ISK

1. INFEKSI SALURAN KEMIH
DWI LESTARI PARTININGRUM
DWI LESTARI PARTININGRUM
Sub. Bag. Nefrologi – Hipertensi
Bag. Ilmu Penyakit Dalam
FK UNDIP / RSDK

2. Introduction: UTI
t b t i l i f ti f GP
 commonest bacterial infection for GP
 substantial morbidity
 wide clinical spectrum (mild – severe – sepsis)
Urinary tract is normally sterile
Definition of UTI:
 any bacteria multiplying in the urinary tract
 regardless of bacterial count
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 regardless of bacterial count

3. INFEKSI SALURAN KEMIH (ISK)
 Infeksi tersering dialami  masalah kesehatan
yg sering dihadapi dokter.
 Dapat mengenai semua umur.
 Spektrum gejala klinik sangat bervariasi dari
p g j g
tanpa gejala/ keluhan sampai kelainan sistemik
yg berat.
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4.  Definisi :
• ISK  akibat invasi mikro organisme pada
ISK  akibat invasi mikro organisme pada
jaringan traktus urinarius (TU) dari orifisium
uretra – korteks ginjal.
uretra korteks ginjal.
• Normal TU steril.
Ad b kt i d l i (b kt i i ) 
• Adanya bakteri dalam urin (bakteriuria) 
TU berisiko alami infeksi.
• Kultur (+) : kuman > 100.000/ml urin.
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5. Prevalensi ISK
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6. KLASIFIKASI
KLASIFIKASI
 Lokasi Anatomis: ISK atas & ISK bawah.
 ISK Complicated & ISK Uncomplicated
 ISK Complicated & ISK Uncomplicated.
 Klasifikasi Klinis :
Asymptomatic bacteriuria
Acute uncomplicated cystitis in women
Recurrent infections in women
Acute uncomplicated pyelonephritis in women
p py p
Complicated UTIs in both sexes
Catheter-associated UTIs
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7. GEJALA
ginjal ISK ATAS
Pyelonefritis
GEJALA
Demam
M i il
ureter
Menggigil
Nyeri pinggang
Mual ± muntah
P BB
ureter
Penurunan BB
± gejala isk bawah
ISK BAWAH
Ureteritis
Cystitis
Nyeri supra pubis
Disuria
Kandung
kemih
Cystitis
Prostatitis
Epididimitis
Urethritis
Frekuensi
Urgensi
Hematuri
Urethritis
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8. Klasifikasi ISK
Dari segi PENATALAKSANAAN dibedakan atas :
ISK li t d ( i l )
1. ISK uncomplicated (simple) :
 ISK sederhana  anatomik maupun fungsional TU
normal.
normal.
 Terutama mengenai wanita.
 Infeksi hanya mengenai mukosa superfisial kandung
kemih.
 Penyebab kuman tersering (90%) adalah E. coli.
2 ISK complicated
2. ISK complicated
 Sering menimbulkan banyak masalah, krn didasari hal ttt.
 Sering kuman penyebab sulit diberantas  resisten
Sering kuman penyebab sulit diberantas  resisten
terhadap beberapa macam antibiotik
 Sering terjadi bakteriemia, sepsis dan syok.
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 Penyebab : Pseudomonas, proteus, klebsiela dll.

