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 : 105 bakt/ml
- Tergantung cara pengambilan sample
- Pada wanita muda  urin S.P.P  102 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
 Girls—6.5-8%
 Boys—2-3%
 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 UTI’s.
 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

13
PREVALENSI ISK MENURUT USIA &
SEKS
KELOMPOK PREVALENSI (%) L : P
USIA
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 ( 30 1:1
65) DIRAWAT DI
R.S.
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
 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

19
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
 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

25
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 >40ºC

 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
 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

35
 Signs and Symptoms –
Children 2 months to 2
years
 Fever—usually 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 Symptoms & Signs

Group Most common → Least
common
< 3mths Fever, Vomiting Poor feeding Abdominal pain
Lethargy, Failure to thrive Jaundice
Irritability Haematuria
Offensive urine
>3mths Fever Abdominal pain, Lethergy,
Preverb Loin tenderness Irritability
al Vomiting Haematuria
Poor feeding Offensive urine
Failure to thrive
>3mths Frequency Abdominal pain Fever, Malaise
Verbal Dysuria Loin tenderness Vomiting
Dysfunctional voiding Haematuria
Changes to continence Offensive/Cloud
 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.
 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

44
 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
 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.

48
 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  10⁵ colony
forming units
• Bag  85% false ₊ve
• Cathterization  10⁴ CFU
• Suprapubic aspiration any growth
 LABORATORY
EVALUATION
Other laboratory
tests
 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
 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
54
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

55
 PEMERIKSAAN RADIOLOGI
 Pada simple (uncomplicated) UTI  tidak perlu
 Indkasi
1. Memerlukan intervensi lain disamping terapi AB
2. Persistence bacteriuria
 FOTO POLOS ABDOMEN
- batu opak
- emphysematous pyelonephritis
 RENAL TOMOGRAM
- batu opak/semi opak
- gas dalam ginjal
  IVP
 Letak & derajat obtruksi
 Kelainan kongenital/anatomis : double
colekting, horse shoe kidney
 VOLDING CYSTOURETEROGRAM
 Vesiko ureteral reflux
 Neurogenik bladder
 Divertikel buli, urachus
 USG
 Hidronefrosis
 Pionefrosis
 Perirenal abses
 SPESIFIK

TRAK.URINARIUS
NON SPESIFIK

- Ginjal

INFEKSI - Ureter
- Buli

- Urethra

TRAK. GENITALIS - Prostat

- Epididymis
- Testis
 Urethritis

 In female infants  In pre-school and school

age girls
 Part of a diaper
 Part of “non-specific”
dermatitis vulvovaginitis
 In adolescent girls  Generally
environmental
and boys
 Bubble bath
 Presenting sign of  Nylon panties (also
STD 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  Improper wiping

 Female gender  Genitourinary
 Uncircumcised abnormalities
males  Vesicoureteral reflux
 Constipation  Obstruction

 Voiding dysfunction  Colonization with

virulent E. Coli
INFEKSI NON SPESIFIK
Akut
 GINJAL - Pielonefritis
- Abses ginjal Kronis
- Abses perirenal
- Interstitial nephritis
 URETER - Ureteritis
 BULI - Sistitis - Akut
- Berulang
 URETHRA - urethritis - 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°- 40°C)
- 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
S/d sembuh
- abstinensia
 Terapi  sexual partner
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 (+)  Biopsi
- Contrakted bladder
 Sistogram
- Vesico ureteral reflux
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

DON’T : Treat asymptomatic bacteuria

Use antibiotic prophylaxis routinely after 1st 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
 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.

94
 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

95
 Klasifikasi glomerulopathy
1. Klasifikasi klinis
2. Klasifikasi lesi histopatologi
3. Klasifikasi berdasar etiologi&patogenesis
4. Klasifikasi berdasar proses imunologi

96
 Klasifikasi klinis:
1. Kelainan urine tanpa keluhan
2. Sindroma nefrotik
3. Sindroma nefritik akut
4. Sindroma nefritik kronik
5. Sindroma RPGN (Rapid Progressive
Glomerulonephritis)

97
 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.

