Urinary Tract Infection/ISK

Urinary Tract Infection/ISK

Berkembang biaknya mikro organisme di dalam saluran kencing. Urin: Piuria(lekosit urin>10/LPB)pd urin sentrifus,lekosit urin porsi tengah 2000/ml atau 200.000/jam (hrs dihindari kontaminasi). Bila yg diperiksa aspirasi kandung kemih,adanya 800/ml dianggap infeksi. Hematuri:juga dpt terjadi pd ISK/bukan jenis glomeruler(+bila >5/LPB) Proteinuri:pd pielonefritis akut/kronik a.tetapi tdk selalu bermakna infeksi.
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Urinary Tract Infection/ISK

Bakteriuria: Dasar diagnosis ISK,dg biakan/tanpa kontaminasi. Pada penelitian adanya kuman hasil biakan 100.000 koloni/ml berarti(+).

Lokasi ISK
ATAS:ginjal/pyelonefritis, dan
intrarenal,abses renal,dg gejala sakit pinggang,suhu tinggi,mual,muntah,hematuria. BAWAH: uretritis,cystitis,prostatitis.dg gejala sering kencing,disuria,nyeri supra pubik.
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Urinary Tract Infection

Lower urethritis/uretra cystitis prostatitis Upper pyelonephritis intrarenal and perinephric abscess
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Urinary Tract Infection

Urinary tract infectionmost common source of bacteremia, a dangerous systemic infection in long-term care facilities Bacteremia40 times more likely to occur in catheterized than non-catheterized residents Bacteremia leads to significant morbidity and mortality in the vulnerable elderly
Nicolle, 2005

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History & Physical Examination

Age-related Risk Factors for UTI
Advanced Age Fecal incontinence/impaction Incomplete bladder emptying or neurogenic bladder Vaginal atrophy/estrogen deficiency Insufficient fluid intake/dehydration Indwelling foley catheter or urinary catheterization or instrumentation procedures

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Urinary Tract Infection

Pathogenic microorganisms in urine, urethra, bladder, kidney, prostate Usually growth > 105 organisms per milliliter From midstream clean catch urine sample If from catheter specimen can be significant with 102 or 104 organisms per mL

Etiology
Most common is Gram neg. bacteria
E. coli = 80% of uncomp. acute UTI Proteus assoc. with stones Klebsiella assoc. with stones Enterobacter Serratia Pseudomonas
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Etiology
Gram pos. cocci
Staphylococcus saprophyticus 10-15 % acute UTI in young females Enterococci occas. in acute uncomp. cystitis Staphylococcus aureus assoc. with renal stones, instrumentation, increased susp. of bacteremic kidney infection
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Etiology
Urethritis from chlamydia, gonorrhea, acute symp female with sterile pyuria Candida or other fungal species commonly assoc. with cath. or DM Mycobacteria

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BENTUK KHUSUS ISK

ISK BERULANG:sumbatan saluran kemih:batu,tumor,prostat,kehamilan ISK BERKOMPLIKASI:kelainan struktur,dg gejala panas sp sepsis,gg akut,kejang,terapi:penambahan cairan,elektrolit,nutrisi. ISK PADA DM(10-50%):neuropati /aliran air kemih,angiopati /kelainan pembuluh darah.prinsip pd DM kuman lebih mudah berkembang.Penanganan dg anti biotik sesuai k/s selama 14 hari,kendalikanDM.

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BENTUK KHUSUS ISK

ISK PADA MANULA:ok proses fisiologis,frekuensi meningkat.ok perubahan degeneratif,imunologi,sekresi menurun,hipertrofi prastat,prolaps uteri,nutrisi,hipertensi,pengobatan sama,sesuaikan,karena fungsi ginjal berkurang. ISK pd KEHAMILAM:yg asimptome 40% Dpt mengalami PNA/Pyelo Nefr.Akut.Perubahan hormonal,fungsi ginjal.Kelahiran prematur,pengelolaan sama.
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Pathogenesis
Usually ascent of bacteria from urethra to bladder to kidney Vaginal introitus, distal urethra colonized by normal flora Gram negative bacilli from bowel may colonize at introitus, periurethra

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Ascending
Dari uretra,-ves.urinaria-ginjal. Penyebab tersering terjadinya ISK.ok penyebaran bakteri melalui cara ini kurang menjaga kebersihan,inkontinensia urine,Jarak uretra-anal yg dekat(Hvidberg et al.2000.)

Hematogen
Sistem imun yg rendah,mempermudah penyebaran infeksi secara hematogen,ada beberapa hal yg mempengaruhi struktur dan fungsi ginjal,mepermudah penyebaran,yi penumpukan urine ,distensi kandung kemih,bendungan intra renal.

