INFEKSI SALURAN KEMIH

BAGIAN BAWAH

Edwin Bonaville
Universitas UKRIDA

PENDAHULUAN

Difinisi:
adalah infeksi saluran kemih bagian bawah
dengan bakteriuria minimal 100.000 cfu/ml urin

Insiden 10-20 % wanita

Wanita > laki2 (20:1)*
Faktor risiko:
Aktifitas seksual,kehamilan,relaksasi
pelvis,penyakit sistemik,instrumentasi
Prevalensi meningkat seiring peningkatan umur

Prevalence of bacteriuria in females

as a function of age
50
p
o
p
u
l
a
ti
o
n

Pelvic relaxation,
40

hospitalization
Etc.

30
20

Onset of
Sexual intercourse

Child bearing

10
10

20

30
40
Age in year

50

60

70

80

PATOGENESIS
SEBAGIAN

BESAR ASENDING INFEKSI

DARI FESES KE INTROITUS VAGINA
JARINGAN PERIURETRA VESIKA
URINARIA
TERJADINYA ISK MERUPAKAN
INTERAKSI SUSCEPTIBILITAS HOST
DAN FAKTOR VIRULENSI KUMAN.

PATHOGENESIS
THE PATHOGENESIS OF URINARY TRACT INFECTION HAS BEEN
POSTULATED TO INVOLVE THREE PRIMARY MECHANISM:
HEMATOGENOUS,LYMPHATIC,ASCENDING EXTENSION OF ORGANISME
DIRECTLY

Faktor host dan virulensi kuman

memegang peranan penting terjadinya ISK.

Host dengan mekanisme pe

1. Proses miksi secara perio
2. Konsentrasi urea dan asa
pada ph rendah.
3. Glikosaminoglikan pd tep
serta immunoglobulin.
4. Protein Tamm-horsfall(loo
uromucoid (manosa).

ETIOLOGI

80-90 %
10%

5%

LESS THAN 5% OF WOMEN WITH RECURRENT LOWER TRACT

INFECTIONS HAVE AN ANATOMICAL OR FUNCTIONAL
ABNORMALITY

= E COLI
= Klebsiella, Protius, Pseudomonas
Enterobacter.
= Staph aureus,Entereococcus
Chlamydia, Fungus, TB,. Other.

Uropathogenic E. coli
Selected O-, H-, K-Clones
fimbriae

hemolysin
aerobactin
K

antigen
serum resistant
uroepithelial adherence
cytotoxic; Fe liberating
Fe scavenger
antiphagocytic
survival

in blood

GAMBARAN KLINIS

Gejala umum yang sering terjadi

adalah:

frekuensi
Disuria
Urgensi
nokturia
Kencing tidak puas*
Hematuria.
Rasa tak nyaman supra pubik

Hooton TM.Recurrent urinary tract infection in women. Int J Antimicrob Agent 2001;17;259-268.

DIAGNOSIS
DIAGNOSIS DITEGAKKAN BERDASARKAN :
GEJALA KLINIS
URINALISIS DAN KULTUR URIN

PENANGANAN
GOAL PENANGANAN ISK ADALAH:
HILANGKAN INFEKSI
HINDARI EFEK SAMPING
CEGAH INFEKSI BERULANG

ANTIBIOTIK PILIHAN ADALAH

First line:
Trimethoprim-Sulfamethoxazol
Cefalexin
Nitrofurantoin
Second line
Quinolones
Drug update 2004

HASIL TERAPI ?

Period of
treatment

INFREQUENT INFECTION

REINFECTION
RELAPSE

PERSISTENCE
Days

Positive urine culture (same strain) Positive urine culture (different strai
Negative urine culture

Natural history of urinary tract infection.(from karram mm;lower urinary tract infection.in oste
Bent AE(eds): Urogynecology and urodynamics Baltimore,1991,Williams & wilkins)

RISK FACTORS FOR

RECURRENT URINARY TRACT
INFECTIONS

intrinsic factors

higher prevalence for adherence of bacteria

higher prevalence for vaginal colonization

extrinsic factors

sexual activity
diaphragm + spermicide

Schaeffer et al (1981); Nicolle et al (1982); Fihn et al (1985)