98
 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

99
 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.

100
 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,
 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 b haemolitik
b. endokarditis bakterialis (nefritis Lohlein)
c. stphylococcus albus ( shunt nephritis)
d. abses visceral
e. hepatitis B

104
3. Disseminated Lupus Erythematosus
(DLE)
4. Vaskulitis:
a. poliarteritis nodosa
b. Wagener Granulomatosis
c. henoch-Schonlein purpura
d. Krioglobulinemia
5. Nephritis herediter.

105
 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

106
 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%)

107
 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

108
 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

109
 Diagnosis etiologi
A. pem.serologi: - ASO titer
- kompleks imun
- antiimunoglobulin
- serum komplemen
B. pem.histopatologi.

110
 Penatalaksanaan:

1. Pengobatan darurat.
2. Pengobatan suportif

111
 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

112
 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.

113
Selamat belajar
&
SUKSES
 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

GNP’s 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 infection—most common source of

bacteremia, a dangerous systemic infection in
long-term care facilities

 Bacteremia—40 times more likely to occur in

catheterized than non-catheterized residents

 Bacteremia leads to significant morbidity and

mortality in the vulnerable elderly
Nicolle, 2005
 Urinary Tract Infection
Physiologic Changes
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
UTI—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
 Age-Related Changes in the
Urinary System
Structure Change Impact
Glomeruli ↓number  ↓filtration of blood
↑surface area  ↓glomerular filtration rate by 30-40%

Tubules thickened membrane  ↓tubule transport

fatty degeneration  ↓urine-concentrating capacity
shortening  ↓Na conservation
 ↓renal acidification
Renal stiffening  ↓blood flow
vasculature narrowing  ↓efficiency in removal of waste
product

Connective ↓expandability &  ↓bladder capacity

tissue compressibility of  ↑residual urine volume after voiding
bladder 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, cont’d

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, cont’d
Female vs. Male Complicating Factors

Age Group Female Male

(years) Risk Factors Risk Factors
50-70 Estrogen deficiency Prostatic obstruction
Diabetes Diabetes
Gynecological diseases— Urological/surgical procedures
cystocele & related surgical
procedures
H & P, cont’d
Female vs. Male Complicating Factors
Age Group Female Male
(years) Risk Factors Risk Factors
>70 Estrogen deficiency Prostatic obstruction
Diabetes Diabetes
Gynecological diseases (cystocele Urological/surgical
& related surgical procedures) procedures
Urological diseases (incontinence, Urinary catheter
residual urine, cystopathy) & Reduced mental status
related surgical procedures Co-morbid diseases
Urinary catheter Immunological changes
Reduced mental status
Co-morbid diseases
Immunological changes Wagenlehner, et al., 2005
Complicated vs Uncomplicated UTI
 UTI’s in elderly men are always considered
complicated
 UTI’s 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 UTI’s—culture-confirmed UTI’s
* >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 coli—gram (-) etiologic =agent
in ~ 80% of all UTI’s
 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, cont’d
Polymicromial bacteriuria

 Contamination most frequent cause of

multiple microorganisms
 25-33% in LTCF’s may be polymicrobic
due to fistulas, urinary retention, infected
stones, or catheters

Midthun, 2004
Causative Pathogens, cont’d
Age/Type Specific Pathogens

 Younger patients, rare in elderly—Staphylcoccus,

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 defined—exists 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, cont’d

