Infeksi Saluran Kemih

INFEKSI SALURAN
KEMIH
Assoc Prof Dr. dr. Shahrul Rahman, Sp.PD, FINASIM
Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
Urinary Tract Infection
Prevalence
• Community-dwelling elders – 25%
Swart, Soler & Holman, 2004
• Long-term care elders

(chronically bacteriuric) } 25-50% of women
15-40% of men
Juthani-Mehta et al., 2005
• Marked increases in women & men after age 65

Wagenlehner, Naber & Weidner, 2005
Overview of UTI
 7 million office visits yearly
 1 million hospitalizations
 About 2/3rds of patients are women; 40% to 50% of
women have UTI at some point during their lives
 Important complications of pregnancy, diabetes
mellitus, polycystic disease, renal transplantation,
conditions that impede urine flow (structural and
neurologic)
Definisi
Dijumpai pertumbuhan kuman dalam jumlah signifikan

dalam urin.
Secara praktis:
Dijumpai koloni kuman 105 atau lebih dari biakan
contoh urin porsi tengah (mid-stream).
atau
Dijumpai ≥ 10.000 kuman /ml urin kateter atau
Berapapun kuman dari urin aspirasi suprapubik.
(UTI)
Background
1. Bacterial infections of urinary tract are a very common
reason to seek health services
2. Common in young females and uncommon in males under
age 50
3. Common causative organisms
 a. Escherichia coli (gram-negative enteral bacteria)
causes most community acquired infections
 b. Staphylococcus saprophyticus, gram-positive
organism causes 10 – 15%
 c. Catheter-associated UTI’s caused by gram-
negative bacteria: Proteus, Klebsiella, Seratia,
Pseudomonas
Overview of UTI by age and
sex
(UTI)
Pathophysiology
1. Pathogens which have colonized urethra, vagina, or
perineal area enter urinary tract by ascending mucous
membranes of perineal area into lower urinary tract
2. Bacteria can ascend from bladder to infect the kidneys
3. Classifications of infections
 a. Lower urinary tract infections: urethritis,
prostatitis, cystitis
 b. Upper urinary tract infection: pyelonephritis
(inflammation of kidney and renal pelvis)
(UTI)
Risk Factors
1. Aging
 a. Increased incidence of diabetes mellitus
 b. Increased risk of urinary stasis
 c. Impaired immune response
2. Females: short urethra, having sexual intercourse, use of
contraceptives that alter normal bacteria flora of vagina
and perineal tissues; with age increased incidence of
cystocele, rectocele (incomplete emptying)
3. Males: prostatic hypertrophy, bacterial prostatitis, anal
intercourse
4. Urinary tract obstruction: tumor or calculi, strictures
5. Impaired bladder innervation
• Urinary tract infection—most common source of

bacteremia, a dangerous systemic infection in long-term
care facilities
• Bacteremia—40 times more likely to occur in

catheterized than non-catheterized residents
• Bacteremia leads to significant morbidity and mortality

in the vulnerable elderly
Nicolle, 2005
Terms
 Urinary tract infection

 Significant bacteriuria
 Asymptomatic bacteriuria
 Acute pyelonephritis
 Chronic pyelonephritis
 “Upper” versus “lower” UTI
 Urethral syndrome
Symptoms versus
Asymptomatic Bacteriuria
Asymptomatic Bacteriuria (ASB)
Defined as the presence of bacteria in urine of
patients who do not have dysuria, urinary
frequency, urgency, fever, flank pain, or other
symptoms related to irritation of the urethra,
bladder, or kidney
Swart, Soler & Holman, 2004
Strictly defined—exists when 2 urine cultures

done with clean-catch specimens are positive in a
patient who has no urinary tract symptoms
Foxman, 2003
Symptomatic vs Asymptomatic
Bacteriuria, cont’d
ASB
 Frequent in elderly, even > prevalent in residents
of LTCF:
elderly >70 yrs old
women: 16-18%
men: 6%
Klasifikasi ISK
(Secara klinik)
 1) ISK sederhana (tak berkomplikasi), dijumpai pada
keadaan saluran kemih dan fungsi ginjal
normal dan
 2) ISK berkomplikasi, dijumpai pada keadaan
saluran kemih abnormal misalnya batu saluran
kemih, refluks vesikoureteral, sikatriks ginjal,
obstruksi, para plegia, atonia vesika, kateterisasi
kontinyu, prostatitis kronik, kelainan daya
tahan tubuh seperti netropenia, terapi
imunosupresif, diabetes mellitus dan gangguan
fungsi ginjal
Hal-hal yang mempermudah ISK :
-Hubungan Sex
-Hamil
-Obstruktif uropati : tumor, striktur, BSK,
Hipertrofi prostat
-Neurogenic bladder
-Vesico ureteral reflux
-DM
-Nefropati diabetik
Catheter-associated UTI
 Over 1 million catheter-associated UTIs

occur in the United States each year
 Risk factors: female sex; duration of
catheterization; disconnecting the
junction between the catheter and the
collecting tube
DIAGNOSA
ANAMNESE
ISK ATAS ISK BAWAH