9. ISK Complicated  terdapat keadaan sbb :
1. Kelainan abnormal saluran kencing.
Contoh : batu, obstruksi, refluks vasikouretral, atoni
kandung kemih, kateter menetap, prostatitis
menahun
menahun.
2. Kelainan faal ginjal. baik GGA maupun GGK.
3. Gangguan daya tahan tubuh. Penderita DM,
3. Gangguan daya tahan tubuh. Penderita DM,
neutropenia, penderita dg terapi imunosupresif.
4. Infeksi disebabkan organisme virulen.
Seperti proteus spp yg memproduksi urease,
Infeksi metastatik staphylococcus.
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10. Pathogenesis
Routes of bacterial invasion
Routes of bacterial invasion
1. Ascending
 common
2. Hematogenous
 staphylococcus
 mycobacterium
y
tuberculosis
 salmonella
 salmonella
3. Lymphatic: rare
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11. Host defences
Host defences
1. Bladder
 bladder emptying
 bladder emptying
 mucosal phagocytes
2 Antibacterial substances
2. Antibacterial substances
3. Anti-adherence
mechanisms
 urine, bladder & prostatic
secretions
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12. Pathogenesis of urinary infection
g y
Bacterial virulence vs. host defences
1 Inoculum
1. Inoculum
2. Adherence characteristics
3. Failure of urinary defence
 obstruction, calculi, VUR
obst uct o , ca cu , U
 incomplete bladder emptying
 diabetes mellitus & elderly
 diabetes mellitus & elderly
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13. Patogenesis lanjutan
g j
 Bacterial factor
 95% dari luar TU
 5% hematogen
g
 Host factor
 Wanita : uretra pendek, kolonisasi kuman pd
introitus vagina, sex intercourse, tampon,
spermatisid, diafragma, menopause
(lactobaccili)
(lactobaccili).
 30% ISK kandung kemih (cystitis)  invasi ke
ginjal  akibat dari VUR
ginjal  akibat dari VUR
 Infeksi pd ginjal sering di medula  kons
amonia ↑, osmol ↑, pH ↓, blood flow ↓, PO2
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rendah↓.

14. DIAGNOSIS
 Jumlah organisme pada ISK :
DIAGNOSIS
 Jumlah organisme pada ISK :
 70% ISK jml kuman > 100.000 kuman/ml urin.
30% ISK j l k l bih d h i d
 30% ISK jml kuman lebih rendah, mis; pend.
pria, wanita dg disuria akut, wanita dg ISK
berulang karena stapphylococcus
berulang karena stapphylococcus.
P ik i li
 Pemeriksaan urinalisa :
 Epitel skuamos  kemungkinan kontaminasi.
 Piuria  infeksi/ peradangan.
 Silinder lekosit  pielonefritis.
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15. Pemeriksaan kultur urin, yg didapat dari :
a Urin porsi tengah (mid stream urin)
a. Urin porsi tengah (mid stream urin)
b. Urin aspirasi suprapubik
Urin kateter kandung kemih (hindari)
c. Urin kateter kandung kemih (hindari)
D l i i k l i i h !! bb
Dalam interpretasi kultur urin porsi tengah !! sbb :
 95% ISK disebabkan monomikrobial
 95% ISK disebabkan gram negatif/ enterococci
 Staphylococcus epidermidis, diptheroids &
p y p p
lactobacilli jarang menimbulkan ISK.
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16. Bakteri penyebab ISK
Bakteri penyebab ISK
Mikroorganisme Kultur positif ( % )
E C li 60 90 %
E. Coli 60 - 90 %
Klebsiela / Enterobacter 10 - 20 %
Proteus 5 10 %
Proteus 5 - 10 %
Pseudomonas aurogenosa 2 - 10 %
Staph Epidermidis 2 10 %
Staph. Epidermidis 2 - 10 %
Enterokokkus 2 - 10 %
Kandida albikan 1 2 %
Kandida albikan 1 - 2 %
Staph. Aureus 1 - 3 %
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17. Asymptomatic Bacteriuria
 Umumnya terjadi pd wanita 
 Umumnya terjadi pd wanita 
2% - 4% wanita muda, 10% wanita >60 th.
Bil d DM i ik ISK 3 4
 Bila ada DM risiko ISK 3 - 4x nya.
 Laki2 jarang sekali, kecuali umur tua dg
hi t fi t t
hipertrofi prostat.
 Tidak perlu antibiotik. (kecuali didapatkan kultur
k ≥ 100 000 CFU/ L d 2 ik
+ kuman ≥ 100.000 CFU/mL pada 2x pemeriksaan,
dg jenis kuman sama)
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18. Asymptomatic UTI
 screening & symptoms minimal (urine odour)
Prevalence (%)
Prevalence (%)
Neonates 1 (-> 50% VUR)
S h l i l 1 2
Schoolgirls 1-2
Young women 10
Non-pregnant women 3-10
Pregnant women 5-6 (15-20% -> PN)
Pregnant women 5 6 (15 20% > PN)
Elderly men & women 5-40 (age)
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19. Terapi ISK Uncomplicated ( Simple )
 ISK yg paling sering dijumpai dlm praktek dokter.
 Manifestasi kliniknya  sindroma disuria-frekuensi.
 Piuria > 10/lpb, kultur (+)
p , ( )
 Keluhan sering kencing sedikit2, sakit waktu
kencing serta rasa tidak enak didaerah suprapubik
kencing serta rasa tidak enak didaerah suprapubik.
Disertai demam subfebril (±).
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21. Faktor risiko dan komplikasi ISK komplikata
Anatomic or structural risk factors
Obstructive utopathy (stones, strictures, tumors, prostate associated
Instrumentation (catheter associated and nosokomial infection)
Instrumentation (catheter associated and nosokomial infection)
Renal cystic disease
Ureteral stents & surgical urinary diversions, ileal loop constructions
Other : vesicoreteral reflux (VUR), urachal remnant
Functional risk factors
Diabetes mellitus
Renal transplantation
S i l d i j & l i d f ti
Spinal cord injury & neurologic dysfunction
Neutropenia
Human immunodeficiency virus
Micellanous complicated infection
Micellanous complicated infection
Pyonephrosis
Emphysematous pyelonephritis & cystitis
Malakoplakia and xantogranulomatous pyelonephritis
Intramural vesical abcess
Urosepsis
Tuberculosis
Infections caused by atipical or resistant organism : vancomycin resistant
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Infections caused by atipical or resistant organism : vancomycin resistant
enterococci, anaerobes, etc