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LIMFOGEN
Penyebaran bakteri secara langsung dari organ yg letakya berdekatan melalui jalur limfatik.Seperti infeksi usus besar yg berat atau abses retro peritoneal(jarang terjadi(Gillenwater et al.,2002).

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Routes of bacterial invasion

1. Ascending
common

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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 kidney, bladder & prostatic secretions

BJN-T3x

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Predisposing conditions to UTI

Female
Short urethra, proximity to anus, termination beneath labia Sexual activity

Pregnancy
2-3% have UTI in preg, 20-30% with asx bacteriuria may lead to pyelo Increased risk of pyelo = decreased ureteral tone, decreased ureteral peristalsis,

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Predisposing conditions

Neurogenic bladder dysfunction or bladder diverticulum (incomplete emptying) Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, concomitant medical conditions such as DM Vesicoureteral reflux Bacterial virulence Genetics Change in urine nutrients, DM.
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Urethritis

Acute dysuria, frequency Often need to suspect sexually transmitted pathogens esp. if sx more than 2 days, no hematuria, no suprapubic pain,

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Cystitis/inf.bladder
Sx: frequency, dysuria, urgency, suprapubic pain Cloudy, malodorous urine (nonspec.) Leukocyte esterase positive = pyuria Nitrite positive (but not always) WBC (2-5 with sx) and bacteria on urine microscopy
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Pyelonephritis
Fever chills, diarrhea, tachycardia, gen. muscle tenderness Tenderness with deep abdominal tenderness Possibly signs of Gram neg. sepsis

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Pyelonephritis
Leukocytosis Pyuria with leukocyte casts, and bacteria and hematuria on microscopy Complications: sepsis, papillary necrosis, ureteral obstruction, abscess, decreased renal function if scarring from chronic infection, in pregnancy may increase incidence of preterm labor
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Catheter-Associated Urinary Tract Infections

10-15% of hosp. patients with indwelling catheter develop bacteriuria Risk of infection is 3-5% per day of catheterization UTI after one-time bladder cath approx. 2% Gram neg. bacteremia most significant complication of cath-induced UTI Greater antimicrobial resistance

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Diagnosis of UTI
History Physical exam Lab
Urinalysis with micro = WBC, bacteria Urine culture Sensitivities of culture for tailored antibiotic therapy May dx acute uncomp. cystitis based on hx, PxExm, no need for culture to treat

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Diagnosis
Urinalysis
Leuk. pos. = pyuria Nitrite pos. from urea prod. bact. (but not always) Micro WBC (even 2-5 in patient with sx) Micro Bacteria

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Diagnosis
Urine culture
Once 105 colonies per mL considered standard for dx but misses up to 50% Now, 102 to 104 accepted as significant if patient symptomatic Needed in upper UTI, comp. UTI, and in failed treatment or reinfection Sensitivities for better tailoring of tx
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Treatment

Uncomp. cystitis with less than 48 hours of sx, non-pregnant, usu. 3 days tx sufficient
Bactrim Cipro or other FQ (avoid in preg.) Nitrofurantoin (7 days) Augmentin Bladder analgesis, Pyridium
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Treatment
Uncomp. cystitis in pregnant patient
Requires longer tx of 7-14 days Cephalosporin, nitrofurantoin, augmentin, sulfonamides.

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Asymptomatic Bacteriuria

105 org/mL growth Empiric treatment of all asymptomatic bacteriuria in pregnancy.

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Asymptomatic Bacteriuria
Treatment failures: repeat tx based on sensitivities for 1 week, then prophylactic therapy for remainder of pregnancy Prophylaxis: Nitrofurantoin, Ampicillin, TMP/SMX

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Treatment Recurrent uncomp. UTI

3 or more episodes in one year, 2 in 6 months Bactrim QD for 3-6 months. Single dose at symptom onset or one tab post-coitus Measures for prevention: voiding after intercourse, good hydration, frequent and complete voiding
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Management RUTI
(Conceptual Model)
Prophylactic antibiotics prevent recurrent UTI
End Stage Renal Disease

RUTI Recurent RENAL SCARRING

VUR (VU Reflux) Surgery corrects VUR
Pre -eclampsia Hypertension

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Reinfection Vs Relapse
Reinfection : RUTI caused by different pathogen
any time or original infecting strain >13 days after of original UTI

Relapse : recurrent UTI caused by same species

causing original UTI w/in 2 wks after therapy

Uncomplicated : UTI in host without underlying

renal or neurologic disease

Complicated : UTI in setting of underlying

structural, medical or neurologic disease
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Pathogenesis
The pathogenesis of recurrent UTI is
assumed to be the same as with sporadic infection. Most uropathogens originate in the rectal flora, colonize the periurethral area and urethra, and ascend to the bladder. Hematogenous spread to kidney is rare.

