Infeksi Saluran Kemih

Bambang Mulyawan
FK UMM
Introduction
Pediatric UTIs often signal an underlying
genitourinary tract abnormality
Can lead to renal scarring with resultant
hypertension and renal failure
Difficult to diagnose because symptoms
are non-specific in this age group and
testing is often invasive


URINARY TRACT INFECTION

DEFINITION:
TISSUE
RESPONSE TO THE
PRESENCE OF
SIGNIFICANT AMOUNT
OF BACTERIA IN THE
URINE

DEFINISI
ISK : Terdapatnya bakteriuri disertai reaksi
inflamasi
BAKTERIURI
- Adanya kuman didalam urin
- Bermakna : 10
5
bakt/ml
- Tergantung cara pengambilan sample
- Pada

wanita muda urin S.P.P 10
2
bakt/ml
- Bisa disertai piuri atau tanpa piuri
PIURI
- Adanya lekosit dalam urin 5/LPB
- Bisa - disertai bakteriuri
- steril TBC

Definition
Infection of kidneys, ureters, bladder and urethera

Upper Urinary tract infection - Pyelonephritis

Lower urinary tract infection- Cystitis, Urethritis

Why ?
Common

Difficult to identify

Significant complications

Guideline for Management ( imaging, prophylaxis and
prolonged follow up )
Which Organism?
Most common organism is

(a) Klebsiella

(b) E. Coli

(c) Pseudomonas
Epidemiology
One of the most common infections of the childhood

Age under one M > F why?
Age above one F > M

4% of boys and 12 % of girls will have had UTI by the age of
16 years
Of these : 4 % will have kidneys scars
50 % will develop hypertension
10% of those scarred will develop renal failure

PATHOGENESIS

Upper urinary
tract infection:

Pyelonephritis


Lower urinary
tract infection:
Cystitis

Pediatric UTIs:
Epidemiology
Prevalence
Girls6.5-8%
Boys2-3%
Uncircumcised boys have a 5-20 X
increase in UTIs vs circumcised boys
Occurs in about 7% of children <2 who
present with fever without a source

PATHOGENESIS

Ascending infection most
UTI beyond the newborn
period are the result of
ascending infection

Descending infection
4 - 9 percent of children with
UTI are bacteremic
Epidemiology
(continued)
Incidence of vesicoureteral reflux (VUR) is 1% in
children < 2 yoa.
50% of kids <1 yoa with UTI have VUR
Early renal scarring is nearly twice as common in
this age group.
Incidence of scarring increases with each
subsequent UTI
Scarring occurs in 5-38% of febrile UTIs.

13
Infeksi sal.kemih
- radang ok adanya mikroorg.di sal.kemih
- Pada semua usia , wanita > pria
- O.k bakteri, virus, yeast dan jamur
- Tersering o.k bakt.E.coli(50-90%), proteus,
klebsiela, enterobakter, pseudomonas; inf. Gram
positif lb.jarang
- Manifestasi dapat berupa asymptomatic
significant bacteriuri(ASB), bact.cystitis,
abacterial cystitis
- Dapat terjadi secara endogen, hematogen,
limfogen, eksogen akibat sistoskopi/kateter
PREVALENSI ISK MENURUT USIA &
SEKS
KELOMPOK
USIA
PREVALENSI (%) L : P

NEONATUS 1 1,5 : 1
USIA PRASEKOLAH 2-3 1 : 10
USIA SEKOLAH 1-2 1 : 30
USIA REPRODUKSI 2.5 1 : 50
USIA 65-70 20 1 : 10
USIA 80 30 1 : 2
USIA LANJUT (
65) DIRAWAT DI
R.S.
30 1 : 1
ETIOLOGI
Nonspesifik disebabkan
- Batang gram (-) aerob : E coli, P mirabilis
- Kokus gram (+) : Stafilokok, Enterokus
- Anaerob obligate : Bakterioides.
- Lain-lain: Chlamidia trachomatis,
Ureaplasma
Spesifik
Disebabkan mikroorganisme spesifik yang
memberikan gejala yang khas
Misal: Tuberkulosis, Gonorrhea, Actinomycosis

Risk Factors
antenatally-diagnosed renal abnormality
family history of vesicoureteric reflux ? (VUR) or renal disease
history suggesting previous UTI or confirmed previous UTI
recurrent fever of uncertain origin
poor urine flow ( phimosis)
dysfunctional voiding
constipation why?
abdominal mass, evidence of spinal lesion
poor growth
high blood pressure
blood group Lewis antigen

PATHOGENESIS


Host factors:

Age
Uncircumcised boys
Female infants
Race/ethnicity
Genetic factors
Urinary obstruction
Neurogenic Bladder, Dysfunctional elimination
Vesicoureteral reflux
Sexual activity
Bladder catheterization
PATHOGENESIS
Bacterial factors:


A variety of virulence factors
enable bacteria to ascend
into the bladder and
kidney
19
Faktor2 predisposisi
1. Bend.urin: kongenital, batu, oklusi ureter
2. Refluks vesikoureter
3. Rest-urine: BPH, striktur ureter, neurogenic-
bladder
4. Ggn. Metabolik: hiperkalemia, hipo kalsemia,
agamaglobulinemi
5. Manipulasi sal.kemih: kateter, dilatasi uretra,
sistoskopi
6. Kehamilan: faktor stasis& bendungan, serta
perubahan pH urine
LOKALISASI
Upper urinary tract. infection
Ginjal, Ureter
Lower urinary tract. ifection
Buli, Urethra
LAMA
Akut
Kronis kurang tepat
- persistent
- recurrent
UTI: Classiffication
Classification:
Upper tract infection
Acute pyelonephritis- fever, bacteriuria, systemic
symptoms
Lower tract infection
Urethritis
Cystitis
Voiding symptoms, little or no fever, no systemic
symptoms
KLASIFIKASI ISK (STAMEY 1980)
1. Infeksi pertama (First infection)
- Infeksi pertama kalinya
- Umumnya uncomplicated, sensitif terhadap AB
- Sering pada wanita muda, 1/3 recurrens
2. Unresolved bacteriuria
- Urine tak pernah steril selama terapi
- Penyebab :
- Resisten terhadap AB - Reinfeksi
- Pasien tidak disiplin - CRF
- Infeksi campuran - Batu staghorn
terinfeksi
- Bact. Cepat berubah menjadi resisten

3. Bacterial Persistence
Kultur urin steril selama th/ tetapi segera (+) bila th/
dihentikan sumber infeksi (+)
Penyebab
- Batu infeksi - Stump ureter terinfeksi
- Prostatitis kronis - Popillary necrosis terinfeksi
- Ginjal atrofi terinfeksi - Kista urachus terinfeksi
- Fistel - Infected medullary sponge kidney
- Obstructive nephropathy - divertikel urethra
- Divertikel pielokaliks - Benda asing
terinfeksi
4. Reinfeksi
- Timbul infeksi baru dengan patogen
yang
baru
- Interval dengan infeksi terdahulu
bervariasi
- 80% rekurensi reinfeksi
25
Patogenesis
1. Hematogen: ok.daya tahan menurun pada
peny.kronis, tx.imunosupresif, adanya fokus
infeksi di tulang/kulit/endotel.
2. Ascending infection:
a. kolonisasi uretra&introitus vagina
b. masuknya mikroorg.dlm.sal.kemih
c. multiplikasi bakteri dlm.kd.kemih &
pertahanan kd.kemih menurun
d. naiknya bakteri kd.kemih ke ginjal
PATOGENESIS
4 route infeksi
Ascending
Dari : - buli ke ginjal refluks
- urethra ke prostat, buli
Hematogen
Ke : ginjal, prostat, testis
Limfogen
Dari usus, cervix ke buli, ginjal
Direct extention
Dari usus ke buli



