Infeksi Saluran

Kemih
Afifah Machlaurin

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 Isi Materi

Definisi & Patofisiologi

Mikrobiologi

Presentase Klinik

Terapi dan Outcome Terapi

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 Definisi ISK

Terdapatnya mikroorganisme patogen

dalam saluran kemih dg
CFU (Colony Forming Unit) > 105/cc urin
(bukan kontaminasi)
lekosituri > 10 /LPB
Bakteriuria
Reaksi radang dr host dg atau tanpa
gejala klinis

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 Epidemiologi ISK

 Sering ♀
 uretra pendek & dekat vagina
 post menopouse   estrogen  gangguan
sal kencing bawah
 hamil : insiden 
 Perubahan fisiologik sal kemih selama hamil
 statis urin, protein uria, glukosuria
 Insiden  dg  umur
 inkontinensia,  penggunaan kateter
Renal insuf,  BPH
 Imunosuppresion  - HIV – AIDS
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 Klasifikasi ISK

Upper urinary tract

Infections:
 Pyelonephritis
Lower urinary tract
infections
 Cystitis
(“traditional” UTI)
 Urethritis (often
sexually-
transmitted)
 Prostatitis
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 (Pratiwi Sudarmono) 2004

Staph.
Epidermis
Alkaligenes
fecalis
(11%)

Kleb Mikroorganisme
Pnemoni
(13%) Patogen Lain
E Coli
(19%) M. tbc
Jamur
Virus

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 Presentase Klinik

 Dysuria
 Increased frequency
 Hematuria
 Fever > 38oC
 Nausea/Vomiting
(pyelonephritis)
 Flank pain
(pyelonephritis)

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 Pemeriksaan Laboratorium

Labs: Urinalysis
 + leukocyte esterase
 + nitrites
• More likely gram-negative rods
 + WBCs
 + RBCs

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 Tujuan Terapi????
Mencegah perluasan infeksi
Membunuh mikroorganisme
Mencegah Relaps

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 Memilih AB
Prinsip
Durasi Terapi
Terapi
Evaluasi Outcome

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 Terapi ISK Sederhana

1 2 3
3 hari dg : IDSA : 7 – 14 hr, Urine Culture
• trimetofrin – anti biotika sama Sensitifitas AB
sulfa dengan sistitis Terapi berdasar
metoxazole
• amok, as akut kultur selama 7-
klavulanat 14 hari
• Fluorokuinolo
• Fosmisin

Pielonefritis Recurrent
Sistitis Akut Akut Cystitis

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 Terapi Empiris

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 Uncomplicated (simple) Cystitis

 Definition
 Healthy adult woman (over age 12)
 Non-pregnant
 No fever, nausea, vomiting, flank pain
 Diagnosis
 Dipstick urinalysis (no culture or lab tests needed)
 Treatment
 Trimethroprim/Sulfamethoxazole for 3 days
 May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrim-
resistance
 Risk factors:
 Sexual intercourse
• May recommend post-coital voiding or prophylactic antibiotic
use.
 Complicated Cystitis

 Definition
 Females with comorbid medical conditions
 All male patients
 Indwelling foley catheters
 Urosepsis/hospitalization
 Diagnosis
 Urinalysis, Urine culture
 Further labs, if appropriate.
 Treatment
 Fluoroquinolone (or other broad spectrum antibiotic)
 7-14 days of treatment (depending on severity)
 May treat even longer (2-4 weeks) in males with UTI
Special cases of Complicated cystitis
 Indwelling foley catheter
 Try to get rid of foley if possible!
 Only treat patient when symptomatic (fever, dysuria)
• Leukocytes on urinalysis
• Patient’s with indwelling catheters are frequently colonized with
great deal of bacteria.
 Should change foley before obtaining culture, if possible
 Candiduria
 Frequently occurs in patients with indwelling foley.
 If grows in urine, try to get rid of foley!
 Treat only if symptomatic.
 If need to treat, give fluconazole (amphotericin if resistance)
 Recurrent Cystitis

Want to make sure urine culture and sensitivity

obtained.
May consider urologic work-up to evaluate for
anatomical abnormality.
Treat for 7-14 days.
 Pyelonephritis

