INFEKSI SALURAN

KEMIH

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.
Urinary Tract Infection (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 UTIs caused by gram-negative
bacteria: Proteus, Klebsiella, Seratia, Pseudomonas
Overview of UTI by age and
sex
Urinary Tract Infection
(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)
 Urinary Tract Infection
(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

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
Terms

Urinary tract infection

Significant bacteriuria
Asymptomatic bacteriuria
Acute pyelonephritis
Chronic pyelonephritis
Upper versus lower UTI
Urethral syndrome
Terms (2)

UTI: the finding of microorganisms in bladder

urine with or without clinical symptoms and
with or without renal disease
Significant bacteriuria: the finding of > 105
colony-forming units (cfu)/mL in a pure
culture of voided clean-catch urine (but lower
counts can be significant)
Terms (3)

Upper UTI: infection above the level of the

bladder
Lower UTI: infection at or below the level of
the bladder
Urethral syndrome: clinical manifestations
of lower UTI (dysuria, frequency, urgency)
without significant bacteriuria
Klasifikasi ISK
(berdasarkan lokalisasi)
1) ISK bawah (lower urinary tract
infection), terdiri dari uretritis,
prostatitis, dan sistitis dan
2) ISK atas (upper urinary tract infection),
terdiri dari ureteritis dan pielonefritis.
Asymptomatic bacteriuria

In patients with asymptomatic bacteriuria

without infection, a colony count of > 105
cfu/ml defines infection
Screening has little apparent value in
adults except during pregnancy and prior
to urologic surgery
Up to 40% of elderly men and women
have asymptomatic bacteriuria
 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 definedexists 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, contd

ASB
Frequent in elderly, even > prevalent in residents
of LTCF:
elderly >70 yrs old
women: 16-18%
men: 6%
Uncomplicated : - Normal Urinary Tract
- Normal Renal Function

Complicated
A. Abnormal Urinary Tract
B. Impaired Host Defences
C. Impaired Renal Function
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
Etiology of community-
acquired UTI
Aerobic gram-negative rods most often
E. coli accounts for about 90%
Staphylococcus saprophyticus has been
increasingly appreciated in recent years
(with seasonality, tending to occur in the
summer)
Rare: anaerobes; pyogenic cocci; viruses
 Etiology of nosocomial UTI
E. coli is the most common pathogen
However, also common are other
Enterobacteriacae (Proteus, Klebsiella,
Enterobacter, Serratia, Providencia species) and
Pseudomonadaceae (notably, Pseudomonas
aeruginosa)
Enterococci: often in obstructive uropathy
Yeasts: Candida albicans, others
UTI in adults

Women: bacteriuria increases with age

and sexual activity
Men: bacteriuria is rare before age 50
(and as a corollary, calls for more
aggressive evaluation than in women).
Subsequently, bacteriuria increases with
onset of prostatism
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
 Long-term bladder
catheterization
Incidence of significant bacteriuria in patients who
are not receiving antibiotics is 8% to 10% per day
More than 85% of patients have at least two
strains of bacteria and 10% have more than five
strains
Some species (notably, enterococci, Pseudomonas,
and Proteus) notoriously tend to persist