ASB
 Frequent in elderly, even > prevalent in
residents of LTCF:
elderly >70 yrs old
women: 16-18%
men: 6%
Symptomatic vs. Asymptomatic
Bacteriuria, cont’d
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 diabetes—29%)
 Immunological: ↑’s in inflammatory mediators (cytokines, acute
phase proteins)
 Instrumental: indwelling catheter→always 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 interpretation—may not be due to UTI
 Change in character of urine
 One study found cloudy, bloody, or malodorous urine in >85%
symptomatic UTI’s
 Others less predictive
Midthun, 2004
Signs and Symptoms, cont’d
 Clarity of urine
 Clear → no bacteria; cloudy, milky or turbid → bacteriuria
 Cloudiness, however, can occur in normal urine—mucus, epithelial cells
 Cloudy character, alone or with (+) dipstick analysis → further lab
analysis
 Study by Loeb et al. (2001) as consensus criteria—cloudy urine not an
indication for antibiotics
 Bloody
 Hematuria not always indicative of infection; possibly
irritation or medication related
 Malodorous
 Not a valid indicator—may be caused by bacteria, but
could be hygiene-related
 Often considered an indicator, however
Midthun, 2004
 Signs and Symptoms,
cont’d
 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 UTI—consider differential diagnoses:
pulmonary or skin infections
 Lack of fever may delay diagnosis
Midthun, 2004
Signs and Symptoms, cont’d
 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, cont’d
 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, cont’d

 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 UTI’s 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
Infectious Disease Society of America:
Guidelines for Dx & Rx of ASB in adults

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
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 (UriscreenTM)
showed 100% sensitivity & specificity of 81%
 No clinical benefit to screen individuals other than
pregnant women—did 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: Catheter is not present:

two of the following must be met three of the following must be met

 Fever (>38°C/100.4°F) or increase of 1.5°C
(2.4°F) 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
(>38°C/100.4°F) or increase of 1.5°C (2.4°F)
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 Urinalysis—Key Indicators of Infection
Urine collection 1st morning specimen is best
Straight catherization for those incontinent, functionally or cognitively
impaired
Specific gravity Measure of kidney’s abiltiy to concentrte urine
Range of SG depends on state of hydration
Appearance Cloudy, may not indicate WBC’s
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 voiding—oxidation of urobilinogen to
urobilin)

Odor nl → faint odor when freshly voided

Foul-smelling—often presence of bacteria which splits urea to form
ammonia
Fischbach, 2004
Laboratory Analysis, continued
Routine Urinalysis, continued
pH Acid or base—measures free H+ ion concentration in urine 7.0—neutral.
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 Always an indicator of kidney/UT damage

Hemoglobin

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 UTI’s are caused by organisms that do not convert nitrate to
nitrite
(e.g., staphylococcus, streptococci)

*Leukocyte Esterase is released by leukocytes (WBC’s) in urine

Microscopic exam & chemical test
Esterase

__________
*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 UTI’s.
 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 UTI’s in the Elderly
Treatment Dosage/Duration Bacterial Coverage/ Common Side Compliance/ Cost Men Women
Resistance Effects Convenience I/E
Sulfonamide 160/800 mg po bid x 3-14* days (E. coli 20%) nausea, rash Fair/Good I √ √
Trimethoprim- *available in a syrup ↑ resistance
Sulfamethoxazole If CrCl <15-30 mL/min, ↓in half Less effective longer duration of bid
TMP-SMX ↓ compliance

Fluoroquinolones 100- 250 mg po bid x 3-14* days gram (-) effective headache, dizziness, Good/Good E √ √
Ciprofloxacin (2nd gen) If CrCL <30mL/min ↓ by half gram (+) only fair nausea, diarrhea bid, longer duration ↓
compliance
Levofloxacin (3rd gen) 250 mg po daily x 10 days Excellent
(complicated upper and lower UTI)

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

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

Miscellaneous ↑ resistance 2° Beta PCN-anaphylaxis Fair for bid dosing I Prostatitis √

Beta Lactam AB’s: Lactamase enzymes in Abdominal cramping NR
Cephalosporins (Cefuroxime, cefpodoxime) resistant bacteria diarrhea
Penicillins (ampicillin), Carbapenems (imipenem) 2nd/3rd gen Cephalosporins
Phenazopyridine (Pyridium)—not appropriate >resistant to beta
for elderly or patients with renal insufficiency lactamase

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 individual’s 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.
*Outcome—bacterial 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./ Proposed long term prophylaxis of recurrent UTI—

Stromm et al., 1980 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
 3rd 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 Findings
Studies
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) Central in folk medicine beneficial effects on urinary
Leading cranberry juice cocktail: juice tract health.
sweetener, water & added Vit. C 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
1984—Sobota 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
(PAC’s) 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
X (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
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.
Raisins—none
Small study

Jepson et al (2004) Cochrane Database 2004 Reviews—

Some evidence from RCT’s 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, RCT’s.

