URINARY TRACT INFECTIONS

Dr. Dame Joyce Pohan MBiomed

 PENGERTIAN

Infeksi saluran kemih (ISK) adalah infeksi

akibat terbentuknya koloni kuman di saluran
kemih. Kuman mencapai saluran kemih
melalui cara hematogen dan ascending.
 Faktor resiko:
Kerusakan atau kelainan anatomi saluran
kencing berupa obstruksi internal oleh jaringan
parut, endapan obat intratubular, refluks,
instrumentasi saluran kemih, konstriksi arteri-
vena, hipertensi, analgetik, ginjal polikistik,
kehamilan, DM, atau pengaruh obat-obat
estrogen.
 ISK sederhana / tak berkomplikasi :

ISK yang terjadi pada perempuan yang tidak

hamil dan tidak terdapat disfungsi structural
ataupun ginjal.
 ISK berkomplikasi:
ISK yang berlokasi selain di vesika urinaria, ISK
pada anak-anak, laki-laki atau ibu hamil.
Pengelolaan menjadi sulit karena faktor
pemberat (DM, Obstruksi, batu,
imunodefisiensi)
KEJADIAN ISK PADA KEHAMILAN

• The National Birth Defect Prevention Study

(Amerika Serikat → 4.760 ibu hamil →
3.690 menderita ISK → 70% kelainan
jantung)
Diagnosis:
Acute Cystitis-Urethritis:
Women and girls older than 2 years
Acute onset dyuria, increased frequency of urination
Pyuria > 5-10 erythrocytes/high power field of centrifuged
urine or positive leukocyte esterase test
Positive urine culture (1000-100,000 colony forming
units/mL) for E.coli, other Enterobacgteriaceae, enterococci,
or Staphylococcus saprophyticus)
 Acute Pyelonephritis:

fever, chills, flank pain

Pyuria

Positive urine Gram stain for gram-negative bacilli

Positive urine culture (> 100.000 colony forming

units) or blood culture with gram-negative bacilli
Acute Prostatitis (subjects older than age 35):

fever, chills, dysuria, increased frequency

of urination, low back or pelvic pain
Pyuria
Positive urine culture for gram-negative
bacilli or enterococci
 Chronic Prostatitis:

Middle-aged to elderly men

Chronic intermittent dysuria, increased frequency of
urination, pelvic pain
Enlarged prostate
Positive culture of prostatic secretions or voided urine
after massage for gram-negative bacilli or enterococci.
The number of colony forming units of bacteria should be
10-fold greater than the number in urine obtained before
prostatic massage
 Microbiology of Community acquired Urinary Tract Infection

Dysuria-Pyuria Syndrome in Females

Children Adults

Escherichia coli E. coli

More Frequent Staphylococcus saprophyticus
(young,
sexually active patients)
Less frequent Other Enterobacteriaceae Other Enterobacteriaceae
Enterococci Enterococci
Streptococcus agalactiae
Other Community-Acquired Infection

More Frequent Children Adults

E coli E coli

Less frequent Other Enterobacteriaceae Other Enterobacteriaceae

Enterococci Enterococci
Ascending route
- Contraceptive devices
- Catheterization of the bladder
- E strogen deficiencies
- UTI in women more frequent than in men
-Bacteria within bladder
multiply and pass up the ureters (esp. if vesicoureteral
reflux present)
renal pelvis, parenchyma
- Most important route of infection
Route of infection
Hematogenous route
The kidney is frequently the site of abscess in
patients with S . aureus bacteremia and endocarditis
Infection of the kidney with Gram negative bacteria
hematogenously is rare
Lymphatic route
Increased pressure in the bladder lymphatic flow to
be directed toward the kidney
 MEKANISME ISK PADA KEHAMILAN

• Panjang uretra pada wanita → pendek → 3 cm

• Uretra → relatif terbuka → berdekatan alat kelamin &
anus → banyak mengandung kuman → potensi ISK
• Trauma (kasar) → saat-saat bersenggama → bakteri
terdorong → uretra → ISK
• Pemasangan catheter → ISK
• Kehamilan → menekan ureter → sumbatan (hidro
nefrosis fisiologis) → ISK
• Progresteron → ↓tonus otot, peristaltik → gangguan
aliran kencing → ISK
Pathogenesis Bacterial colonization of
vaginal introitus and
periurethral area

Ascendence through
the urethra

Entry to the bladder and

multiplication of bacteria

Ascendence through the ureters to

the renal pelvis and parenchyma
 Microbial factors:

- Uropathogenic strains of E coli:

virulence factors:
-enhancement of colonization of vaginal and periurethral
cells
- attachment to uroepithelium
- invasion of tissue: adhesion, resistance to serum
bactericidal activity and phagocytosis, K antigen,hemolysin:
 Microbial factors:

Uropathogenic strains of E coli:

virulence factors:
-Fimbriae: major type of surface adhesions of uropathogenic
E.coli
- Nonfimbriated uropathogenic E. coli:
expression of a variety of adhesions that bind to uro
epithelium
Pathogenesis of UTI caused by
uropathogenic E. coli.

Nature Reviews Microbiology 2004; 2, 123-40.

 Microbial factors:

Attachment to uroepithelial cells by other

bacteria:
- Expression of fimbriae:
- Proteus mirabilis
- Klebsiella sp.
- Staphylococcus saprophyticus adheres
better to uroepithelial cells than
Staphylococcus epidermidis or
Staphylococcus aureus
 Microbial factors:

Production of urease by Proteus sp. and

other microorganisms: increase potential to
cause pyelonephritis
- Bacterial K-antigen inhibits phagocytosis
- Most uropathogenic bacterial strains
produce hemolysins:
- facilitate tissue invasion and enhance renal
cell damage
 Diagnosis of UTI
Urine culture:
• Significant bacteriuria= 100K cfu/ml
• symptoms: 1 +ve cuture = infection
• Symptoms: 10K cfu/ml = propable
infection
• Asymptomatic: 2 +ve cultures = infection
• False negative : antibiotics, antiseptics,
urethral syndrome,TB kidney, diuresis.
 SALURAN KEMIH: URIN
• Pemeriksaan semikuantitatif
• Sampel:
– Mid stream urine ( Clean catch urine, urin porsi tengah)
– Supra pubic puncture – terutama kultur anaerob
– Urin kateter
• Transport :
– minimal 2 jam setelah pengumpulan spesimen
– > 2 jam : lemari es (bukan freezer)
 Cara pengumpulan spesimen urin

1. Mid stream urine ( Clean catch

urine )
Explain to patients !
urine pertama di pagi hari
spesimen dikumpulkan di
pertengahan urine dikeluarkan
Penis / vulva dibersihkan
dengan air sabun atau tissue
basah steril
Hindari kemih mengenai kulit
 Cara pengumpulan spesimen urin

2. Urin Kateter
• bukan dari catheter bag

• kumpulkan dari selang indwelling catheter

melalui sampling port setelah dibersihkan
dengan swab alkohol terlebih dahulu
Cara pengumpulan spesimen urin
 Cara pengumpulan spesimen urine

3. Urine Aspirasi Suprapubik

Spesimen urine paling

baik
Invasif
Tindakan secara aseptik
Dikerjakan bila urin porsi
tengah sulit didapatkan
TERIMA KASIH