 Infection of the kidney

 Associated with constitutional symptoms – fever, nausea, vomiting,
headache
 Diagnosis:
• Urinalysis, urine culture, CBC, Chemistry
 Treatment:
• 2-weeks of Trimethroprim/sulfamethoxazole or
fluoroquinolone
• Hospitalization and IV antibiotics if patient unable to take po.
 Complications:
 Perinephric/Renal abscess:
• Suspect in patient who is not improving on antibiotic therapy.
• Diagnosis: CT with contrast, renal ultrasound
• May need surgical drainage.
 Nephrolithiasis with UTI
• Suspect in patient with severe flank pain
• Need urology consult for treatment of kidney stone
 Prostatitis

 Symptoms:
 Pain in the perineum, lower abdomen, testicles, penis, and with
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen
 Diagnosis:
 Typical clinical history (fevers, chills, dysuria, malaise, myalgias,
pelvic/perineal pain, cloudy urine)
 The finding of an edematous and tender prostate on physical
examination
 Will have an increased PSA
 Urinalysis, urine culture
 Treatment:
 Trimethoprim/sulfamethoxazole, fluroquinolone or other broad
spectrum antibiotic
 4-6 weeks of treatment
 Risk Factors:
 Trauma
 Sexual abstinence
 Dehydration
 Urethritis
 Chlamydia trachomatis
 Frequently asymptomatic in females, but can present with dysuria,
discharge or pelvic inflammatory disease.
 Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
 Pelvic exam – send discharge from cervical or urethral os for chlamydia
PCR
 Chlamydia screening is now recommended for all females ≤ 25 years
 Treatment:
• Azithromycin – 1 g po x 1
• Doxycycline – 100 mg po BID x 7 days
 Neisseria gonorrhoeae
 May present with dysuria, discharge, PID
 Send UA, urine culture
 Pelvic exam – send discharge samples for gram stain, culture, PCR
 Treatment:
• Ceftriaxone – 125 mg IM x 1
• Cipro – 500 mg po x 1
• Levofloxacin – 250 mg po x 1
• Ofloxacin – 400 mg po x 1
• Spectinomycin – 2 g IM x 1
 You should always also treat for chlamydia when treating for
gonnorhea!
 Question #1

An 18-year old woman presents with urinary

frequency, dysuria, and low-grade fever.
Urinalysis shows pyuria and bacilli. She has
never had similar symptoms or treatment for
urinary tract infection.
 Question # 1

What category of UTI does this patient have?

Does this patient require further testing?
Would you treat this patient, and if so, with what
and how long?
 Question # 2

An 18-year old woman present with her third

episode of urinary frequency, dysuria, and
pyuria in the past 4 months.
 Question # 2

What further questions do you have for this

patient?
What type of UTI does this patient have?
What testing might you perform in this patient?
How would you treat her, and for how long?
 Question #3

A 24-year old woman presents with fever, chills,

nausea, vomiting, flank pain and tenderness.
Her temperature is 40°C, pulse rate is 120/min.,
and blood pressure is 100/60 mm Hg.
 Question # 3

What further studies do you want in this patient?

How would you treat this patient?
What might you do if she does not improve after
3-4 days?
 Question # 4

A 78-year old female presents with an indwelling

foley catheter and pyuria.
 Question # 4

What would you do for this patient at this time?

How might your work-up/management change if
she was having fevers and confusion?
 Question # 5

58-year old man presents with his first episode

of urinary frequency and dysuria. Urinalysis
shows pyuria and bacilli.
 Question # 5

What type of UTI does this patient likely have?

How would you treat this man, and for how long?
What activities would put this patient at risk for
UTI?
 Question # 6

A 28-year old male had a sexual encounter with

a prostitute while on a business trip in Seattle 1
week ago. After returning home, he noted a
burning sensation on urination and a yellow
discharge in his underwear. Microscopic
examination of the discharge reveals 4+
leukocyte esterase, and the following gram stain.
Question # 6
 Question # 6

 Which of the following is the best course of action for

this patient?

a) Give the patient a prescription for doxycycline, 100 mg po BID for

7 days
b) Give the patient two prescriptions for ofloxacin 300 mg po QDay
for 7 days, one for him, and one for his wife.
c) Administer ceftriaxone – 125 mg IV x 1 and Azithromycin – 1 g po
x 1, draw blood for a VDRL and HIV – antibody arrange for his
wife to be examined and treated.
d) Administer a single dose of Ceftriaxone – 125 mg IV x 1, and
ciprofloxacin – 500 mg po x 1 draw blood for a VDRL and HIV-
antibody, and arrange for his wife to be examined and treated.
e) Administer a single dose of cefixime – 400 mg, draw blood for a
VDRL and arrange for his wife to be examined and treated.