Kasus:

Seorang ♂ 45 thn dtg ke IGD dgn demam 3 hari, nyeri pinggang & mual-muntah.
Vital sign:
Sens : CM, TD: 120/70 mmHg, nadi: 90 x/i, pernafasan: 24x/I , suhu : 38⁰C,
Pemeriksaan fisik : tapping pain (+)

Pertanyaan :
1. Apakah kemungkinan diagnosa pada pasien ini?
2. Pemeriksaan penunjang apa yang diperlukan untuk membuktikan diagnosa sementara
pada pasien tersebut?
3. Jelaskan pengelolaan pada pasien ini ?
z
Getting Clear on the Terminology

Asymptomatic
Bacteriuria
UTI
Symptomatic
Asymptomatic UTI
Cystitis UTI

Pylonephritis
Urosepsis Prostatitis
 z Terminology

 Infection is defined as the entry and multiplication of microorganism(s) in the

tissues of the host that produces injurious effects.
 Infeksi saluran kemih (ISK) adalah infeksi akibat terbentuknya koloni kuman di
saluran kemih. Kuman mencapai saluran kemih melalui cara hematogen dan
asending.
 Pyelonephritis is an infection of the kidney usually resulting from travel of the
infection from the bladder to the ureter and then to the kidney. (ascending)
 Cystitis is an Infection of the urinary tract limited to the bladder, usually
involving only the mucosal surface.
 z

 Asymptomatic bacteriuria is a presence of bacteria in

the urine of a person without symptoms of infection.
1. Should not be called a UTI
2. Should not be treated with antibiotics
3. investigations and treatment of asymptomatic
bacteriuria should be instigated only in pregnant
women
 z

 Sepsis occurs when bacteria have entered the bloodstream and lead to
a widespread (systemic) inflammatory response.

 Urosepsis means the infection has stemmed from an infection of the

urinary tract

 Pyuria: the presence of white blood cells in the urine.

1. The body’s reaction to invasion by bacteria.

2. One of the key differentiating points between UTI and assymptomatic

bacteriuria
z
Getting Clear on the Terminology

Pyuria
Pollakisuria
Anuria
Oliguria
Dysuria
Cylindruria
Polyuria Hematuria
Urinary Tract Infections
Division of Nephrology and Hypertension, Department of Internal
Medicine, Faculty of Medicine, Universitas Sumatera Utara
z
Definition UTI

Is a broad term used to described microbial

contamination of the urine and infection of
the structure of the urinary tract

The infection process may involve kidney,

renal pelvis, ureters, bladder, and urethra
z

Upper Urinary Tract Infection

• Pyelonephritis

Lower Urinary Tract Infection

• Cystitis (Traditional UTI)
• Urethritis (often sexually transmitted)
• Prostatitis
 Uncomplicated
z UTI

generally defined as one occurring in a healthy, young,

non pregnant woman, with no previous urinary or vaginal
infection, no family history, no history suggestive of
anatomical & functional abnormality of urinary tract

Complicated UTI
11
 z PREVALENCE
 UTI is rare in young and middle-aged men

 UTI in men is often associated with catheterisation or urological procedures.

 bacteriuria in elderly men occurs in

 about 10% of those living at home,

 about 20% of those living in nursing homes and

 30% of those who are in-patients in hospitals

 urinary catheter increases the risk almost ten-fold in hospitalised patients and those
in other care homes.
 pyelonephritis is common in patients who have been catheterised for over a month.
 z Predisposing factors
 Sexual activity in females (75–90%)
 Abnormality of the UT that obstructs or slows the flow of urine (i.e. kidney stone)
 Elderly males: prostatic hypertrophy
 Pregnancy
 Catheterisation
 Surgery, e.g. prostatectomy
 Diabetes mellitus

 Immunosuppressed patients

 Congenital abnormalities in infants that sometimes require surgery, e.g. vesico-uretic reflux

 Women who use the diaphragm and spermicides

 Patients with a neurogenic bladder or bladder diverticulum

z
 z Causative agent

 Escherichia coli

 most common

 about 80% of primary care infections

 about 50% of hospital-acquired infections

 Others:

 enterococci

 Staphylococcus saprophyticus and

 klebsiellas

 various types of pseudomonas and proteus are more rare

Common pathogen in acute simple pyelonephrits

Meyrier A . UTI.
z Pathogenese UTI
 z PATOFISIOLOGI

1. Pada Wanita
-Terjadi karena urethra pendek atau akibat hubungan
seksual dengan pria penderita ISK
-Pada wanita hamil, kandung kemih mengendur
sehingga bakteri mudah masuk.
- batu ginjal
2.Pada Pria
Adanya pembesaran prostat & batu ginjal yang dapat
menghambat pengelaran urin.
3.Pada Anak-anak
Karena kelainan congenital.
z
 z SIMPTOMS OF UTI

Cystitis:
 typical symptoms include frequency and burning sensation when passing urine.
Pyelonephritis:
 only some patients have difficulties in micturition
 temperature (> 38oC) and flank or back pain
 nausea in the elderly or sudden collapse in health status (”off-legs”)
 Incontinence or offensive urine in the elderly should not be considered as UTI as
such; even though they may be indicative signs of an infection
 UTI in the elderly may manifest itself as incontinence or retention.
 z DIAGNOSIS OF UTIs