FAKTOR-FAKTOR YANG MEMPENGARUHI
TIMBULNYA I.S.K.
1. Faktor virulensi bakteri
2. Faktor kepekaan ekstrinsik
2.1. Pada wanita
2.1.1. Introitus
2.1.2. Urethra pendek
2.2. Pada pria Prostat mensekresi zat anti bakteri
bila /(-) Bacterial prostatitis
3. Faktor kepekaan intrinsik
Neurogenic bladder, rest urine, batu memudahkan
infeksi.
Surface mucin, GAG, urinary antibody, PH urine.
4. Faktor ureter & ginjal
Adanya Vesicoureteral reflux, kualitas
pristaltik ureter & kepekaan medula ginjal
terhadap infeksi
Obstructive uropathy, renal blood flow
& adanya benda asing me (+)
kepekaan terhadap infeksi.
CLINICAL PRESENTATION

Younger
children:
nonspecific
symptoms and
signs


CLINICAL PRESENTATION
Other Less common symptoms of UTI
in infants include
conjugated hyperbilirubinemia (in those
<28 days)
irritability
poor feeding
failure to thrive
CLINICAL PRESENTATION
S & S most helpful in identifying young
children with UTI:
History of previous UTI
Temperature >40C
Suprapubic tenderness
Lack of circumcision

CLINICAL PRESENTATION
Older children:
Fever
Urinary symptoms
Abdominal pain
Back pain
New onset urinary incontinence
fever, chills, vomitting and flank pain are
suggestive of pyelonephritis in older children
short stature, poor weight gain, or hypertension
secondary to renal scarring
Suprapubic and costovertebral angle tenderness
CLINICAL PRESENTATION
Older children:
Fever
Urinary symptoms
Abdominal pain
Back pain
New onset urinary incontinence
fever, chills, vomitting and flank pain are
suggestive of pyelonephritis in older children
short stature, poor weight gain, or hypertension
secondary to renal scarring
Suprapubic and costovertebral angle tenderness
35
Gejala klinis
- sering tidak khas/ tanpa gejala
- Disuria, polakisuri, nyeri suprapubik,
stranguria, tenesmus, nokturia, enuresis
- ISK.bawah: nyeri uretra, suprapubik
- ISK.atas: demam menggigil, nyeri
pinggang malaise, mual, muntah, nyeri
kepala
Signs and Symptoms
Children 2 months to 2
years
Feverusually unexplained
Vomiting and/or diarrhea
Abdominal Pain
Failure to thrive
Malodorous urine
Crying on urination
Signs and Symptoms
Children >2
Fever
Vomiting and/or diarrhea
Abdominal pain
Malodorous urine
Frequency and/or urgency
Dysuria
New incontinence
Clinical Presentation
Age and gender dependent
0 - 2 months:
Fever
2 mo. 2 y/o:
Fever (>38 C)
Irritability
Vomiting and Diarrhea
Decrease appetite
Between 1-2 y/o = crying on urination, foul smelling odor


Clinical Presentation
2 y/o 6 y/o:
Systemic symptoms
Fever
Flank or back pain
Urgency, urinary incontinence, dysuria
Suprapubic or abdominal pain
Foul smelling odor
> 6 y/o and adolescents:
Same as above
Clinical evaluation
HISTORY
history of the acute illness:
documentation of the height and duration of fever
urinary symptoms (dysuria, frequency, urgency,
incontinence),
abdominal pain,
suprapubic discomfort
back pain
vomiting
recent illnesses
antibiotics administered
and sexual activity (if applicable).



Clinical evaluation
HISTORY
past medical history :
Chronic urinary symptoms Incontinence, lack of proper stream,
frequency, urgency, withholding maneuvers
Chronic constipation
Previous UTI
Vesicoureteral reflux (VUR)
Antenatally diagnosed renal abnormality
Elevated blood pressure
Poor growth
In sexually active girls, whether barrier contraception with
spermicidal agents is used
Previous undiagnosed febrile illnesses
family history :
of frequent UTI, VUR, other genitourinary abnormalities and renal
failure.

Presentation
Age
Group
Symptoms & Signs
Most common Least
common
< 3mths Fever, Vomiting
Lethargy,
Irritability
Poor feeding
Failure to thrive
Abdominal pain
Jaundice
Haematuria
Offensive urine
>3mths
Preverb
al
Fever Abdominal pain,
Loin tenderness
Vomiting
Poor feeding
Lethergy,
Irritability
Haematuria
Offensive urine
Failure to thrive
>3mths
Verbal
Frequency
Dysuria
Abdominal pain
Loin tenderness
Dysfunctional voiding
Changes to continence
Fever, Malaise
Vomiting
Haematuria
Offensive/Cloud
y urine
Clinical evaluation
PHYSICAL EXAMINATION
Documentation of blood pressure and
temperature.
Growth parameters.
Abdominal examination for tenderness or
masses
Assessment of suprapubic and costovertebral
tenderness.
Examination of the external genitalia.
Evaluation of the lower back for signs of spina
bifida occulta.
Evaluation for other sources of fever.
44
Laborat:
1. Urinalisis: lekosituri, hematuri
2. Bakteriologis: mikros., kultur
3. Tes kimiawi: tes reduksi Griess-nitrate
4. Tes plat-celup (Dip-Slide)

Pem.penunjang:
- mencari kausa : batu, anomali sal.kemih
- IVP, USG, CT-Scanning
LABORATORY
EVALUATION
Urine:


Dipstick
microscopy
Culture &
sensitivity
LABORATORY
EVALUATION
Urine sampling: How to obtain???

Midstream clean catch
Bag
Cathterization
Suprapubic aspiration
LABORATORY
EVALUATION
Urine dipstick
88 % sensitive

Leukocytes
Protein
Red blood cells
Leukocyte esterase
Nitrite

48
Pengelolaan:
- Prinsip: eradikasi bakteri dg.Ab. Sesuai, koreksi
kelainan anatomis& faktor-faktor predisposisi.
- Cara : dosis tunggal
jangka pendek: 10 14 hari
jangka panjang 4 - 6 minggu
pengobatan profilaksis
pengobatan supresif
- antibiotik broadspektrum: amoksisilin, baktrim,
asam nalidiksat, asam pipemidat, sefaleksin.
LABORATORY
EVALUATION
Microscopic exam
White Blood Cells: in a
centrifuged sample of
unstained urine pyuria
is defined as 5
WBC/high power field ,
or 10 WBC/mm3 in an
uncentrifuged sample
Bacteria: bacteriuria is
the presence of any
bacteria per hpf.
Gram stain
CARA PENGAMBILAN SAMPLE
Untuk me (-) kontaminasi terutama pada wanita

1. Aspirasi supra pubik
2. Mid Stream
Posisi lithotomy, perinum & gen.ext dibersihkan
dengan sabun.
3. Kateterisasi (jangan dari urine bag)

Untuk mengambil sample urine dari ginjal
pakai kateter ureter.
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 clean catch 10 colony
forming units
Bag 85% false ve
Cathterization 10 CFU
Suprapubic aspiration any growth
LABORATORY
EVALUATION
Investigate the fever.
Markers of inflammation (WBC, ESR,
CRP)
Serum creatinine
Blood culture Bacteremia occurs in 4-9 % of
infants with UTI
Lumbar puncture Infants <1 month of age with
fever and a positive urinalysis; approximately 1 % of
infants with UTI also have meningitis
Other laboratory
tests
54
Pengobatan:
1. Uretritis/sistitis:
- Terapi konvensional dg broadspektrum
antibiotik 3-10 hari
- terapi dosis tunggal: amoks. 3 g, baktrim 4
tab., gentamisin 120 mg im, kanamisin
2. PNA( pielonefritis akut):
- kasus berat MRS dg antib. Parenteral
kombinasi aminoglikosid-ampisilin, sambil
menunggu tes kepekaan; bila perlu
diberikan
piperasilin, sefalosporin generasi III.
- kasus ringan: dg antibiotik broadspektrum
55
3. Pielonefritis kronik: diobati bila ada bakteriuri
dg antibiotik yg sesuai, koreksi kelainan
anatomis.
4. ASB: pada wanita hamil.
dosis tunggal observasi 2-4 mg
jangka pendek obs.; bila rekuren Ab.
Diteruskan s/d 6 mg/partus
5. ISK rekuren: antibiotik profilaksis
cara pemberian: 3 kali/mg atau tiap hari
selama 6 bulan sampai 3 tahun lebih
PEMERIKSAAN RADIOLOGI
Pada simple (uncomplicated) UTI tidak perlu
Indkasi
1. Memerlukan intervensi lain disamping terapi AB
2. Persistence bacteriuria
O FOTO POLOS ABDOMEN
- batu opak
- emphysematous pyelonephritis
O RENAL TOMOGRAM
- batu opak/semi opak
- gas dalam ginjal
O IVP
Letak & derajat obtruksi
Kelainan kongenital/anatomis : double
colekting, horse shoe kidney
O VOLDING CYSTOURETEROGRAM
Vesiko ureteral reflux
Neurogenik bladder
Divertikel buli, urachus
O USG
Hidronefrosis
Pionefrosis
Perirenal abses

