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INFEKSI SALURAN KEMIH

DWI LESTARI PARTININGRUM


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
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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
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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

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
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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

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

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

screening & symptoms minimal (urine odour)

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)

Terapi ISK Uncomplicated ( Simple )


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
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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
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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

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
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BF

PMN

Bacterial casts

bacilli

pyelonephritis
usually with leukocytes
PMN
bacilli

bacilli
PMN

EM
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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
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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
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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
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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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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