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INFEKSI SALURAN KEMIH

DWI LESTARI PARTININGRUM
Nephrology and Hypertension Division
Internal Medicine Department
Medical Faculty Diponegoro University/ Kariadi Hospital
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Introduction: UTI
commonest bacterial infection for 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.
Adanya bakteri dalam urin (bakteriuria) 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.
Klasifikasi Klinis :
*Asymptomatic bacteriuria
*Acute uncomplicated cystitis in women
*Recurrent infections in women
*Acute uncomplicated pyelonephritis in women
*Complicated UTIs in both sexes
*Catheter-associated UTIs
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ginjal
ureter
Kandung
kemih
ISK ATAS
ISK BAWAH
Pyelonefritis
Ureteritis
Cystitis
Prostatitis
Epididimitis
Urethritis
GEJALA
Demam
Menggigil
Nyeri pinggang
Mual muntah
Penurunan BB
gejala isk bawah
Nyeri supra pubis
Disuria
Frekuensi
Urgensi
Hematuri
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Klasifikasi ISK
Dari segi PENATALAKSANAAN dibedakan atas :
1. ISK uncomplicated (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. 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.
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
tuberculosis
salmonella

3. Lymphatic: rare
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Host defences
1. Bladder
bladder emptying
mucosal phagocytes
2. Antibacterial substances
3. Anti-adherence mechanisms
urine, bladder & prostatic
secretions
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Pathogenesis of urinary infection
Bacterial virulence vs. host defences

1. Inoculum
2. Adherence characteristics
3. Failure of urinary defence
obstruction, calculi, VUR
incomplete bladder emptying
diabetes mellitus & elderly
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Patogenesis lanjutan
+Bacterial factor
-95% dari luar TU
-5% hematogen
+Host factor
-Wanita : uretra pendek, kolonisasi kuman pd
introitus vagina, sex intercourse, tampon,
spermatisid, diafragma, menopause (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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Jumlah organisme pada ISK :
70% ISK jml kuman > 100.000 kuman/ml urin.
30% ISK jml kuman lebih rendah, mis; pend. pria,
wanita dg disuria akut, wanita dg ISK berulang
karena stapphylococcus.

Pemeriksaan urinalisa :
Epitel skuamos kemungkinan kontaminasi.
Piuria infeksi/ peradangan.
Silinder lekosit pielonefritis.
DIAGNOSIS
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Pemeriksaan kultur urin, yg didapat dari :
a. Urin porsi tengah (mid stream urin)
b. Urin aspirasi suprapubik
c. Urin kateter kandung kemih (hindari)

Dalam interpretasi kultur urin porsi tengah !! sbb :
95% ISK disebabkan monomikrobial
95% ISK disebabkan gram negatif/ enterococci
Staphylococcus epidermidis, diptheroids &
lactobacilli jarang menimbulkan ISK.
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Bakteri penyebab ISK
Mikroorganisme Kultur positif ( % )

E. Coli 60 - 90 %
Klebsiela / Enterobacter 10 - 20 %
Proteus 5 - 10 %
Pseudomonas aurogenosa 2 - 10 %
Staph. Epidermidis 2 - 10 %
Enterokokkus 2 - 10 %
Kandida albikan 1 - 2 %
Staph. Aureus 1 - 3 %
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Asymptomatic Bacteriuria
wUmumnya terjadi pd wanita
2% - 4% wanita muda, 10% wanita >60 th.
wBila ada DM risiko ISK 3 - 4x nya.
wLaki2 jarang sekali, kecuali umur tua dg
hipertrofi prostat.
wTidak perlu antibiotik. (kecuali didapatkan kultur +
kuman 100.000 CFU/mL pada 2x pemeriksaan, dg jenis
kuman sama)
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Asymptomatic UTI
screening & symptoms minimal (urine odour)

Prevalence (%)
Neonates 1 (-> 50% VUR)
Schoolgirls 1-2
Young women 10
Non-pregnant women 3-10
Pregnant women 5-6 (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, kultur (+)
=Keluhan sering kencing sedikit2, sakit waktu kencing
serta rasa tidak enak didaerah suprapubik. Disertai
demam subfebril ().

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Antibiotika dosis
tunggal
Observasi 4-7 hari
Tanpa gejala Gejala positif
Kultur urin
Urinalisis (piura)
Kultur (bakteriuri)
negatif
positif
sembuh
Antibiotika
5-14 hari
Observasi
analgetik
Antibiotik
4 6 Minggu
Anti Chlamidia
Trachomatis
(-) (-) (+) (-)
Penatalaksanaan klinis wanita dg sindroma disuria frekuensi
(+/-) (+)
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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
Spinal cord injury & neurologic dysfunction
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
Faktor risiko dan komplikasi ISK komplikata
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TREATMENT
1. Empiric therapy must be broad spectrum with
definitive therapy based on culture and sensitivity
2. Moderately : Levofloxacin (500 mg IV/PO 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 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: pyelonephritis
1. Fever T > 38
0
C, rigors, chills, sweats
2. Loin pain
3. Constitional symptoms
anorexia, nausea, vomiting, diahorrea, myalgia,
headache
4. Lower urinary symptoms
dysuria, frequency (30 - 50%)
supra-pubic discomfort
UA: pyuria, leukocytes, hematuria
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Leukocyte casts
2. Passage into urine
1. Formation of WBC cast
3. Degenerate WBC cast
in fibrillar matrix
PMN
EM
BF
Tubular lumen
Matrix
PMN
H&E
PMN
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Bacterial casts
pyelonephritis
usually with leukocytes
EM
EM
PMN
bacilli
PMN
bacilli
bacilli
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Pyelonephritis
80%
Uncomplicated
Acute
pyelonephritis
10%
Complicated
Acute
pyelonephritis
10%
Chronic
pyelonephritis
smouldering
Medical
therapy
Medical and/or
surgical therapy
Medical and/or
surgical therapy
100%
Cured
100%
Progressive
renal damage
60%
Cured
40%
Progressive
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 :
O 5-14 hari = 50% relaps.
O 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, sepsis
symptoms attributable to UTI (e.g. agitation)
short-term catheter & UTI
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
Adult males
prostate often source
antibacterial prostatic secretion
-> fails in chronic prostatitis
Homosexual males
5% with UTI
E Coli: same serotype
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Acute bacterial prostatitis
Young men < 35 y.o. or STD risk
C. trachomatis or N. gonorrhoeae
1. Rx. as gonorrhoea then
2. doxycycline 100 mg / d x 7 days

Older men > 35 y.o.
Enterobacteriaceae
ciprofloxacin 500 mg BD x 14 days
co-trimoxazole BD x 14 days
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