INFEKSI
TRAK.URINARIUS
TRAK. GENITALIS
SPESIFIK
NON SPESIFIK
- Ginjal
- Ureter
- Buli
- Urethra
- Prostat
- Epididymis
- Testis
Urethritis
In female infants
Part of a diaper
dermatitis
In adolescent girls
and boys
Presenting sign of
STD

In pre-school and school
age girls
Part of non-specific
vulvovaginitis
Generally
environmental
Bubble bath
Nylon panties (also
biker shorts, leotards,
bathing suits)
Poor hygiene (not
wiping, wiping back to
front)
Overzealous hygiene
Use of baby powder,
perfumes

Symptoms of urethritis
Dysuria
Reluctance to void
Perineal discomfort, erythema
May be associated with vaginal irritation
and erythema in girls
In older boys, urethral discharge
In adolescent girls associated with PID
symptoms
Risk Factors

Age <1 year
Female gender
Uncircumcised
males
Constipation
Voiding dysfunction

Improper wiping
Genitourinary
abnormalities
Vesicoureteral reflux
Obstruction
Colonization with
virulent E. Coli

INFEKSI NON SPESIFIK
GINJAL - Pielonefritis
- Abses ginjal
- Abses perirenal
- Interstitial nephritis
URETER - Ureteritis
BULI - Sistitis - Akut
- Berulang
URETHRA - urethritis - Akut
- kronis
Akut
Kronis
PIELONEFRITIS AKUT
Infeksi pada parenkim & pelvis ginjal
Etiologi : E coli, Proteus, Klebsiella, Strept,
Fecalis.
Patogenesis
Umumnya infeksi ascending
Jarang hematogen atau limfogen
Temuan Klinis
Gejala-gejala - demam & menggigil tiba-tiba
- nyeri menetap pada pinggang
- sistitis (frekwensi, nokturia,
urgensi & disuri)
- malaise, mual, muntah, diare.

Tanda-tanda - tampak sakit
- demam (38,5- 40C)
- takikardia (90x/i - 140x/i)
- nyeri ketok pada pinggang
- ginjal sukar diraba
- distensi abdomen
- paralitik ileus
Laboratorium
- Leukositosis, BSR
- Urin : keruh, piuria, bakteriuria, proteinuria kadang-
kadang hematuria.
- Fungsi ginjal : normal
Radiologis
* BNO - bayangan ginjal tidak jelas
- batu ginjal
* IVP - ginjal membesar
- neprogram ber (-)
Diagnosis banding
- Pankreatitis
- Basal pneumonia
- Appendisitis, Cholesistitis
- PID

Komplikasi
- Septikemi
Pengobatan
- Segera buat kultur urin dan darah
- Antibiotik : - Aminoglikosid + Ampisilin IV
selama 1 minggu disambung AB sesuai
kultur.
- Bed rest
- Analgenik / Antipiretik.



Cystitis
Afebrile usually
Frequency
Enuresis
Dysuria
Reluctance to void
SISTITIS AKUT
Etiologi : E coli (terbanyak), Staphylococcus
saprophyticus, Enterococcus
Umumnya asal infeksi dari urethra
Insidens : lebih sering pada wanita dari pada laki-
laki.
Patologi :
Stad awal : mukosa hiperemis, edema.
Stad lanjut : mukosa rapuh, hemorrhgis, ulkus
dangkal yang berisi eksudat.
Temuan Klinis
Gejala-gejala :
- freukwensi, disuri, urgensi, nokturi &

- rasa terbakar pada saat miksi
- urge incontinence, hematuri
- nyeri suprapubik & pinggang
- honeymoon cystitis
Tanda-tanda :
- nyeri ketok suprapubis
- vagina - discharge
- VT adnexa ?
- defisiensi estrogen pucat
- urethra tumor, karunkulae.

Pyelonephritis
Usually associated with fever and
systemic signs 2 renal parenchymal
inflammation
Older children
Flank pain or abdominal pain
Younger children
Fever, irritability, vomiting, poor feeding
Laboratorium
- Hemogram : lekositosis ringan
- Urinalisa : piuria, bakteriuria, hematuria
(mikro/gross)
- Kultur urine & tes sensitivitas
Pielografi intravena
Indikasi - Th/ A.B tidak membaik
- Sistitis tanpa piuria, gejala (+)
- Sistitis berulang
- Hematuria

Sistoskopi & kalibrasi urethra
- Indikasi sistoskopi : hematuri, pada IVP tidak
ditemukan kelainan pada traktus urinarius
bagian atas.
- Kalibrasi dengan bougie a boule snapping
stenosis
Pengobatan
- A.B. sesuai kultur
- Anticholinergic Probanthine
- Urinary analgesic Pyridium
- Stiktur/stenosis dilatasi
- Karunkulae ekstirpasi

URETHRITIS AKUT
Etiologi
- Ascending : meatus, urethra distal
- Descending : traktus urinarius bagian atas buli
& prostat
- Penyebab
* N gonorrhoeae terbanyak
* NGU : Chlamydia trachomatis, U urealyticum
Patologi
- mukosa eritema, edema, eksudat purulen
- ulserasi
Temuan klinis
Gejala-gejala :
- discharge pada urethra
- disuri
- gatal & rasa terbakar pada urethra
- Go masa inkubasi 1-5 hari discharge
purulent (seperti susu)
- NGU : masa inkubasi 5-21 hari discharge
mukoid, disuri bisa (+)/(-)

Tanda-tanda :
- discharge (+)
- meatus urethra : merah, edematous
Laboratorium
- Urin : lekosituria
- Gram -stained smear
* intracelluler gram (+) cocci Go
* gram (+) cocci tidak ditemukan NGU
- Kultur & tes sentivitas urin
Tanda-tanda :
- discharge (+)
- meatus urethra : merah, edematous
Laboratorium
- Urin : lekosituria
- Gram -stained smear
* intracelluler gram (+) cocci Go
* gram (+) cocci tidak ditemukan NGU
- Kultur & tes sentivitas urin
Komplikasi
- infeksi keatas : prostat, ductus ejaculatorius,
vesicula seminalis, vas deferens, epididymis &
buli.
- abses periurethral
- stricture urethra
Terapi
1. Gonorrhea infeksi non spesifik
2. NGU sesuai hasil kultur.

A.B. - Tetrasiklin 4x500 mg
- Doksisiklin 2x100 mg
- Minosiklin 2x100 mg
- Eritromisin 4x500 mg
- Tmp - sm
- lama terapi 7-14 hari
Laki-laki : - pakai kondom
- abstinensia
Terapi sexual partner

S/d sembuh
URETER
Akibat infeksi descending dari ginjal
Ureter menjadi fibrosis, memendek menjadi
lurus, atau striktur
Muara ureter golf hole
Akibat stenosis ureter hidronefrosis
autonefrektomi
Striktur tersering pada uretero - vesikal
Radiologis
IVP - gambaran striktur ureter single atau
multiple
- dilatasi ureter
- ureter pendek, lurus
BULI
Gejala awal irritasi buli
Miksi terasa panas, frekwensi, nokturi hematuri
Gejala lanjut
- Ulserasi buli nyeri suprapubis
- Contracted bladder Frekwensi >> OK
kapasitas buli
Sistoskopi
- tuberkel (+)
- Ulserasi (+)
- Contrakted bladder
Sistogram
- Vesico ureteral reflux

Biopsi
Terapi
(1) Cycloserine + PAS + INH
(2) Cycloserine + Ethambutol + INH
(3) Rifampisin + Ethambutol + INH
Dosis
- Cycloserine 2x250mg/hr
- PAS 15gr/hr
- INH 300mg/hr
- Ethambutol 1200mg/hr
- Rifampisin 600mg/hr
Lama terapi
Gow (1979) 6 bulan
Antibiotics
DONT : Treat asymptomatic bacteuria
Use antibiotic prophylaxis routinely after 1
st
UTI

DO : Use different antibiotic, not a higher dose of same
antibiotic, for children who are already on
prophylactic antibiotic
A Cochrane systematic review suggests that treatment for 2-4
days seems to be as effective as treatment for 7 - 14 days for
eradicating lower tract UTI in children.
Prognosis
Most recover quickly and completely with antibiotic
treatment.

