Urinary Tract Infection

Iin Novita Nurhidayati Mahmuda

Internal Medicine Departement
Faculty of Medicine
Muhammadiyah University of Surakarta
 Urinary Tract Infection
• Infeksi saluran kemih atas:
– pielonefritis
• Infeksi saluran kemih bawah
– Cystitis (“tradisional” UTI)
– Uretritis (sering menular seksual)
– prostatitis
 Symptoms of Urinary Tract Infection
• Dysuria
• Urgency
• Increased frequency
• Hematuria
• Fever
• Abdominal pain (supra-pubic pain)
• Nausea/Vomiting (pyelonephritis)
• sakit nyeri-costovertebral Flank
(pyelonephritis)
 Findings on Exam in UTI
• Physical Exam:
– CVA tenderness (pyelonephritis)
– Urethral discharge (urethritis)
– Tender prostate on DRE (prostatitis)
• Labs: Urinalysis
– + leukocyte esterase
– + nitrites
• More likely gram-negative rods
– + WBCs
– + RBCs
 Culture in UTI
• Positive Urine Culture = >105 CFU/mL
• Kebanyakan patogen umum untuk cystitis,
prostatitis, pyelonephritis:
– Escherichia coli
– Staphylococcus saprophyticus
– Proteus mirabilis
– Klebsiella
– Enterococcus
• Kebanyakan patogen umum untuk uretritis
• Chlamydia trachomatis
• Neisseria Gonorrhea
 Lower Urinary Tract Infection - Cystitis

• Uncomplicated (Simple) cystitis

– Pada wanita yang sehat, dengan tidak ada tanda-
tanda penyakit sistemik
• Cystitis complicata
– Pada laki-laki, atau perempuan dengan masalah
medis penyerta, wanita hamil, kelainan anatomi
• Recurrent cystitis (berulang)
 Uncomplicated (simple) Cystitis
• Definisi
– wanita dewasa sehat (di atas usia 18)
– Tidak hamil
– Tidak ada demam, mual, muntah, nyeri pinggang
• Diagnosa
– Dipstick urinalisis (kultur atau lab ada tes diperlukan)
• Pengobatan
– Trimethroprim / Sulfametoksazol selama 3 hari
– Mungkin menggunakan fluorokuinolon (ciprofoxacin atau
levofloxacin) pada pasien dengan alergi sulfa, daerah dengan
tingkat tinggi Bactrim-resistance
• Faktor risiko:
– Persetubuhan/hubungan seksual
– Mungkin merekomendasikan berkemih pasca-coital atau
penggunaan antibiotik profilaksis.
 Complicated Cystitis
• Definisi
– Wanita dengan kondisi medis komorbid
– Semua pasien laki-laki
– Berdiamnya Foley kateter
– Urosepsis / rawat inap
• Diagnosa
– Urinalisis, kultur urin
– laboratorium lebih lanjut, jika sesuai.
• Pengobatan
– Fluorokuinolon (atau antibiotik spektrum luas lainnya)
– 7-14 hari pengobatan (tergantung pada tingkat keparahan)
– Dapat mengobati bahkan lebih lama (2-4 minggu) pada laki-laki
dengan ISK
 Special cases of Complicated cystitis
• Berdiamnya kateter Foley
– Cobalah untuk melepas Foley jika mungkin!
– Hanya mengobati pasien ketika gejala (demam, disuria)
– Leukosit pada urinalisis
• pasien dengan kateter sering didiami dengan banyak bakteri.
• Harus mengganti Foley sebelum memperoleh cultur, jika
memungkinkan
• kandiduria
– Sering terjadi pada pasien dengan berdiamnya Foley.
– Jika tumbuh dalam urin, cobalah untuk melepas Foley!
– Perlakukan hanya jika gejala.
• Jika kebutuhan untuk mengobati, memberikan flukonazol
(amfoterisin jika resistance)
 Recurrent Cystitis
• Ingin memastikan kultur urin dan sensitivitas
diperoleh.
• Dapat mempertimbangkan pemeriksaan
urologi untuk mengevaluasi kelainan anatomi.
• Perlakukan selama 7-14 hari.
 Pyelonephritis
• Infeksi ginjal
• Dikaitkan dengan gejala konstitusional - demam, mual, muntah, sakit
kepala
• Diagnosa:
– Urinalisis, kultur urin, CBC, Kimia
• Pengobatan:
– 2-minggu Trimethroprim / sulfametoksazol atau fluorokuinolon
– Rawat inap dan IV antibiotik jika pasien tidak mampu po.
• komplikasi:
– Perinefrik / abses ginjal:
• Terjadi pada pasien yang tidak membaik dengan terapi antibiotik.
• Diagnosis: CT dengan kontras, USG ginjal
• Mungkin perlu drainase bedah.
– Nefrolitiasis dengan ISK
• Terjadi pada pasien dengan nyeri pinggang yang parah
• Perlu urologi berkonsultasi untuk pengobatan batu ginjal
 Prostatitis
• Gejala:
– Nyeri pada perineum, perut bagian bawah, testis, penis, dan dengan
ejakulasi, iritasi kandung kemih, obstruksi kandung kemih, dan kadang-
kadang darah dalam air mani
• Diagnosa:
– riwayat klinis yang khas (demam, menggigil, disuria, malaise, mialgia,
panggul / nyeri perineum, urin keruh)
– Temuan prostat edema dan lembut pada pemeriksaan fisik
– Akan memiliki PSA meningkat
• Urinalisis, kultur urin
• Pengobatan:
– Trimetoprim / sulfametoksazol, fluroquinolone atau antibiotik spektrum
luas lainnya
– 4-6 minggu pengobatan
• Faktor risiko:
– trauma
 Urethritis
• Chlamydia trachomatis
– Sering tanpa gejala pada wanita, namun dapat hadir dengan disuria, debit atau penyakit
radang panggul.
– Kirim UA, cultur Urine (jika piuria dilihat, tetapi tidak ada bakteri, tersangka Chlamydia)
– pemeriksaan panggul - mengirim discharge dari serviks atau uretra os untuk klamidia PCR
– skrining klamidia sekarang direkomendasikan untuk semua wanita ≤ 25 tahun
– Pengobatan:
• Azithromycin – 1 g po x 1
• Doxycycline – 100 mg po BID x 7 days
• Neisseria gonorrhoeae
– Mungkin hadir dengan disuria, debit, PID
– Kirim UA, kultur urin
– Panggul ujian - mengirimkan sampel debit untuk gram stain,kultur, PCR
– Pengobatan:
• 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
Hospital Associated Infection

Cathether Associated UTI

EXERCISE MAKE PERFECT
 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?
 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.
 Final thoughts!
• Antibiotic choice and duration are determined by
classification of UTI.
• Biggest bugs for UTI are E. Coli, Staph. Saprophyticus,
Proteus mirabilis, Enterococci and gram-negatives
• Chlamydia screening is now recommended for all
women 25 years and under since infection is
frequently asymptomatic, and risk for PID/infertility
is high!