 NYERI PINGGANG  POLAKISURIA
 DEMAM  DISURIA
 MENGGIGIL  NYERI SUPRA PUBIK
 MUAL
 MUNTAH
 HEMATURI
PEMERIKSAAN FISIS
 FEBRIS
 NYERI TEKAN SUPRA PUBIK
 NYERI KETOK SUDUT KOSTOVERTEBRA
Mid Stream Urina (MSU) / Urine Pancaran Tengah (UPT)
WANITA
-Telanjang badan bagian bawah
-Jongkok dengan kaki terbuka lebar
-Bersihkan Genitalia dgn kapas basah pakai air hangat
3x dari depan ke belakang
-Buka labia
-Ambil aliran tengah
PRIA
- 1, 2 idem
-Buka preputium
-Cuci glans penis dan orificium urethra sda
-Ambil aliran tengah
Urine Culture and Sensitivity
 Traditional gold standard for significant bacteriuria

>100,000 cfu/mL of urine. Some argue criteria for
bacteriuria is only 100 cfu/mL of a uropathogen in
symptomatic females or 1,000 in symptomatic males.
 Bacterial identification from urine C&S, key in males

and females with complicated UTI’s.
Other Laboratory Tests
Complete Blood Count with Differential
 Indicated to R/O bacterial infection supports treatment plan
 Careful evaluation of WBC & differential (left shift)
Electrolytes
 R/O dehydration & if IV fluids replacement needed
BUN, Creatinine
 Determine ↓ renal function for nephrotoxic medications
Blood Culture
 Identify bacteremic organism in suspected urosepsis
PENATALAKSANAAN
BUNUH KUMAN - Cegah infeksi berulang
- Cegah Bakteriemia & kematian
- Cegah progresifitas ke GGK
- Cegah Kerusakan
-Sebelum Th/ kultur
-Anti biotika sesuai dgn sensitifiti test
-Koreksi faktor predisposisi
-Gejala hilang kuman ?
-Kultur ulang dan nilai ulang
-Respons : kuman hilang
-Relaps : kambuh dgn kuman yang sama
-Reinfeksion : kambuh dgn kuman yang beda
-Persisten : kuman tetap ada
PENATALAKSANAAN
 NON FARMAKOLOGIS
BANYAK MINUM (BILA FUNGSI GINJAL
BAIK)
MENJAGA HIGENE GENITALIA EKSTERNA
 Berubahnya lingkungan kuman dan
penggunaan antibiotika yang tidak rasional di
masyarakat dan di RS akan merubah pola
kuman penyebab ISK dan resistensi kuman thd
antibiotika konvensional
 Survey epidemiologik kuman penyebab ISK
lokal secara berkala perlu dilakukan untuk
pertimbangan terapi empirik
 Terapi empirik sebaiknya didasarkan pada
pola kepekaan antibiotika terhadap populasi
kuman setempat (di masyarakat atau RS)
ANTIBIOTIKA
-Atas : lama dan mudah relaps

-Bawah : dosis rendah & singkat, mudah reinfeksi
Oral cure 7 hari : sulfonamid, ampisilin, tetrasiklin,

PNC, Nitrofurantoin, Nalidixic acid,
sefalosporin, amoxilin, kotromoksazol
Pielonefritis akut, cure 10-14 hari (rawat inap)

Prevention & Treatment Plan
Recommendations/Considerations/Prevention
Indwelling-Catheterization
Foley catheterization should be avoided if at all possible
 Most effective means of UTI prevention is limitation of chronic

indwelling catheters.
Wagenlehner et al. 2005
PROGNOSA
Th/ tepat ------------ resolusi komplit

Kurang tepat --------------GGK
ISK sering berulang ------------GGK
ISK uncomplicated -------------jarang menjadi GGK
ISK complicated ---------------Sering GGK

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INFEKSI SALURAN

Assoc Prof Dr. dr. Shahrul Rahman, Sp.PD, FINASIM

Departemen Ilmu Penyakit Dalam

• Long-term care elders

• Marked increases in women & men after age 65

Dijumpai pertumbuhan kuman dalam jumlah signifikan

• Urinary tract infection—most common source of

• Bacteremia—40 times more likely to occur in

• Bacteremia leads to significant morbidity and mortality

 Urinary tract infection

Strictly defined—exists when 2 urine cultures

 Over 1 million catheter-associated UTIs

ISK ATAS ISK BAWAH

 Traditional gold standard for significant bacteriuria

 Bacterial identification from urine C&S, key in males

-Atas : lama dan mudah relaps

Oral cure 7 hari : sulfonamid, ampisilin, tetrasiklin,

Pielonefritis akut, cure 10-14 hari (rawat inap)

 Most effective means of UTI prevention is limitation of chronic

Th/ tepat ------------ resolusi komplit

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