Recurrence of urinary tract infection is more likely in:
Younger children i.e. aged less than 6 months
Girls compared to boys
Vesicoureteral reflux

Vesicoureteric reflux (VUR) is found in about 1% of normal
infants and normally resolves over several years.However, it
is a risk factor for pyelonephritis, which can cause renal
scarring, which can lead to hypertension & impaired renal
function.

MANAGEMENT
MANAGEMENT
GOALS:
Elimination of infection and prevention of
urosepsis
Relief of acute symptoms
Prevention of recurrence and long-term
complications


MANAGEMENT
Decision to hospitalize:
Age <2 months
Clinical urosepsis or potential bacteremia
Immunocompromised patient
Vomiting or inability to tolerate oral
medication
Lack of adequate outpatient follow-up
Failure to respond to outpatient therapy

MANAGEMENT
ANTIBIOTIC THERAPY:
Choice of agent: provide adequate coverage for
E. coli.
Oral therapy: Cefixime, amoxicillin-clavulanate.
Parenteral therapy: Third- or fourth-generation
cephalosporins and aminoglycosides are
appropriate first-line agents for empiric
treatment of UTI in children.
In children receiving antibiotic prophylaxis.

MANAGEMENT
ANTIBIOTIC THERAPY
Duration of therapy: 5-14 days
Response to therapy:
Clinical response
Repeat urine culture
MANAGEMENT
FURTHER INVESTIGATIONS
Indications:
1. Girls younger than 3 years of age with a first
UTI
2. Boys of any age with a first UTI
3. Children of any age with a febrile UTI
4. Children with recurrent UTI
5. First UTI in a child of any age with a family
history of renal disease, abnormal voiding
pattern, poor growth, hypertension
PROGNOSIS
Recurrent UTI
14 percent of children younger than 6
years with UTI have a subsequent UTI
associated with a higher risk of UTI
recurrence
-white race
-age 3 to 5 years
-VUR of grade IV to V
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.


URINARY TRACT
INFECTION

WHY IMPORTANT????

May lead to renal scarring
RENAL SCARRING
The loss of renal parenchyma between the calyces and
the renal capsule, a potential complication of UTI.

Long-term consequences include hypertension,
decreased renal function, proteinuria, and end-stage
renal disease

The development of renal scarring has been associated
with:
-Recurrent febrile UTI
-Delay in treatment of acute infection
-Dysfunctional elimination
-Obstructive malformations
-VUR
94
Sindroma nefritik akut
Batasan: SNA (glomerulonefritis akut)
adalah sidroma klinik yg ditandai oliguri,
kelainan urinalisis (proteinuri < 2 g/hr),
hematuria,azotemia, hipertensi,
bendungan sirkulasi, kenaikan tek.vena
jugularis, hepatomegali, edema.
95
Glomerulopathy
- adalah proses inflamasi glomerulus
- Terjadi akibat berbagai sebab yg berbeda
etiologi, patofisiologi ataupun
patogenesanya
- Dulu dikenal dg istilah glomerulonephritis
- Peyebab utama Gagal Ginjal
- Manifestasi klinis bisa tanpa gejala sampai
gejala yang berat
- Terpenting:menghambat progresifitas
kerusakan
96
Klasifikasi glomerulopathy
1. Klasifikasi klinis
2. Klasifikasi lesi histopatologi
3. Klasifikasi berdasar etiologi&patogenesis
4. Klasifikasi berdasar proses imunologi
97
Klasifikasi klinis:
1. Kelainan urine tanpa keluhan
2. Sindroma nefrotik
3. Sindroma nefritik akut
4. Sindroma nefritik kronik
5. Sindroma RPGN (Rapid Progressive
Glomerulonephritis)

98
Klasifikasi lesi
histopatologis
a. Lesi minimal
b. Lesi glomerulosklerosis fokal segmental
c. Lesi mesangioproliferatif (IgM)
d. Lesi mesangioproliferatif (IgA) (penyakit
Berger)
e. Lesi proliferatif akut
f. Lesi membranoproliferatif
g. Lesi membranosa
h. Lesi bulan sabit (crescentic)
i. Lesi glomerulosklerosis.
99
Klasif. Etiologi& patogenesa
a. Kelainan imunologi
b. Kelainan metabolik:
- nefropati diabettik
- nefropati as. Urat
- amiloidosis primer/sekunder
c. Kelainan vaskuler
d. Disseminated Intravascular Coagulopathy
(DIC)
e. Kel. Herediter: sindr.Alport, peny.Fabry
f. Patogenesis tak diketahui: lipoid nefrosis
100
Klasif. imunologi
a. peny. Kompleks immun:
1. Circulating immune complex:
Nephropathy Berger
Henoch-Schonlein Purpura
Nefritis Lohlein (endokar.bakteri)
2. Pembentukan komplek imun insitu:
Glom. Post Streptococcus infection
Glom. Membranosa
b. peny.AGBM: sindroma Goodpasteur.

FUNGSI GINJAL
FUNGSI UTAMA : MEMBERSIHKAN PLASMA DARAH
DARI ZAT-ZAT YANG TIDAK DIPERLUKAN TUBUH,
TERUTAMA HASIL-HASIL METABOLISME PROTEIN.
Secara keseluruhan dapat dibagi 2 golongan : I.
Fungsi ekskresi : sisa metabolisme, regulasi volume
cairan tubuh, menjaga keseimbangan asam basa.
II. Fungsi endokrin : partitipasi dalam eritropoesis (
pembentukan eritrosit ), pengaturan tekanan darah,
keseimbangan kalsium dan fosfor


Faal Ginjal
A. Faal glomerulus, yaitu filtrasi darah
B. Faal tubulus, yaitu mengatur aliran dan
konsentrasi urine. Mengatur
keseimbangan asam basa dengan
pertukaran ion hidrogen, produksi amonia
dan reabsorpsi bikarbonat; mengatur
pengeluaran elektrolit, asam amino dan
asam organik,
104
Etiologi :
1. Glomerulopati (GP)idiopatik /primer
a. GP akut proliferatif
b. GP mesangioproliferatif (IgA)
(penyakit Burger)
c. GP membranoproliferatif.
2. GP post-infeksi:
a. post-infection streptococcus bhaemolitik
b. endokarditis bakterialis (nefritis Lohlein)
c. stphylococcus albus ( shunt nephritis)
d. abses visceral
e. hepatitis B
105
3. Disseminated Lupus Erythematosus
(DLE)
4. Vaskulitis:
a. poliarteritis nodosa
b. Wagener Granulomatosis
c. henoch-Schonlein purpura
d. Krioglobulinemia
5. Nephritis herediter.
106
Patofisiologi
1. Kel.urinalisis: ok. Kerusakan dd. Kapiler
glomerulus selektif proteinuri < 2g/hr,
hematuria disertai silinder eritrosit.
2. LFG menurun, disertai reabsorbsi Na.
dan air sehingga terjadi oliguri ,edema,
edema paru dan hipertensi

107
Gejala klinis:
1. 90% G/ subklinis ,kelainan urinalisis +
hipertensi.
2. 10% dg G/klinik:
a. sindroma nefrotik (4%)
b. sindroma RPGN (1%)
c. sindr.nefritik akut (5%)
108
Klinis:
1. Riwayat infeksi streptokok
2. Oliguri dan hematuri tanpa rasa sakit.
3. Hipertensi terutama pada anak2
4. Sembab & bendungan sirkulasi:
- kardiomegali
- bendungan paru akut
- kenaikan tek.vena jugularis.
- hepatomegali
5. bradikardi
109
Pemeriksaan & diagnosis
1.diagnosis:
a. kelainan urinalisis: proteinuri, hematuri
b. foto thorax: kardiomegali&bend.paru
c. ECG: voltase rendah, T inverted, QT >
2. Diagnosis perjalanan penyakit:
a. faal ginjal kenaikan BUN & kreatin
b. elektrolit serum: Na.turun, K naik.
c. protein darah tetap/turun, profil lemak normal
d. ggn.faktor pembekuan: fibrinogen, F.VII, fibrinolitik