 Based on the symptoms of UTI → a differentiation between lower or upper UTI should
be made
 No need to do any urinalysis, if a female patient, who does not belong to any of the risk
groups, clearly has occasional cystitis based on her symptoms
 Urine microscopy is not usually necessary to diagnose cystitis

 Bacterial culture of urine should be carried out in all cases, except in uncomplicated
cystitis, even though the results will not be available when medication is commenced (B)
 In early pregnancy bacterial culture should be carried out in all pregnant women if only to
diagnose asymptomatic bacteriuria (A)
 In adult febrile infections with generalised symptoms, and in children’s infections, C-
DIAGNOSIS ALGORITHM

Symptomatic
patient

Uncomplicated cystitis
in a woman, Yes
no risk factors
not a relapse

No
Typical symptoms,
No < 2 infections / year,
Bacterial culture,
patient familiar with
"on the spot" testing
her illness
to confirm diagnosis

Yes

Start
Antibiotic
treatment
based on therapy
results
 z
COLLECTING A SAMPLE

 in adults and older children a mid stream urine (MSU) sample usually
reliably represents the urine in the bladder.
 samples collected from urinary bags or bedpans should not be used to
diagnose UTI as they invariably will be contaminated
 the most reliable sample is obtained via a suprapubic puncture
 urine in bladder >4 hours (any shorter time will increase the risk of false
negative findings)
 z
Clinically significant pathogen
concentrations
Clinical status or methods of Significant
sampling concentration
(microbes / ml)
MSU; symptomatic patient or urine in >103
bladder <4 h

MSU; urine in bladder >4 h >104-5

Male patient, catheter specimen sample >103

Female patient, catheter specimen sample >104

Asymptomatic bacteriuria >105

Suprapubic puncture sample any growth

z

Nicolle EL . Urinary Tract Infection in Adults In Brenner & Rector’s

The Kidney 9th Edition 2012 : p 1356 -1382.
z
UPPER URINARY TRACT INFECTION

“PYELONEPHRITIS”
z
DEFINITION

 Inflammation of the parenchyma and

lining of renal pelvis of kidney.
 z
Clinical Manifestation

 Mild pyelonephritis

 Low-grade fever

 With or without lower-back or costovertebral-angle pain

 Severe pyelonephritis

 High fever

 Nausea in the elderly or sudden collapse in health status (“off-legs”)

 Flank or Back pain

 z
DIAGNOSIS

 Anamnesis:

Flank pain, Fever, nausea and vomitting, hematuria.

 Physical finding:

Fever, Tapping pain on the CVA

 Lab :

leukositosis, leukosituria, urine culture (+): bakteriuria > 105/ml

 z
TREATMENT

Uncomplicated Pyelonephritis

 A pyelonephritis patient who is not unduly ill can be looked after at

home (C)

 Treatment with either a fluoroquinolone or sulphatrimethoprim

orally for 10-14 days
 z
TREATMENT DURING PREGNANCY

 Bacteriuria during pregnancy is associated with increased risk of

premature labour and pyelonephritis
 asymptomatic bacteriuria and cystitis are treated in the same way
 single-dose treatment is not recommended
 drugs of choice
 nitrofurantoin 75 mg twice daily for 5 - 7 days or
 beta-lactamase (mecillinam, amoxicillin or first-generation
cephalosporins) for 5 – 7 days.
 due to foetal risk fluoroquinolones should be avoided during the whole
of pregnancy, and SMZ-TM during the latter part of pregnancy
 z
TREATMENT OF PYELONEPHRITIS IN CHILDREN

all infants with febrile UTI should be admitted to hospital

 drugs of choice
 cefuroxime (100 mg/kg/day in 3 divided doses) or
 ceftriaxone (80 mg/kg/day daily)
 intravenous therapy until obvious response
 when obvious response to treatment is observed, medication is changed over to oral until
the total course of treatment, i.e. 10 days, is completed

 follow-up treatment according to culture and sensitivity results, with an antibiotic with good tissue
penetrability (e.g. sulphatrimethoprim or a cephalosporin)
 z
Treatment of UTI in diabetics

Cystitis in diabetics

 drugs of choice for initial treatment are same as for uncomplicated UTI

 antibiotic treatment must always be based on the results of urine culture

 treatment to continue for 7 days

Acute pyelonephritis in diabetics

 treatment is the same as for uncomplicated pyelonephritis

 consider urological imaging earlier than normal, if there is no response to appropriately chosen
medication

 the causative agents of recurrent UTI’s in diabetics are often unusual, resistant microbes (species of
pseudomonas, enterococci and enterobacter) and various candida species.
z
Antimicrobial Outpatient Management Of Acute Uncomplicated
z
Pyelonephritis
z

Nicolle EL . Urinary Tract Infection in Adults In Brenner & Rector’s

The Kidney 9th Edition 2012 : p 1356 -1382.
 z
An unwell pyelonephritis patient with or without high temperature
should be admitted to hospital

 in hospital the treatment is commenced with cefuroxime i.v. 0.75-1.5g every 8 hours or with
fluoroquinolone orally
 it is usually possible to change over to oral medication with first-generation cephalosporins in 2-3
days, when response to treatment is obvious
 third-generation cephalosporins are usually not recommended for the treatment of
uncomplicated pyelonephritis, but ceftriaxone may be chosen as the initial therapy, if either once
a day or intramuscular administration are considered beneficial
 aminoglycosides have shown no additional benefits over other forms of treatment
z
COMPLICATION

 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
z