Sub. Bag. Nefrologi Hipertensi Bag. Ilmu Penyakit Dalam FK UNDIP / RSDK
Introduction: UTI
commonestt bacterial b t i l iinfection f ti for f GP substantial morbidity wide clinical spectrum (mild severe sepsis)
Urinary tract is normally sterile
Definition of UTI: any bacteria multiplying in the urinary tract regardless of bacterial count wie pm
INFEKSI SALURAN KEMIH (ISK)
Infeksi tersering dialami masalah kesehatan yg sering dihadapi dokter. Dapat mengenai semua umur. Spektrum p g gejala j klinik sangat g bervariasi dari tanpa gejala/ keluhan sampai kelainan sistemik yg berat.
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Definisi
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ISK akibat invasi mikro organisme pada
jaringan traktus urinarius (TU) dari orifisium uretra korteks ginjal. Normal TU steril. Ad Adanya b kt i dalam bakteri d l urin i (bakteriuria) (b kt i i ) TU berisiko alami infeksi. Kultur (+) : kuman > 100.000/ml urin.
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 wie pm
GEJALA Demam M Menggigil i il Nyeri pinggang Mual muntah P Penurunan BB gejala isk bawah
Nyeri supra pubis
Disuria Frekuensi Urgensi Hematuri
Klasifikasi ISK Dari segi PENATALAKSANAAN dibedakan atas : 1. ISK uncomplicated li t d (simple) ( i l ):
ISK complicated
2 2.
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ISK sederhana anatomik maupun fungsional TU
normal. Terutama mengenai wanita. Infeksi hanya mengenai mukosa superfisial kandung kemih. Penyebab kuman tersering (90%) adalah E. coli. Sering menimbulkan banyak masalah, krn didasari hal ttt. Sering kuman penyebab sulit diberantas resisten terhadap beberapa macam antibiotik Sering terjadi bakteriemia, sepsis dan syok. Penyebab : Pseudomonas, proteus, klebsiela dll.
ISK Complicated terdapat keadaan sbb :
1.
2. 3. 4.
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Kelainan abnormal saluran kencing.
Contoh : batu, obstruksi, refluks vasikouretral, atoni kandung kemih, kateter menetap, prostatitis menahun. menahun Kelainan faal ginjal. baik GGA maupun GGK. Gangguan daya tahan tubuh. Penderita DM, neutropenia, penderita dg terapi imunosupresif. Infeksi disebabkan organisme virulen. Seperti proteus spp yg memproduksi urease, Infeksi metastatik staphylococcus.
Pathogenesis Routes of bacterial invasion 1. Ascending common 2. Hematogenous staphylococcus mycobacterium y tuberculosis salmonella 3. Lymphatic: rare wie pm
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
organisme pada ISK :
70% ISK jml kuman > 100.000 kuman/ml urin. 30% ISK jml j l kuman k lebih l bih rendah, d h mis; i pend. d pria, wanita dg disuria akut, wanita dg ISK berulang karena stapphylococcus stapphylococcus.
Pemeriksaan P ik
urinalisa i li : Epitel skuamos kemungkinan kontaminasi. Piuria infeksi/ peradangan. Silinder lekosit pielonefritis.
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Pemeriksaan kultur urin, yg didapat dari :
a a. Urin porsi tengah (mid stream urin) b. Urin aspirasi suprapubik c. Urin kateter kandung kemih (hindari) Dalam D l i interpretasi i kultur k l urin i porsii tengah h !! sbb bb : 95% ISK disebabkan monomikrobial 95% ISK disebabkan gram negatif/ enterococci Staphylococcus p y epidermidis, p diptheroids p & lactobacilli jarang menimbulkan ISK.
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Bakteri penyebab ISK
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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
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
screening & symptoms minimal (urine odour)
Neonates S h l il Schoolgirls Young women Non-pregnant women Pregnant women Elderly men & women wie pm
ISK yg paling sering dijumpai dlm praktek dokter. Manifestasi kliniknya sindroma disuria-frekuensi. Piuria > 10/lpb, p , kultur ((+)) Keluhan sering kencing sedikit2, sakit waktu kencing serta rasa tidak enak didaerah suprapubik suprapubik. Disertai demam subfebril ().
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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 wie pm
TREATMENT 1.
2.
3.
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Empiric therapy must be broad spectrum with
definitive therapy based on culture and sensitivity Moderatelyy : Levofloxacin (500 ( mg g IV/PO q q24), ), ciprofloxacin (500 mg PO twice-daily/400 mg q 12h IV)) Severely : cefepime 2g IV q12 hrs, ceftazidime 2 g IV q8 hrs, Imipenem 500 mg IV q6 hrs, meropenem 1 g IV q8 hrs, doripenem 50 mg IV q8 hrs, piperacillin-tazobactam piperacillin tazobactam 3.375-4.5g 3.375 4.5g IV q6 hrs
Acute pyelonephritis
hemorrhage & swelling PMN infiltration
H&E wie pm
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 wie pm
Leukocyte y casts
PMN
1. Formation of WBC cast
3. Degenerate WBC cast
in fibrillar matrix
H&E
T b l llumen Tubular
Matrix
2. Passage into urine
PMN EM wie pm
BF
PMN
Bacterial casts
bacilli
pyelonephritis usually with leukocytes PMN bacilli
bacilli PMN
EM wie pm
EM
Catheter associated UTI
biofilm colonisation common with long-term
urinary catheters may cause septicemia in debilitated patient
Treat with A/B when:
fever, fever sepsis symptoms attributable to UTI (e.g. agitation) short-term catheter & UTI g biofilm colonisation Observe long-term wie pm
Prevention of catheter-associated UTI
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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 wie pm
Acute bacterial prostatitis
p Young men < 35 y.o. or STD risk g C. trachomatis or N. gonorrhoeae 1. Rx. as gonorrhoea then 2 doxycycline 100 mg / d x 7 days 2. Older men > 35 y.o. Enterobacteriaceae ciprofloxacin co trimoxazole co-trimoxazole wie pm
500 mg BD x 14 days BD x 14 days
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Pengelolaan : 1. 2. 3. 4.
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Umum : cairan cukup, elektrolit & nutrisi.
Atasi komplikasi : syok, urosepsis, GGA atau DIC. Pikirkan tindakan bedah, ( pus karena obstruksi saluran kemih). Antibiotika parenteral sampai 24 jam bebas demam ganti oral.
Sambil menunggu hasil kultur, diberikan antibiotika
berspektrum luas seperti :
Kombinasi ampicilin dan sefalosporin gen I
Aminoglycoside dg Betalactam.
Ticarcillin dg clavulanic acid.
Quinolone
Antibiotika oral selama :
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5-14 hari = 50% relaps.
4-6 minggu = angka keberhasilan mencapai 90%.
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.
The life must move on, and loop its course,
descend and then to ascend. We must advance and yearn, to overcome and transcend. transcend
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In our youth, youth we stand firm and resolute. We age and experience, distal years of our lives convolute.
The art of improvement and discipline,
through counter current and autoregulation. Akin to self-control and evolution, through practise, practise prayer and meditation. meditation Like our life, where experiences abound, we improve, develop and rectify. A little nephron sits there, to secrete secrete, adsorb and purify purify. As life wanders and winds, the nephron meanders its way. To part with toxins and miseries, all through the night and day. day