110
Diagnosis etiologi
A. pem.serologi: - ASO titer
- kompleks imun
- antiimunoglobulin
- serum komplemen
B. pem.histopatologi.
111
Penatalaksanaan:

1. Pengobatan darurat.
2. Pengobatan suportif
112
Pengobatan darurat:
1. Mengatasi bendungan sirkulasi dan paru:
a. posisi tidur setengah duduk
b. oksigen
c. diuresis paksa : lasix intravena
d. morfin
e. obat antihipertensi oral
f. hemodialisis: bila tx 24 jam gagal/GGA
2. Ensefalopati hipertensi akut :
a. hidralazin 20 mg I.V. & diuretik furosemid
b. nifedipin im. /sublingual dan furosemid
113
Pengobatan suportif
1. Diet: a. tinggi kalori 35 kal./kgBB/hr
b. lemak tak jenuh
c. rendah protein 0,5-
0,75/kgBB/hr
d. elektrolit: Na.&K. dibatasi
Ca. 600-1000 mg/hr
2. Cairan: harus dibatasi untuk menjaga
keseimbangan cairan tubuh.
Selamat belajar
&

Urinary Tract Infection:
Guidelines to assessment,
treatment, and prevention
in the older adult

33:610 Gerontological Nursing
University of Massachusetts Lowell

Mary Ellen Powers, BSN, RN

March 30, 2006
Urinary Tract Infection
The Agency for Healthcare Research and
Quality (AHRQ) and the U.S. Preventive
Services Task Force (USPSTF)
Mission

Improve quality, efficiency and effectiveness of
healthcare for all Americans

Supports health services research that will
improve the quality of healthcare & promote
evidence-based decision making
Urinary Tract Infection
GNPs Role

Develop and implement evidence-based
health promotion strategies, as well as
prevention and treatment criteria in UTI
management of the older adult, both in the
community and long-term care setting
Urinary Tract Infection
Prevalence

Community-dwelling elders 25%
Swart, Soler & Holman, 2004

Long-term care elders 25-50% of women
(chronically bacteriuric) 15-40% of men
Juthani-Mehta et al., 2005

Marked increases in women & men after age 65
Wagenlehner, Naber & Weidner, 2005

}
Urinary Tract Infection Defined
Definition

Women: Presence of at least 100,000 colony-
forming units (cfu)/mL in a pure
culture of voided clean-catch urine

Men: Presence of just 1,000 cfu/mL
indicates urinary tract infection

*Some labs do not routinely identify & determine the
sensitivity of organisms for specimens with <10,000
cfu/mL. May have to special request.
Swart, Soler & Holman, 2004




Urinary Tract Infection

Urinary tract infectionmost common source of
bacteremia, a dangerous systemic infection in
long-term care facilities

Bacteremia40 times more likely to occur in
catheterized than non-catheterized residents

Bacteremia leads to significant morbidity and
mortality in the vulnerable elderly
Nicolle, 2005

Physiologic changes with aging in the urinary tract
Age-Related Changes Men Women
Decreased bladder capacity and increased
urine production (especially at night)

Decreased voided volume

Decreased estrogen w/menopause leads to
thinning of vaginal & urethral mucosa

Decreased lower urinary tract sensory
threshold

















Palmer, 2004
Urinary Tract Infection
Physiologic Changes
Physiologic changes with aging in the urinary tract
Age-Related Changes Men Women
Problems of urinary storage & emptying

incidence of overflow incontinence from
urethral obstruction or stricture

Decreased estrogen levels leads to pH
changes in vagina, favoring colonization of
E. coli, risk of UTI

Prostatic enlargement can lead to urinary
obstruction, increased residual urine &
infection

























Palmer, 2004
UTIPhysiologic Changes
Age-Related Changes in the
Urinary System
Structure Change Impact
Glomeruli number
surface area
filtration of blood
glomerular filtration rate by 30-40%
Tubules thickened membrane
fatty degeneration
shortening
tubule transport
urine-concentrating capacity
Na conservation
renal acidification
Renal
vasculature
stiffening
narrowing
blood flow
efficiency in removal of waste
product
Connective
tissue
expandability &
compressibility of
bladder
bladder capacity
residual urine volume after voiding
Palmer, 2004
History & Physical Examination
Age-related Risk Factors for UTI

Advanced Age
Fecal incontinence/impaction
Incomplete bladder emptying or neurogenic bladder
Vaginal atrophy/estrogen deficiency
Pelvic prolapse/cystocele
Insufficient fluid intake/dehydration
Indwelling foley catheter or urinary catheterization or
instrumentation procedures
H & P, contd

Age-related Risk Factors for UTI

Diabetes or immunosuppression
Benign prostatic hypertrophy
Bladder or prostate cancer
Urinary tract obstruction
Spinal cord injury

Mahan-Buttaro, Aznavorian & Dick, 2006

H & P, contd
Age Group
(years)
Female
Risk Factors
Male
Risk Factors
50-70 Estrogen deficiency
Diabetes
Gynecological diseases
cystocele & related surgical
procedures
Prostatic obstruction
Diabetes
Urological/surgical procedures
Female vs. Male Complicating Factors
H & P, contd
Age Group
(years)
Female
Risk Factors
Male
Risk Factors
>70 Estrogen deficiency
Diabetes
Gynecological diseases (cystocele
& related surgical procedures)
Urological diseases (incontinence,
residual urine, cystopathy) &
related surgical procedures
Urinary catheter
Reduced mental status
Co-morbid diseases
Immunological changes
Prostatic obstruction
Diabetes
Urological/surgical
procedures
Urinary catheter
Reduced mental status
Co-morbid diseases
Immunological changes


Wagenlehner, et al., 2005
Female vs. Male Complicating Factors
Complicated vs Uncomplicated UTI
UTIs in elderly men are always considered
complicated
UTIs in women are complicated when:
Hx of recurrent UTI
Secondary to structural abnormalities
Catheters
Stones
Urinary retention
Abscess formation or urosepsis
Primary diagnostic and treatment focus in
research studies have been related to the elderly
female population

Swart, Soler & Holman, 2004
Complicated vs Uncomplicated UTI
Recurrent UTIsculture-confirmed UTIs
* >3 in 1 year or
* > 2 in 6 months

Relapse UTI occurs within 2 weeks of Rx
of an earlier UTI
same pathogen
Re-infection UTI occurs >4 weeks after
earlier UTI
different pathogen

Swart, Soler & Holman, 2004

Causative Pathogens
UTI in Women
Escherichia coligram (-) etiologic agent
in
~
80% of all UTIs
Research indicates primary source of
microbial invasion is retrograde
colonization by intestinal pathogens
Other factors influencing colonization:
vaginal pH, urethral length, capacity of
bacteria to adhere to urothelium
Osborne, 2004
=
Causative Pathogens, contd
Polymicromial bacteriuria

Contamination most frequent cause of
multiple microorganisms
25-33% in LTCFs may be polymicrobic
due to fistulas, urinary retention, infected
stones, or catheters


Midthun, 2004

Causative Pathogens, contd
Age/Type Specific Pathogens

Younger patients, rare in elderlyStaphylcoccus,
saprophyticus (gram pos.) 10-15%
Elderly diabetics
Klebsiella species (gram neg.) most common
LTCF elderly
E. coli ~ 30%
Proteus species (part of host flori in GI tract) ~ 30%
Staphylcoccus aureus, Klebsiella, Pseudomonas
(gram neg.) and Enterococcus (gram pos.) ~ 40%