22. TREATMENT
TREATMENT
1. Empiric therapy must be broad spectrum with
definitive therapy based on culture and
sensitivity
2. Moderately : Levofloxacin (500 mg IV/PO q24),
y ( g q ),
ciprofloxacin (500 mg PO twice-daily/400 mg q
12h IV)
)
3. Severely : cefepime 2g IV q12 hrs, ceftazidime
2 g IV q8 hrs, Imipenem 500 mg IV q6 hrs,
2 g IV q8 hrs, Imipenem 500 mg IV q6 hrs,
meropenem 1 g IV q8 hrs, doripenem 50 mg IV
q8 hrs, piperacillin-tazobactam 3.375-4.5g IV
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q8 hrs, piperacillin tazobactam 3.375 4.5g IV
q6 hrs

23. Acute pyelonephritis
 hemorrhage &
swelling
swelling
 PMN infiltration
H&E
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H&E

24. Clinical diagnosis: pyelonephritis
g py p
1. Fever T > 38 0C, rigors, chills, sweats
2 Loin pain
2. Loin pain
3. Constitional symptoms
 anorexia, nausea, vomiting, diahorrea, myalgia,
headache
4. Lower urinary symptoms
 dysuria frequency (30 - 50%)
 dysuria, frequency (30 - 50%)
 supra-pubic discomfort
UA i l k h i
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UA: pyuria, leukocytes, hematuria

25. Leukocyte casts PMN
y
1. Formation of WBC cast
3. Degenerate WBC cast
in fibrillar matrix T b l l H&E
2. Passage into urine
in fibrillar matrix Tubular lumen
Matrix
H&E
PMN
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EM BF PMN

26. Bacterial casts bacilli
 pyelonephritis
 usually with leukocytes
PMN
bacilli bacilli
PMN
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EM EM

