Introduction: UTI
commonestt bacterial
b t i l iinfection
f ti for
f GP
substantial morbidity
wide clinical spectrum (mild severe sepsis)
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Definisi
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Prevalensi ISK
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KLASIFIKASI
Lokasi Anatomis: ISK atas & ISK bawah.
ISK Complicated & ISK Uncomplicated.
Uncomplicated
Klasifikasi Klinis :
Asymptomatic
bacteriuria
Acute uncomplicated cystitis in women
Recurrent infections in women
Acute uncomplicated
p
py
pyelonephritis
p
in women
Complicated UTIs in both sexes
Catheter-associated UTIs
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ginjal
ISK ATAS
Pyelonefritis
ureter
ISK BAWAH
Kandung
kemih
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Ureteritis
Cystitis
Prostatitis
Epididimitis
Urethritis
GEJALA
Demam
M
Menggigil
i il
Nyeri pinggang
Mual muntah
P
Penurunan
BB
gejala isk bawah
Klasifikasi ISK
Dari segi PENATALAKSANAAN dibedakan atas :
1.
ISK uncomplicated
li t d (simple)
( i l ):
ISK complicated
2
2.
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2.
3.
4.
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Pathogenesis
Routes of bacterial invasion
1. Ascending
common
2. Hematogenous
staphylococcus
mycobacterium
y
tuberculosis
salmonella
3. Lymphatic: rare
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Host defences
1. Bladder
bladder emptying
mucosal phagocytes
2 Antibacterial substances
2.
3. Anti-adherence
mechanisms
urine, bladder & prostatic
secretions
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Pathogenesis
g
of urinary
y infection
Bacterial virulence vs. host defences
1. Inoculum
1
2. Adherence characteristics
3. Failure of urinary defence
obst
obstruction,
uct o , calculi,
ca cu , VUR
U
incomplete bladder emptying
diabetes mellitus & elderly
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Patogenesis
g
lanjutan
j
Bacterial factor
95% dari luar TU
5% hematogen
g
Host factor
Wanita : uretra pendek, kolonisasi kuman pd
introitus vagina, sex intercourse, tampon,
spermatisid, diafragma, menopause
(lactobaccili).
(lactobaccili)
30% ISK kandung kemih (cystitis) invasi ke
ginjal akibat dari VUR
Infeksi pd ginjal sering di medula kons
amonia , osmol , pH , blood flow , PO2
rendah.
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DIAGNOSIS
Jumlah
Pemeriksaan
P
ik
urinalisa
i li :
Epitel skuamos kemungkinan kontaminasi.
Piuria infeksi/ peradangan.
Silinder lekosit pielonefritis.
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Mikroorganisme
Kultur positif ( % )
E. Coli
E
C li
Klebsiela / Enterobacter
Proteus
Pseudomonas aurogenosa
Staph Epidermidis
Staph.
Enterokokkus
Kandida albikan
Staph. Aureus
60 - 90 %
10 - 20 %
5 - 10 %
2 - 10 %
2 - 10 %
2 - 10 %
1-2%
1-3%
Asymptomatic Bacteriuria
Umumnya terjadi pd wanita
2% - 4% wanita muda, 10% wanita >60 th.
Bila
Bil ada
d DM risiko
i ik ISK 3 - 4x
4 nya.
Laki2 jarang sekali, kecuali umur tua dg
hi t fi prostat.
hipertrofi
t t
Tidak perlu antibiotik. (kecuali didapatkan kultur
+ kuman
k
100.000
100 000 CFU/
CFU/mL
L pada
d 2
2x pemeriksaan,
ik
dg jenis kuman sama)
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Asymptomatic UTI
Neonates
S h l il
Schoolgirls
Young women
Non-pregnant women
Pregnant women
Elderly men & women
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Prevalence (%)
1 (-> 50% VUR)
12
1-2
10
3-10
5-6
5
6 (15-20%
(15 20% ->
> PN)
5-40 (age)
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FaktorrisikodankomplikasiISKkomplikata
Anatomic or structural risk factors
Obstructive utopathy (stones, strictures, tumors, prostate associated
Instrumentation (catheter associated and nosokomial infection)
Renal cystic disease
Ureteral stents & surgical urinary diversions, ileal loop constructions
Other : vesicoreteral reflux (VUR), urachal remnant
Functional risk factors
Diabetes mellitus
Renal transplantation
S i l cord
Spinal
d injury
i j
& neurologic
l i dysfunction
d f
ti
Neutropenia
Human immunodeficiency virus
Micellanous complicated infection
Pyonephrosis
Emphysematous pyelonephritis & cystitis
Malakoplakia and xantogranulomatous pyelonephritis
Intramural vesical abcess
Urosepsis
Tuberculosis
Infections caused by atipical or resistant organism : vancomycin resistant
enterococci, anaerobes, etc
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TREATMENT
1.
2.
3.
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Acute pyelonephritis
hemorrhage &
swelling
PMN infiltration
H&E
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Clinical diagnosis:
g
py
pyelonephritis
p
1. Fever T > 38 0C, rigors, chills, sweats
2 Loin pain
2.
3. Constitional symptoms
anorexia, nausea, vomiting, diahorrea, myalgia,
headache
4. Lower urinary symptoms
dysuria,
dysuria frequency (30 - 50%)
supra-pubic discomfort
UA pyuria,
UA:
i lleukocytes,
k
h
hematuria
i
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Leukocyte
y casts
PMN
H&E
T b l llumen
Tubular
Matrix
PMN
EM
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BF
PMN
Bacterial casts
bacilli
pyelonephritis
usually with leukocytes
PMN
bacilli
bacilli
PMN
EM
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EM
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short duration
insert under aseptic technique by trained
staff (or trained patient for intermittent selfcatheterisation)
bag below bladder & emptied regularly
keep system closed - sample urine by sterile
aspiration
antimicrobial cream in women
A/B for cardiac valvular abnormalities
UTI in males
Uncircumcised boys
bacteria under foreskin -> UTI
Ad lt males
Adult
l
prostate often source
antibacterial prostatic secretion
-> fails in chronic prostatitis
Homosexual males
5% with
ith UTI
E Coli: same serotype
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500 mg BD x 14 days
BD x 14 days
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Pengelolaan :
1.
2.
3.
4.
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Aminoglycoside dg Betalactam.
Quinolone
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Pyelonephritis
80%
Uncomplicated
Acute
pyelonephritis
Medical
therapy
py
100%
Cured
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10%
Complicated
Acute
pyelonephritis
10%
Chronic
pyelonephritis
smouldering
Medical and/or
surgical
g
therapy
py
Medical and/or
surgical
g
therapy
py
60%
Cured
40%
Progressive
renal damage
100%
Progressive
renal damage
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AN ODE TO A NEPHRON
Like thoughts in ones life,
life
some superficial and some deep.
Some cortical, whilst other,
down close to medulla they seep.
All along our life,
life we learn and adsorb
adsorb,
with efforts active and passive.
Concentrate and dilute our endeavors,
by proportions little and massive.
Like experiences of life
life,
which we filter and retain.
So does the nephron,
adsorbs the electrolytes rain.
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In our youth,
youth
we stand firm and resolute.
We age and experience,
distal years of our lives convolute.