Swart, Soler & Holman, 2004

Symptoms versus
Asymptomatic Bacteriuria
Asymptomatic Bacteriuria (ASB)
Defined as the presence of bacteria in
urine of patients who do not have dysuria,
urinary frequency, urgency, fever, flank
pain, or other symptoms related to
irritation of the urethra, bladder, or kidney
Swart, Soler & Holman, 2004
Strictly definedexists when 2 urine
cultures done with clean-catch specimens
are positive in a patient who has no
urinary tract symptoms
Foxman, 2003
Symptomatic vs Asymptomatic
Bacteriuria, contd
ASB
Frequent in elderly, even > prevalent in
residents of LTCF:
elderly >70 yrs old
women: 16-18%
men: 6%
Symptomatic vs. Asymptomatic
Bacteriuria, contd
Asymptomatic Bacteriuria (ASB)

Most ASB in the elderly is associated with complicating
factors such as:
Hormonal: post-menopausal women
Anatomical: prostatic obstruction in men, cystocele in women
Functional: CNS, i.e., P.D. & dementia
Metabolic: diabetics (ASB females with Type 2 diabetes29%)
Immunological: s in inflammatory mediators (cytokines, acute
phase proteins)
Instrumental: indwelling catheteralways bacteriuric symptoms

Wagenlehner, Naber & Weidner, 2005
UTI Signs and Symptoms in
Elderly
Very difficult to assess and recognize, even when present in the
older adult.
Signs & Symptoms that indicate further evaluation for UTI elicited
from H&P:

New or increased urgency, frequency, dysyuria:
> in younger patients, still can be present in elderly
These complaints can be common & chronic without
bacteriuria
Requires careful interpretationmay not be due to UTI
Change in character of urine
One study found cloudy, bloody, or malodorous urine in >85%
symptomatic UTIs
Others less predictive
Midthun, 2004
Signs and Symptoms, contd
Clarity of urine
Clear no bacteria; cloudy, milky or turbid bacteriuria
Cloudiness, however, can occur in normal urinemucus, epithelial cells
Cloudy character, alone or with (+) dipstick analysis further lab
analysis
Study by Loeb et al. (2001) as consensus criteriacloudy urine not an
indication for antibiotics
Bloody
Hematuria not always indicative of infection; possibly
irritation or medication related
Malodorous
Not a valid indicatormay be caused by bacteria, but
could be hygiene-related
Often considered an indicator, however
Midthun, 2004
Signs and Symptoms,
contd
Elevated temperature(vital signs)
Elderly require > time to present with fever, may not have any
increase in temperature may even be hypothermic
Elderly at d risk for masked or absent fever response due to
antipyretics, corticosteroids, chemo Rx, alcoholism,
hypothyroidism, malnutrition and renal insufficiency
Studies indicate fever is a marker for serious infection & most
important clinical indicator for antibiotic treatment
Other studies, fevers can resolve without treatment; antibiotics
did not improve outcomes in elderly
Not always due to UTIconsider differential diagnoses:
pulmonary or skin infections
Lack of fever may delay diagnosis
Midthun, 2004
Signs and Symptoms, contd
Pain
Despite limitations of assessment in the elderly, suprapubic,
flank or CVA pain can indicate UTI
(abdominal, rectal & vaginal exam)
Agitation, irritability, restlessness, decreased appetite,
increased confusion, or even falls may indicate pain
(Neuro & GI exam)
Cultural differences in interpretation of pain, symptoms

Incontinence
May be caused by UTI or the altered mental status that
that occurs with the elderly
Commonly caused by other conditions
Symptom and a risk factor of UTI

Midthun, 2004
Signs and Symptoms, contd
Decline or Sudden Change in Mental Status
(Neuro, MMSE)
Hallmark symptom of UTI in elderly in most studies
Altered mental status, lethargy & confusion are the most
common indicators of bacteremia in elderly UTI

Falls
Not specific to UTI, but may indicate a change in status,
evaluate clinical picture

Appearance(general survey)
Vague assessment
General decline in status
Listen to family and staff that know the patient well
Midthun, 2004
Signs and Symptoms, contd
Other Possible Signs & Symptoms of UTI
Signs of sepsis other than fever or decline in M.S.
Hypotension
Tachycardia
Tachypnea
Rales
Respiratory distress
Anorexia, nausea, vomiting
Abdominal tenderness
Midthun, 2004
Diagnostic Criteria
Pyuria
A host response to infecting bacteria causing an increase of
white blood cells or pus in the urine
Associated with presence of both symptomatic and
asymptomatic UTIs in elderly
Level of pyuria is when infected with a gram negative
organism
Most research finds this is so common that it has questionable
value in UTI detection and as an indicator for Rx in the
absence of clinical symptoms
McGeer et al. (one of the most commonly used consensus criteria in
LTCF for UTI detection in Canada) rejects it as being a reliable predictor
of bacteriuria or symptomatic infection
Midthun, 2004
Juthani-Mehta,, 2005
Screening/Diagnosis
Asymptomatic Bacteriuria

No universally accepted criteria for the
diagnosis, treatment, or surveillance of UTI,
specifically in LTCF residents

Treatment of ASB is associated with adverse
antimicrobial effects, re-infection with organisms
or increasing resistance
Nicolle, et al., 2005
Screening/Diagnosis
1. ASB Dx based on results of a culture from clean-catch
specimen (* important to minimize contamination)
+ Women: bacteriuria = 2 consecutive voided urine samples
w/isolation of same strain in cfu/mL >100,000
+ Men: bacteria = single, clean-catch specimen with 1
bacterial species isolated in > 100,000 cfu/mL
+ Both: single catheterized urine specimen with 1 bacterial
species isolated in a count of > 1,000 cfu/mL


Infectious Disease Society of America:
Guidelines for Dx & Rx of ASB in adults
Screening/Diagnosis
Guidelines, continued
2. Pyuria accompanying ASB not an indication for
antimicrobial Rx (A-2)
3. Pregnant women should be screened in early
pregnancy, at least once & treated if positive (A-1)
4. Screening of ASB & Rx if positive before these
urological procedures:
+ Transurethral resection of prostate (A3)
+ Procedures anticipated to cause possible mucosal
bleeding (A-3)


Screening/Diagnosis
Guidelines, continued
5. No screening for ASB: (A-1 & A-2 strongly recommended via
research evidence)
+ Pre-menopausal, non-pregnant women (A-1)
+ Diabetic women (A-1)
+ Community older adults (A-2)
+ Institutionalized elderly (A-1)
+ Spinal cord injury (A-2)
+ Indwelling-catheterized patients (A-1)
6. Antimicrobial Rx of asymptomatic women with catheter-
acquired bacteriuria persisting 48 hrs after removed, should
be considered (B-1/good)
7. No screening or Rx of ASB renal transplant or solid organ
transplant recipients (C-3/weak)
Infectious Disease Society of America, 2005
Nicolle et al. 2005
www.guideline.gov/summary/summary

Screening/Diagnosis
Guidelines, continued
Guide to Clinical Preventive Services, 2005
Similar consensus of IDSA recommendations
Clinical considerations
Dipstick analysis & direct microscopy have poor
positive & negative predictive value for detecting ASB
Urine culture = gold standard, but expensive for
routine screening in populations of low prevalence
New enzymatic urine screening test (Uriscreen
TM
)
showed 100% sensitivity & specificity of 81%
No clinical benefit to screen individuals other than
pregnant womendid not improve clinical outcomes.
Guide to Clinical Preventive Services, 2005
http://www.ahrq.gov/clinic/ppcletgp/geps2b.htm#bacteriaria


Screening & Diagnosis
Guideline Criteria for Treatment
The following are a recommended minimum set of criteria adapted from the McGeer
(1991) and Loeb et al. (2001) studies necessary to initiate diagnostics and AB Rx.

Indwelling catheter present:
two of the following must be met
Catheter is not present:
three of the following must be met

Fever (>38C/100.4F) or increase of 1.5C
(2.4F) above baseline temperature.
Chills
New costovertebral angle tenderness
New suprapubic pain, flank pain or
tenderness
Decreased mental or functional status
(delirium)
New-onset hematuria, foul-smelling urine,
or amount of sediment
Acute dysuria alone (key indicator) or fever
(>38C/100.4F) or increase of 1.5C (2.4F)
above baseline temperature
Chills
Frequency
Urgency
New costovertebral angle tenderness
Decreased mental or functional status (may be
new or increased incontinence related) *
New-onset hematuria, foul-smelling urine or
(+) sediment
New suprapubic pain, flank pain or tenderness

Laboratory Analysis
Dipstick Testing

Used in primary care & LTC settings. But for institutionalized adults,
urinalysis is preferable.