 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, cont’d

Interactions No significant herb-drug reactions reported

Dosage Varies. Cranberry extract tablets/capsules: 1 tablet (300-
400mg) twice daily. CranMax—500mg 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 Age-related changes and risk factors Indwelling catheter present (2 S&S):
Personal & Social Co-morbidities (diabetes, cancer, GU  Fever (>38°C/100.4°F) or increase of 1.5°C (2.4°F) above
history dx) baseline temperature.
Pregnancies  Chills

Urological & gynecological procedures  New CVA tenderness

History of UTI, recurrent UTI  New suprapubic/flank pain or tenderness

Medication/allergies  Decreased mental or functional status (delirium)

Cultural S&S interpretation  New-onset hematuria, foul-smelling urine, or (+) sediment

Catheter is not present (3 S&S):

 Acute dysuria alone (key indicator) or fever (>38°C/100.4°F)

Review of Systems *General appearance or increase of 1.5°C (2.4°F) above baseline temperature
Physical Skin/hydration  Chills
Examination *Fever, vital signs  Frequency

Cardiac-↑BP, AP, arrhythmias  Urgency

Pulmonary-lung sounds, DOE  New costovertebral angle tenderness

*CVA tenderness  Decreased mental or functional status (may be new or

Appetite, *abdominal pain, bowel increased incontinence related) *

pattern  New-onset hematuria, foul-smelling urine or (+) sediment

*Urine—color, character, odor, catheter,  New suprapubic/flank pain or tenderness

continence changes, dysuria

*Mental status—cognition, memory,
reporting reliability, decline,
↑ confusion, agitation/restlessness
UTI in the Elderly: Guidelines—Diagnosis, Treatment & Prevention
Clinical Plan Key Determinants Rationale
Urinalysis Indirect dipstick U/A for bacteriuria (+) nitrite Useful for screening asymptomatic individuals
Leukocyte esterase R/o’s urinary source of infection/less reliable

Lab urinalysis Pyuria—WBC’s in urine Indicates inflammatory response, not used as

w/microscopic exam indicator to treat ASB
Pyuria alone not specific for infection

Urine C&S Identifies organisms in urine and antimicrobial Organisms count must be sufficient to r/o contamination
sensitivity Identify antimicrobial effective against organism

CBC w/Diff Suspect bacterial infection To support treatment decision

Evaluate WBC & Diff Elevated WBC with left shift

Electrolytes Current status R/o dehydration, ? need for fluid replacement

BUN, Cr Current renal status Baseline for nephrotoxic meds

Blood culture Identify organism in suspected bacteremia Documents urosepsis

AB Rx determination

Treatment *See guidelines for empirical Rx Calculate CrCl: (140-Age) x weight in Kg (0.85 if female)
Other supports: 72 x serum creatinine
 hydration/fluid replacement/IV therapy
 fever—treat if present
 pain, discomfort—relieve symptoms Prevention Strategies
 cranberry extract tablets, 300-400 mg po bid and/or juice,
Asymptomatic bacteriuria
minimum of 240 mL/day
Rx not indicated due to risk of AB resistance
 ensure hydration of 2.5 L/day
Confirm with 2nd urine specimen
 strict hand and perineal hygiene
Monitor clinical status, assess for contributing factors, urinary  Staff ed r/t early detection of UTI S&S
incontinence
 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 LTCF’s.
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!