INFEKSI SALURAN KEMIH

DWI LESTARI PARTININGRUM

Nephrology and Hypertension Division
Internal Medicine Department
Medical Faculty Diponegoro University
 Introduction: UTI

 commonestt bacterial
b t i l iinfection
f ti forf 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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  Definisi :

• 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.

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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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 GEJALA
ginjal ISK ATAS
Pyelonefritis Demam
M
Menggigil
i il
Nyeri pinggang
Mual ± muntah
ureter
P
Penurunan BB
± gejala isk bawah

ISK BAWAH
Nyeri supra pubis
Ureteritis Disuria
Kandung Cystitis Frekuensi
kemih Prostatitis Urgensi
Epididimitis Hematuri
Urethritis

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 Klasifikasi ISK
Dari segi PENATALAKSANAAN dibedakan atas :
1. ISK uncomplicated ( i l ):
li t d (simple)
 ISK sederhana  anatomik maupun fungsional TU
normal.
 Terutama mengenai wanita.
 Infeksi hanya mengenai mukosa superfisial kandung
kemih.
 Penyebab kuman tersering (90%) adalah E. coli.
2
2. ISK complicated
 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.

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 ISK Complicated  terdapat keadaan sbb :

1. Kelainan abnormal saluran kencing.

Contoh : batu, obstruksi, refluks vasikouretral, atoni
kandung kemih, kateter menetap, prostatitis
menahun.
menahun
2. Kelainan faal ginjal. baik GGA maupun GGK.
3. Gangguan daya tahan tubuh. Penderita DM,
neutropenia, penderita dg terapi imunosupresif.
4. Infeksi disebabkan organisme virulen.
Seperti proteus spp yg memproduksi urease,
Infeksi metastatik staphylococcus.

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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 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
interpretasii kultur
k l urin
i porsii tengahh !! 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

Mikroorganisme Kultur positif ( % )

E. Coli
E C li 60 - 90 %
Klebsiela / Enterobacter 10 - 20 %
Proteus 5 - 10 %
Pseudomonas aurogenosa 2 - 10 %
Staph Epidermidis
Staph. 2 - 10 %
Enterokokkus 2 - 10 %
Kandida albikan 1-2%
Staph. Aureus 1-3%

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 Asymptomatic Bacteriuria

 Umumnya terjadi pd wanita 

2% - 4% wanita muda, 10% wanita >60 th.
 Bila
Bil ada
d DM risiko
i ik ISK 3 - 4x4 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 22x pemeriksaan,
ik
dg jenis kuman sama)

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 Asymptomatic UTI
 screening & symptoms minimal (urine odour)

Prevalence (%)
Neonates 1 (-> 50% VUR)
S h l il
Schoolgirls 12
1-2
Young women 10
Non-pregnant women 3-10
Pregnant women 5-6
5 6 (15-20%
(15 20% ->
> PN)
Elderly men & women 5-40 (age)

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 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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 Penatalaksanaan klinis wanita dg sindroma disuria frekuensi

Antibiotika dosis
tunggal

Observasi 4-7 hari

T
Tanpa gejala
j l G j l positif
Gejala itif

Kultur urin Urinalisis (piura)

Kultur (bakteriuri)

negatif positif

( ) (-)
(-) () (+) ((-)) (+/ ) (+)
(+/-)
sembuh Antibiotika
5-14 hari
Observasii
Ob Anti
A ti Chl
Chlamidia
idi Antibiotik
A tibi tik
analgetik Trachomatis 4 – 6 Minggu
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 Faktor risiko dan komplikasi ISK komplikata 
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. Empiric therapy must be broad spectrum with
definitive therapy based on culture and
sensitivity
2. Moderatelyy : Levofloxacin (500
( mgg IV/PO q
q24),),
ciprofloxacin (500 mg PO twice-daily/400 mg q
12h IV))
3. 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
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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

1. Formation of WBC cast

3. Degenerate WBC cast

in fibrillar matrix T b l llumen
Tubular H&E

Matrix 2. Passage into urine

PMN

EM BF PMN

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 Bacterial casts bacilli

 pyelonephritis
 usually with leukocytes
PMN

bacilli bacilli

PMN

EM EM

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 Pyelonephritis

80% 10% 10%

Uncomplicated Complicated Chronic
Acute Acute pyelonephritis
pyelonephritis pyelonephritis “smouldering”

Medical Medical and/or Medical and/or

therapy
py surgical
g therapy
py surgical
g therapy
py

100% 60% 40% 100%

Cured Cured Progressive Progressive
renal damage renal damage

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 Pengelolaan :

1. Umum : cairan cukup, elektrolit & nutrisi.

2. Atasi komplikasi : syok, urosepsis, GGA atau
DIC.
3. Pikirkan tindakan bedah, ( pus karena
obstruksi saluran kemih).
4. Antibiotika parenteral sampai 24 jam bebas
demam ganti oral.

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 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 :

 5-14 hari = 50% relaps.
 4-6 minggu = angka keberhasilan mencapai 90%.

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 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
Observe long-term biofilm colonisation

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 Prevention of catheter-associated UTI

 short duration
 insert under aseptic technique by trained
staff (or trained patient for intermittent self-
catheterisation)
 bag below bladder & emptied regularly
 keep system closed - sample urine by sterile
aspiration
 antimicrobial cream in women
 A/B for cardiac valvular abnormalities

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 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

C. trachomatis or N. gonorrhoeae
g
1. Rx. as gonorrhoea then
2 doxycycline 100 mg / d x 7 days
2.

Older men > 35 y.o.

Enterobacteriaceae
ciprofloxacin 500 mg BD x 14 days
co trimoxazole
co-trimoxazole BD x 14 days
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