Chemically impregnated reagent strips (UA Chemstrip Screen) provide
preliminary/quick determinations of:

pH bilirubin
protein blood
glucose *nitrite
ketones *leukocyte esterase
urobilinogen specific gravity
Fischback, 2004
Fairly reliable, although U.S. Preventive Services Task Force (USPSTF)
report from research studies these have poor positive & negative
predictive value for detecting bacteriuria in asymptomatic patients.
www.ahrq.gov/clinic (2005)

Laboratory Analysis, continued
Routine UrinalysisKey Indicators of Infection
Urine collection 1
st
morning specimen is best
Straight catherization for those incontinent, functionally or cognitively
impaired
Specific gravity Measure of kidneys abiltiy to concentrte urine
Range of SG depends on state of hydration
Appearance Cloudy, may not indicate WBCs
Could indicate a change in urine pH causes precipitation
Alkaline urine phosphates cloudy
Acid urine urates cloudy
Color Pale yellow to amber
Variations can be caused by medications, disease processes (*nl urine
darkens on standing 30 min. after voidingoxidation of urobilinogen to
urobilin)
Odor nl faint odor when freshly voided
Foul-smellingoften presence of bacteria which splits urea to form
ammonia
Fischbach, 2004
Laboratory Analysis, continued
Routine Urinalysis, continued
pH Acid or basemeasures free H
+
ion concentration in urine 7.0neutral.
Indicates kidney function
Determines if systemic acid-base disorders of metabolic/resp. origin
control of pH manages bacteriuria, renal calculi & drug Rx
bacteria from a UTI produce alkaline urine
Blood or
Hemoglobin
Always an indicator of kidney/UT damage
Protein (Albumin) Single most important indication of renal disease
Microalbuminuria Below dipstick range of detection
Detects deteriorating renal function in diabetic patients (standard
screener)


Fischbach, 2004
Laboratory Analysis, continued
Routine Urinalysis, continued
*Nitrite (Bacteria)
Dipstick - rapid, indirect method to detect bacteria
common gram-negative organisms contain enzymes reduce nitrate
in urine to nitrite
some UTIs are caused by organisms that do not convert nitrate to
nitrite
(e.g., staphylococcus, streptococci)
*Leukocyte
Esterase
Esterase is released by leukocytes (WBCs) in urine
Microscopic exam & chemical test

__________
*U/A testing positive for nitrite & leukocyte esterase should be cultured for bacterial pathogen

Fischbach, 2004
Urine Culture and Sensitivity
Traditional gold standard for significant
bacteriuria >100,000 cfu/mL of urine. Some
argue criteria for bacteriuria is only 100 cfu/mL of
a uropathogen in symptomatic females or 1,000
in symptomatic males.

Bacterial identification from urine C&S, key in
males and females with complicated UTIs.
Other Laboratory Tests
Complete Blood Count with Differential
Indicated to R/O bacterial infection supports treatment
plan
Careful evaluation of WBC & differential (left shift)
Electrolytes
R/O dehydration & if IV fluids replacement needed
BUN, Creatinine
Determine renal function for nephrotoxic
medications
Blood Culture
Identify bacteremic organism in suspected urosepsis
Treatment Plan
Early detection/Rx goal is to prevent systemic infection,
bacteremia
Initiation of antibiotic treatment is recommended for a
clinically-diagnosed UTI. Adjust medication when urine C&S
is final
Selection of antibiotic must be individualized and consider:
Side effect profile
Cost
Bacterial resistance
Likelihood of compliance (convenience, fewer pills/day s
compliance)
Effect of impaired renal function on dosing
Possible adverse drug reactions in elderly (multiple drugs, co-
morbidities.
Osborne, 2004
Swart et al. 2004
Treatment Plan
Recommended Treatment Regimens for Acute, Uncomplicated UTIs in the Elderly
Treatment Dosage/Duration Bacterial Coverage/
Resistance
Common Side
Effects
Compliance/
Convenience
Cost
I/E
Men Women
Sulfonamide
Trimethoprim-
Sulfamethoxazole
TMP-SMX
160/800 mg po bid x 3-14* days
*available in a syrup
If CrCl <15-30 mL/min, in half
(E. coli 20%)
resistance
Less effective
nausea, rash Fair/Good

longer duration of bid
compliance
I

Fluoroquinolones
Ciprofloxacin (2
nd
gen)

Levofloxacin (3
rd
gen)

100- 250 mg po bid x 3-14* days
If CrCL <30mL/min by half

250 mg po daily x 10 days
(complicated upper and lower UTI)
gram (-) effective
gram (+) only fair
headache, dizziness,
nausea, diarrhea
Good/Good
bid, longer duration
compliance
Excellent

E



Fosfomycin 3 g powder, dissolved in water
*single dose
gram (-) effective
gram (+) less effective
diarrhea, vaginitis,
nausea, rhinitis
Excellent VE, often
not on
formularies




Nitrofurantoin
(Macrobid)
100 mg po bid x 7 days
If CrCL <40 mL/min
not recommended
Narrow spectrum
gram (-) effective
gram (+) effective
nausea, vaginitis,
diarrhea
rate of severe
pulmonary &
hepatotoxicity
Fair
7-day regimen &
bid, compliance
I Prostatitis
NR


Miscellaneous
Beta Lactam ABs:
Cephalosporins (Cefuroxime, cefpodoxime)
Penicillins (ampicillin), Carbapenems (imipenem)
Phenazopyridine (Pyridium)not appropriate
for elderly or patients with renal insufficiency
resistance 2 Beta
Lactamase enzymes in
resistant bacteria
2
nd
/3
rd
gen Cephalosporins
>resistant to beta
lactamase
PCN-anaphylaxis
Abdominal cramping
diarrhea
Fair for bid dosing I Prostatitis
NR


Data adapted from Swart et al. (2004), Osborne (2004), Wagenlehner et al. (2005), Mahan-Buttaro et al. (2006) and Evercare
Corp (2004)
I = inexpensive; E = expensive; VE = very expensive; NR = not recommended
*Longer duration for complicated UTI per individuals clinical status
Treatment Plan
Duration of Antibiotic Therapy: Ongoing Debate
Research
Vogel et al., 2004 Double-blind randomized controlled trial compared 3-and
7-day courses of oral ciprofloxacin, 250mg bid.
183 elderly women > 65 yrs old. Acute, uncomplicated
UTI.
*Outcomebacterial eradiation @ 2 days, Rx was 98%
in 3-day group; 93% in 7 day group.
3-day course not inferior to 7 day
Better tolerated
Rates of relapse & re-infection 6 weeks later, both
groups similar
Brumfitt et al./
Stromm et al., 1980
Proposed long term prophylaxis of recurrent UTI
demonstrated benefits from low dose, long term Rx with
nitrofurantoin macrocrystals 100 mg po at bedtime.
There was minimal/no association w/development of
resistance in susceptible strains.
Treatment Plan
AB Rx for at least 10 days for institutionalized
elderly, as short-term therapy may not be as
effective.

