria disertai gejala akibat infeksi
pada saluran kemih:

- Bladder: cystitis - Urethra: urethritis

- Renal pelvis: pyelitis - Renal parenchyma: pyelonephritis
 PATHOGENESIS

 Upper urinary tract

infection:

Pyelonephritis

 Lower urinary tract

infection:
Cystitis
 Istilah
 “Upper UTI”: infection diatas kandung kemih
 “Lower UTI”: infection pada atau dibawah
kandung kemih
 “Urethral syndrome”: manifestasi klinik lower
UTI (dysuria, frequency, urgency) tanpa
bacteriuria yang significant
Bacteriuria Presence of bacteria in the urine

Pyuria Presence of WBCs in the urine

Uncomplicated UTI Infection involving structurally and functionally normal

urinary tract (simple UTI)

Complicated UTI Infection involving structurally and functionally abnormal

urinary tract

5
Overview of UTI by age and sex
Virulence Host factors

Infection No infection

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

8
 Host defenses:
antibacterial pada urine
 Osmolality  ↑↑/↓↓
 Urea↑
 Asam organic ↑
 pH ↓
Urinary Tract
Hanya bagian bawah urethra
merupakan tempat bacteri
sebagai flora normal

Saluran kemih yang lain

normalnya sterile

Ada aktifitas phagocytic lokal

Ada IgA dari sekresi prostat

dan kelenjar urethral
11
 PATHOGENESIS

 Ascending infection
Pada kebanyakan UTI

 Descending infection
Pada 4 - 9 % anak
(bakteriemi)
 Pathogens
Type of infection Organisms

Complicated Escherichia coli (tersering)

Enterococcus
Psuedomonas aeruginosa
Uncomplicated Escherichia coli (tersering)
Staphylococcus saprophyticus
Enterobacter spp.
Klebsiella spp.
Proteus spp.
 Clinical Manifestations
Uncomplicated Complicated
Dysuria High fever
Urgency Chills
Low-grade fever Flank and/or abdominal
Frequency pain
Suprapubic discomfort Nausea
Daytime or noctural Vomiting
enuresis +/- lower urinary tract
symptoms
 Understanding Lower Urinary Tract
Symptoms (after Abrams, Bristol, UK)

Detrusor Instability Bladder Hypersensitivity Bladder Outlet Obstruction Detrusor Failure

Storage Symptoms
 Frequency Voiding Symptoms
 Nocturia  Slow stream
 Intermittent flow
 Urgency
 Hesitancy
 Urge incontinence
 Straining
 Bladder Pain  Terminal dribble
 Diagnosis
 Cara pengambilan urine
 Suprapubic aspirate (SPA)
 Kateterisasi kandung kemih
 Midstream
 Kantung urine (bagged specimen)
 Urine culture adalah gold standard
 Bila didapatkan culture satu jenis kuman patogen 100,000
colonies/ml
 Urinalysis dipstick
 Hemoglobin test strip
 Leukocyte esterase: (+) WBC
 Nitrite: (+) gram-negative bacteria
 LABORATORY EVALUATION

Urine:

 Dipstick
 microscopy
 Culture & sensitivity
 LABORATORY EVALUATION
Urine dipstick
88 % sensitive

 Leukocytes
 Protein
 Red blood cells
 Leukocyte esterase
 Nitrite
 Urinary Tract Infection
Definition

Wanita: Minimal ada 100,000 colony-

forming units (cfu)/mL pada kultur urine

Pria: Minimal ada 1,000 cfu/mL pada kultur urine

 Prostatitis
 chronic prostatitis sering menyebabkan
kekambuhan isk
 Gejala:
 pelvic “berat,”
 rectal atau perineal pain
 urinary hesitancy, dribbling, atau
panas/terbakar
 Duplex system

 Terjadi pada 0.9% population

 Obstruction most commonly in upper pole
 May be secondary to an ectopic ureter or ureterocoele
 Lower pole obstruction uncommon
 May be secondary to PUJ obstruction or VUR
 Pemeriksaan
 Ultrasound
 VCUG/Dynamic isotope study
 Bila asymptomatic  prophylaxis
 Bila sering ISK  operasi
 Horseshoe Kidney