COLONIZATION
WITH UROPATHOGENS

AT HIGH RISK FOR

RECURRENT BACTERIA

ENTRANCE OF
BACTERIA
INTO BLADDER

DEFECT IN
LOCAL HOST
DEFENSE

Mickey M Karram. Lower Urinary Tract Infection. In Clinical Urogynecology copyright 1993 by mosby-year .310-27

THREE APPROACHES
TO ANTIBIOTIC THERAPY

1.Patient initiated therapy

2.Post coital therapy
3.Long term prophylaxis therapy

MANAGEMENT.
A.Single dose
1.trimethoprim sulfamethoxazole DS for 2 tablets
2.Sulfisoxazole 2 g
3.Trimethoprim 400 mg
4.Amoxicillin 3g
5.ciprofloxacin 250-500mg
6.Norfloxacin 400mg.
B.Short course(3-5days)
1.TMP-SMS DS PO bid
2.Sulfisoxasole 500 mg qid
3. Amoxicillin 500mg tid
4.Nitrofurantoin 100 mg qid
5.Macrobid 100mg.bid
Management : UTI Prophylaxis
A. Continuous UTI Prophylaxis ( average course: 6 months)
1. Nitrofurantoin 50 mg qd
2. Trimethoprim Sulfamethoxazole 40/200 qd or 3 x/ week
3. Cephalexin 125 mg qd
B. Postcoital Prophylaxis
1. Trimethoprim Sulfamethoxazole 80/400
2. Nitrofurantoin 100 mg
3. Cephalexin 250 mg
C. Home antibiotics to start at first symptom onset.

RELAPSE
Seek occult source of infection or
urologic abnormality
Treat longer (2-6 wk)

RECURRENT
CYSTITIS

REINFECTION
If woman uses diagphragm and
spermicide,
Consider changing contraceptive method
Urologic evaluation not routinely indicated

>3 UTI/yr
< 3 UTI / yr
No relation
to coitus

Temporally related
to coitus

Daily or thrice
weekly prophylaxis

Postcoital
prophylaxis

(recommended daily regimens:

Trimethoprim, 100 mg; trimethoprimsulfamethoxazole 40/200 mg;
Nitrofurantoin 50-100 mg; norfloxacin
200 mg; cephalexin 250 mg )

Patient initiated therapy

for symptomatic episodes
( See Table 2 for single-dose
Or 3 day regimens)

( recommended regimens:
Trimethoprim-sulfamethoxazole 40/200
mg;
Cephalexin 250 mg; nitrofurantoin 50100 mg )

Recurrent UTI in women

Upper
tract

Lower tract
Persistent or relapsed

Investigate for structural

abnormalities

Reinfection

Clinical assessment

Treat reversible factors

Young

Perimenopausal and elderly Catheterized

Consider self initiated

Therapy with trimethoprim
Or trimethoprim prophylaxis
For 6 months

Topical vaginal estrogen,

Hormone replacement
Therapy, continence
management

Figure 13.3
Approach to management of reccurent UTI in womwn

Review:
Catheter care, bowel care,
Hydration, avoid long term
antibiotics

PREVENTING RECURRENT URINARY

TRACT INFECTIONS

Increasing fluid intake

Cleanse the genital area before sexual intercourse
Voiding after intercourse
Do not use spermicides or diaphragm for contraception
Women should clean perineum wiping front to back
Avoid using feminine hygiene sprays and scented douches.

Lynch 2004

PROPHYLAXIS OF RECURRENT
CYSTITIS
daily or after intercourse
nitrofurantoin
trimethoprim
TMP-SMZ

50-100 mg/day
50-100 mg/day
40/200 mg/day

in case of break through infection

Fosfomycin trometamol 1 sachet 3gr every 10 days for 3 months
norfloxacin
200 mg/day
ciprofloxacin
125 mg/day
in case of pregancy
cephalexin

125-500 mg/day

KESIMPULAN

ISK adalah infeksi saluran kemih dengan bakteriuria

100.000 cfu/ml
Penyebab terbanyak adalah E Coli
Sebagian besar kasus karena ascending infeksi
ISK meningkat seiring peningkatann umur.
Antibiotik pilihan adalah TMP-SMX
Infeksi ISK berulang merupakan problem utama wanita
semua umur
Pencegahan ISK berulang adalah strategi yang efektif .