Ten-14 days, if indicated, for complicated UTI.
(recommended for males)
Evercare, 2004

Conventional regimen of 7-10 days duration is
usually recommended.
Wagenlehner et al. 2005

Treatment Plan
Complicated UTI
Can be common in LTC patients
Associated with azotemia, obstruction, or indwelling foley
Can lead to bacteremia, life-threatening systemic infection

Recommended Treatment for Acute Complicated UTI
IV antibiotic therapy--*consider renal & hepatic elimination,
creatinine clearance for dosage adjustment
3
rd
generation cephalosporin (Ceftriaxone = Rocephin) Rx 1
gram IV every 24 hours
Or if fluoroquinolones (Levofloxacin = Levaquin) 250-500 mg IV
every 24 hours
Continue until afebrile, minimum of 48 hrs, then start oral
therapy and fluids x 14 days.
Mahan-Buttaro et al., 2006
Prevention & Treatment Plan
Recommendations/Considerations/Prevention

Indwelling-Catheterization
Foley catheterization should be avoided if at all possible

Most effective means of UTI prevention is limitation of
chronic indwelling catheters.
Wagenlehner et al. 2005


Prevention & Treatment
Recommendations/Considerations/Prevention
Research
Studies
Findings
Wilde & Carrigan (2003) Patients with indwelling catheters, maintaining urine flow was a key finding in preventing
UTI
Muder et al. (2006) Urinary catheterization is a major risk factor for S. aureus bacteriuria in long-term
care patients, so reducing prevalence of indwelling catheters is key. Majority of these
cases are methicillin-resistant S. aureus, which can lead to bacteremia
Need for optimal infection-control measures & limit unnecessary AB admin. in LTCF.
Focus on urine as potential infection reservoir, may be effective preventive strategy
Nicolle ( 2005) Study focused on catheter-related UTI.
Catheter infection rate of 5%/day
*Formation of biofilm on catheters leads to infection as this protects pathogens from
antimicrobials & host immune response

Johnson et al (2006) Studied efficacy of antimicrobial urinary catheters in hospitalized patients.
prevent or delay onset of catheter-associated bacteriuria
Alternative Therapies in UTI Prevention
Old adage: An ounce of prevention is worth a pound of cure.
Cranberry (Vaccinium macrocarpon, fruit)
Leading cranberry juice cocktail: juice
sweetener, water & added Vit. C
Central in folk medicine beneficial effects on urinary
tract health.
Longstanding Rx for UTI prophylaxis
Well-tolerated, key factor with older adults
Mechanism Cranberry prevents bacterial (E. coli & other gram-
negative uropathogens) binding to host cell surface
membranes
1984Sobota demonstrated a mode of action in
cranberry juice that interferes with the adherence of
E. coli and other bacteria to uroepithelial cells
Scientific Rationale E. coli & other bacteria have different types of
adhesins on their fimbriae that allow the organism
to adhere to epithelial cells & proliferate.
Cranberries unique compound, proanthocyanidins
(PACs) adhesins inhibit this process
Prevention & Treatment
Recommendations/Considerations/Prevention
Post-menopausal women w/recurrent infection may
require estrogen replacement to restore atrophic
vaginal mucosa, vaginal pH (topical creams)
Always adjust antibiotic dosage for renal
impairment/insufficiency using the Cockcroft-Gault
equation:
(140-Age) x weight in Kg (0.85 if female)
72 x serum creatinine
http://www.fhea.com/op/ch14.htm
Ensure adequate hydration
Recommended 2.5 L/day in patients with recurrent UTI
Often signs & symptoms similar to UTI in elderly are actually
caused by dehydration

X
Alternative Therapies for Prevention
Cranberry juice, dried cranberries, raisins
Research Studies Findings/Evidence
Greenberg et al. (2005) Boston pilot-study on 5 subjects.
Some evidence of anti-adherence activity using dried cranberry
consumption.
Raisinsnone
Small study
Jepson et al (2004) Cochrane Database 2004 Reviews
Some evidence from RCTs to show cranberries (juice & capsules) can
prevent recurrent infections in women (especially older women). No
significant difference between juice or capsules. Safe & well-tolerated
McHarg et al. (2005) May alter or even prevent formation of calcium oxalate kidney stones vs.
just water consumption (upper UT)
Multiple studies Pilot, double-blind crossover design, prospective, RCTs.
All support a moderately preventive role for cranberry juice or capsule
concentrates against UTI
No significant findings or support in treatment of bacteriuria
Key Points in Cranberry Therapy, contd
Interactions No significant herb-drug reactions reported
Dosage Varies. Cranberry extract tablets/capsules: 1 tablet (300-
400mg) twice daily. CranMax500mg once daily (potent
cranberry supplement)
Cost Tablets: $10-$15/30-day supply
Unsweetened juice: varies
*Safe botanical alternative, effective in UTI prophylaxis

Other Alternative Therapies in UTI Management
Grapefruit Seeds Case study by Oyelami et al (2005)4 middle-aged patients
treated w/seeds x 2 weeks upon dx of UTI.
Concluded: adequate clinical response
5-6 seeds every 8 hrs comparable to antibacterials
Oral Lactulose May reduce rate of UTIs in elderly.
Possible mechanism: increase in fecal Lactobacillus organisms
& avoidance of constipation
Urinary Tract Infections in the Elderly:
Guidelines for Assessment, Diagnosis, Treatment and Prevention
Assessment
Key Determinants Evaluation
Past medical history
Personal & Social
history


Age-related changes and risk factors
Co-morbidities (diabetes, cancer, GU
dx)
Pregnancies
Urological & gynecological procedures
History of UTI, recurrent UTI
Medication/allergies
Cultural S&S interpretation
Indwelling catheter present (2 S&S):
Fever (>38C/100.4F) or increase of 1.5C (2.4F) above
baseline temperature.
Chills
New CVA tenderness
New suprapubic/flank pain or tenderness
Decreased mental or functional status (delirium)
New-onset hematuria, foul-smelling urine, or (+) sediment
Catheter is not present (3 S&S):
Acute dysuria alone (key indicator) or fever (>38C/100.4F)
or increase of 1.5C (2.4F) above baseline temperature
Chills
Frequency
Urgency
New costovertebral angle tenderness
Decreased mental or functional status (may be new or
increased incontinence related) *
New-onset hematuria, foul-smelling urine or (+) sediment
New suprapubic/flank pain or tenderness

Review of Systems
Physical
Examination
*General appearance
Skin/hydration
*Fever, vital signs
Cardiac-BP, AP, arrhythmias
Pulmonary-lung sounds, DOE
*CVA tenderness
Appetite, *abdominal pain, bowel
pattern
*Urinecolor, character, odor, catheter,
continence changes, dysuria
*Mental statuscognition, memory,
reporting reliability, decline,
confusion, agitation/restlessness
UTI in the Elderly: GuidelinesDiagnosis, Treatment & Prevention
Clinical Plan Key Determinants Rationale
Urinalysis

Lab urinalysis
w/microscopic exam
Indirect dipstick U/A for bacteriuria (+) nitrite
Leukocyte esterase
PyuriaWBCs in urine
Useful for screening asymptomatic individuals
R/os urinary source of infection/less reliable
Indicates inflammatory response, not used as
indicator to treat ASB
Pyuria alone not specific for infection
Urine C&S Identifies organisms in urine and antimicrobial
sensitivity
Organisms count must be sufficient to r/o contamination
Identify antimicrobial effective against organism
CBC w/Diff
Evaluate WBC & Diff

Electrolytes

BUN, Cr

Blood culture
Suspect bacterial infection
Elevated WBC with left shift

Current status

Current renal status

Identify organism in suspected bacteremia
To support treatment decision


R/o dehydration, ? need for fluid replacement

Baseline for nephrotoxic meds

Documents urosepsis
AB Rx determination
Treatment *See guidelines for empirical Rx
Other supports:
hydration/fluid replacement/IV therapy
fevertreat if present
pain, discomfortrelieve symptoms
Asymptomatic bacteriuria
Rx not indicated due to risk of AB resistance
Confirm with 2
nd
urine specimen
Monitor clinical status, assess for contributing factors, urinary
incontinence
Calculate CrCl: (140-Age) x weight in Kg (0.85 if female)
72 x serum creatinine

Prevention Strategies
cranberry extract tablets, 300-400 mg po bid and/or juice,
minimum of 240 mL/day
ensure hydration of 2.5 L/day
strict hand and perineal hygiene
Staff ed r/t early detection of UTI S&S

GNP Implications
Overuse of antibiotics is problematic in UTI management
in elderly
Careful individualized assessment & evaluation of elder.
Must consider differential diagnoses before treatment,
even when urine culture is positive.
Identification of subtle, atypical symptoms of UTI is
critical. Listen to family and staff
UTI most common nosocomial infection in LTCFs.
Opportunity to educate staff and implement preventative
measures to incidence.
Lack of consensus criteria related to UTI management in
elderly emphasizes need for further research in urinary
health promotion. Be proactive!