 Incidence 1 pada 400

 M:F 2:1
 Sering terjadi urolitiasis dan ISK
 Penyebab wanita sering ISK
 Jarak urethra dan anus pendek
 Kebiasaan “pembersihan” setelah kencing yang
tidak benar (dari rectum ke uretra)
 Kelainan biokimia epitel urogenital
 Cairan vagina tidak mengandung antibodi
 Aktivitas sexual
 Pada usia lanjut
 Kapasitas kandung kemih menurun
 Sensitifitas kandung kemih meningkat
 Kemampuan pengosongan kandung kemih
menurun
 Atropi urogenital
 Penyakit penyerta:
 stroke, dementia, BPH, DM
 resiko peningkatan ISK pada
kehamilan

pyelonephritis
 preterm birth
 low birth weight
perinatal mortality
 LABORATORY EVALUATION
Microscopic exam
 Lekosituria: ≥5 WBC/high
power field (pada sampel
urine dengan sentrifuge),
atau ≥10 WBC/mm3 pada
sampel tanpa sentrifuge
 LABORATORY EVALUATION
Urine culture &
sensitivity
 Urine culture is the gold
standard for the diagnosis of
UTI

 Urine obtained for culture

should be processed as soon
as possible after collection
 LABORATORY EVALUATION

Urine culture
 Midstream  10⁵ colony forming units
 Bag  85% false ₊ve
 Cathterization  10⁴ CFU
 Suprapubic aspiration any growth
 Penilaian Urine culture

 Midstream  + bila ada 10⁵ colony forming units

 Kantung urina (Bag)  85% false +
 Cathterization  + bila ada 10⁴ CFU
 Suprapubic aspiration + bila ada pertumbuhan
bakteri berapapun
 Catheter-associated UTI
Risk factors:
 Wanita
 lama kateterisasi
 Overview of UTI

 Sekitar 2/3 pasien adalah wanita

 Merupakan complications
 pregnancy
 diabetes mellitus
 polycystic disease
 renal transplantation  conditions menghambat
aliran urine (structural dan neurologic)
Kemungkinan adanya bacteriuria yang
significant

 Sesudah kateterisasi: 2%
 Kehamilan at term: 10%
 Hypertensive patients: 14%
 Diabetes mellitus: 20%
 Wanita dengan cystocoele: 23%
 Asymptomatic bacteriuria

 Pasien dengan bakteriuria tanpa gejala

 40% pria dan wanita tua mengalami

asymptomatic bacteriuria
 Silinder lekosit

 Sangat penting
 Dx:
pyelonephritis
 Pathogen-Specific Treatment

Pathogen Treatment options

Escherichia coli Ceftriaxone 50 mg/kg
Psuedomonas aerginosa IV/IM Qday
Enterobacter spp. Gentamicin 6-7.5 mg/kg
Klebsiella spp. IV Q8hr/Qday
Proteus spp. Ceftazidime 100-150 mg/kg/day IV
Q8hr
Enterococcus Ampicillin 100-400 mg/kg/day Q6hr
 Treatment Options
Antibiotic Dosing
Trimethoprim/sulfamethoxazole 6-12 mg TMP/kg/day
(Bactrim) BID
Nitrofurantoin 5-7 mg/kg/day
(Macrodantin) QDay
Cefixime 16 mg/kg/day x 1 day
(Suprax) 8 mg/kg/day BID
Cephalexin 25-50 mg/kg/day
(Keflex) TID or QID
Amoxicillin 40 mg/kg/day
(Amoxil) TID
 Prophylaxis
Antibiotic Prophylactic Dose
Sulfamethoxazole/ 2 mgTMP/kg/day
Trimethoprim QHS
Trimethoprim 2 mg/kg/day
QHS
Amoxicillin 10 mg/kg/day
QHS
Cephalexin 10 mg/kg/day
QHS
Nitrofurantoin 1-2.5 mg/kg/day
QHS
 PROGNOSIS
Long-term sequelae
 Approximately 40 percent
had VUR

 Renal scars developed in

approximately 8 % of
patients, 15 % of those had
abnormal DMSA scan at the
time of diagnosis.