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Management of RUTI
1. One effective approach: prevention of infection through the use of long-term, prophylactic antimicrobials (at least 6 months )

2. Initial prevention of UTI as a way of minimizing antibiotic exposure

Changes in behavior Contraception Postcoital voiding and liberal fluid intake Cranberry/strawberries juice

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Antimicrobial prophylaxis
It has been demonstrated to be highly
effective in reducing the risk of recurrent UTI in women Advocated for women who experience two or more symptomatic UTIs within six months or more over 12 months : - Continuous prophylaxis - Postcoital prophylaxis - Self-treatment
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Guidelines for Uncomplicated and Recurrent Urinary Tract Infection

Frequent UTI
Patient education
Failed prior antibiotic prophylaxis Or Relapse? (Same organism w/in 2 weeks of previous UTI)

yes

Seek occult source (IVP or renal ultrasoundonsider Urology referral Treat longer (2-6 weeks)

No yes
3 or more episodes/year

No

Episodes related to intercourse

Initiated 3 day antibiotic regimen

yes
Post coital single-dose prophylaxis: TMP/Sx 40/200 mg Cephalexin 250 mg Nitrofurantoin 50-100mg

No

Daily / thrice weekly prophylaksis: TMP 100 mgor TMP/Sx 40/200 mg Cephalexin 250 mg Nitrofurantoin 50-100mg Sentara Healthcare (SHC), Optima Health. 40 2007

Treatment of Pyelonephritis - Outpatient

Uncomp. Nonpreg pyelo Primary any FQ x 7 days, cipro Alt. -- Augmentin, TMP/SMX, for 14 days

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Treatment of Pyelonephritis Inpatient

Treat IV until patient is afebrile 24-48 hours. Then, complete 2 week course with PO meds Use FQ or amp/gent or ceftriaxone or piperacillin If no improvement on IV, consider imaging studies to look for abscess or obstruction All pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediately
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Treatment of Complicated UTI

Catheter related Amp/gent or Zosyn or ticaricillin/clav or imipenem or meropenem x 2-3 weeks Switch to PO FQ or TMP/SMX when possible Rule out obstruction Watch out for enterococci and pseudomonas
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Nephrolithiasis
Supersat. of urine by stone forming constituents Crystals of foreign bodies Freq. stone types: Calcium (most common), struvite, oxalate, uric acid, staghorn Risk factors: metabolic disturbances, previous UTI, gout, genetic

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Nephrolithiasis
Incidence = 2-3% Morbidity
Obstruction pain Chronic obstruction, may be asx loss of renal function Hematuria (rarely dangerous by itself) Dangerous combo = obstruction + infection
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Nephrolithiasis
More prev. in Asians and whites Males > females, 3:1 Struvite stones from infection, increased in females Ages 20-49 Recurrent Uncommon after 50 y.o.

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Nephrolithiasis Patient History

Often dramatic pain, poss. infection, hematuria Even nonobst. May cause sx Bladder irritating sx Renal colic because of stone in ureter
Severe, undulating cramps because of ureter peristalsis, sever pain, Pain may migrate

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Nephrolithiasis Patient History

Duration, char, location of pain Hx of stones? UTI? Loss of renal function?

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Nephrolithiasis Physical Exam

Dramatic, may migrate as stone moves Usu. Lacking peritoneal signs Calculus often in area of maximum discomfort

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Nephrolithiasis Workup
Urinalysis
Evid. Of hematuria and infection 24-hour urinalysis helpful in identifying cause

Uric acid. Calcium, oxalate, uric acid in the 24 hour urine

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Nephrolithiasis Workup
Plain abd film Renal USG IVP Helical CT without contrast (stone protocol)

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Nephrolithiasis Treatment
If no obstruction or infection, stones < 56mm may likely pass Restore fluid volume if dehyd. Analgesics narcotics, nsaids Antiemetics Occasionally nifedipine to relax ureteral smooth muscle and prednisone used Urology consult
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Nephrolithiasis Treatment
Surgical intervention (call urology)
Extracorporeal shock-wave lithotrypsy (not in pregnancy) Ureteral stent Percutaneous nephrostomy Ureteroscopy Indications = pain, infection, obstruction Contraindications = active untx infection, uncorrected bleeding diathesis, pregnancy (relative)

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Nephrolithiasis Prophylaxis
Increase fluid intake (2 liters per day) 24 hour urine, eval calcium, oxalate, uric acid to determine dietary prevention metabolic tests to determine cause (Ex: hyperparathyroidism) Decrease salt intake
THE END
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Terima kasih

ALHAMDULILLAH

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