27. Catheter associated UTI
Catheter associated UTI
 biofilm colonisation common with long-term
urinary catheters
 may cause septicemia in debilitated patient
Treat with A/B when:
 fever sepsis
 fever, sepsis
 symptoms attributable to UTI (e.g. agitation)
 short-term catheter & UTI
Observe long-term biofilm colonisation
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g

28. Prevention of catheter-associated UTI
 short duration
 insert under aseptic technique by trained
 insert under aseptic technique by trained
staff (or trained patient for intermittent self-
catheterisation)
catheterisation)
 bag below bladder & emptied regularly
 keep system closed sample urine by sterile
 keep system closed - sample urine by sterile
aspiration
antimicrobial cream in women
 antimicrobial cream in women
 A/B for cardiac valvular abnormalities
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29. UTI in males
Uncircumcised boys
Uncircumcised boys
 bacteria under foreskin -> UTI
Ad lt l
Adult males
 prostate often source
 antibacterial prostatic secretion
-> fails in chronic prostatitis
fails in chronic prostatitis
Homosexual males
5% ith UTI
 5% with UTI
 E Coli: same serotype
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30. Acute bacterial prostatitis
p
Young men < 35 y.o. or STD risk
C. trachomatis or N. gonorrhoeae
g
1. Rx. as gonorrhoea then
2 doxycycline 100 mg / d x 7 days
2. doxycycline 100 mg / d x 7 days
Older men > 35 y.o.
Enterobacteriaceae
ciprofloxacin 500 mg BD x 14 days
co trimoxazole BD x 14 days
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co-trimoxazole BD x 14 days

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33. Pengelolaan :
Pengelolaan :
1. Umum : cairan cukup, elektrolit & nutrisi.
2. Atasi komplikasi : syok, urosepsis, GGA atau
DIC.
3. Pikirkan tindakan bedah, ( pus karena
obstruksi saluran kemih).
4. Antibiotika parenteral sampai 24 jam bebas
demam ganti oral.
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34. Sambil menunggu hasil kultur, diberikan antibiotika
berspektrum luas seperti :
berspektrum luas seperti :
 Kombinasi ampicilin dan sefalosporin gen I
 Aminoglycoside dg Betalactam.
 Ticarcillin dg clavulanic acid.
 Quinolone
Antibiotika oral selama :
 5-14 hari = 50% relaps.
 4-6 minggu = angka keberhasilan mencapai 90%.
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35. Pyelonephritis
80%
Uncomplicated
Acute
10%
Complicated
Acute
10%
Chronic
pyelonephritis
Acute
pyelonephritis
Acute
pyelonephritis
pyelonephritis
“smouldering”
Medical
therapy
Medical and/or
surgical therapy
Medical and/or
surgical therapy
py g py g py
100%
40%
100%
Cured
100%
Progressive
renal damage
60%
Cured
40%
Progressive
renal damage
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36. wie pm

37. AN ODE TO A NEPHRON
Like thoughts in one’s life In our youth
Like thoughts in one’s life,
some superficial and some deep.
Some cortical, whilst other,
down close to medulla they seep.
All along our life we learn and adsorb
In our youth,
we stand firm and resolute.
We age and experience,
distal years of our lives convolute.
All along our life, we learn and adsorb,
with efforts active and passive.
Concentrate and dilute our endeavors,
by proportions little and massive.
Like experiences of life
…………………
The art of improvement and discipline,
through counter current and autoregulation.
Akin to self-control and evolution,
through practise prayer and meditation
Like experiences of life,
which we filter and retain.
So does the nephron,
adsorbs the electrolytes’ rain.
through practise, prayer and meditation.
Like our life, where experiences abound,
we improve, develop and rectify.
A little nephron sits there,
to secrete adsorb and purify
……………………
The life must move on, and loop its course,
descend and then to ascend.
We must advance and yearn,
to overcome and transcend
to secrete, adsorb and purify.
As life wanders and winds,
the nephron meanders its way.
To part with toxins and miseries,
all through the night and day
to overcome and transcend. all through the night and day.
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