INFEKSI SALURAN KEMIH

Oleh
Hendra Santoso
Pembimbing
dr. Hasnawaty Sp.OG
 EPIDEMIOLOGY

• Extremely common
• 50-60% women experiencing at least 1 during lifetime, 25% recurrent within 6
months
• Most frequent: infants, young women (1/3 women by the age of 24 require
treatment, 50% having had an episode of UTI in their lifetime), elderly
• Invasive infection (pyelonephritis) à less common (250,000 cases à 200,000
admissions in USA/year)
 URINARY CHANGES DURING PREGNANCY

Dilatations of calices Dilatation of ureters (evident

as early as 12 w)
High progesterone 
relaxation of smooth
Hypomotility of ureters
muscle
+ Compression of bladder by
Ureters pressed to pelvic uterus and fetus  bladder
brim pressure > ureter  reflux
 Diagnostic Criteria by Infectious Diseases Society of America
Category Descriptions Clinical Features Laboratory Investigations

1 Asympstomatic Bacteriuria No urologic symptoms ≥ 10 WBC/mm3

≥ 105 CFU/m* in two consecutive
MSU cultures
24 h apart

2 Acute Uncomplicated UTI in women Dysuria, urgency, frequency, suprapubic pain, no ≥10 WBC/mm3
Acute Uncomplicated cystitis in women urinary symptoms in 4 wk before this episode ≥103 CFU/ml

3 Acute uncomplicated pyelonephritis Fever, chills, flank pain; other diagnoses excluded; no ≥10 WBC/mm3
history or clinical evidence of urological a ≥104 CFU/ml
bnormalities (ultrasonography, radiography)

4 Complicated UTI Any combination of symptoms from categories 1 and ≥ 10 WBC/mm3

2 above; one or more factors associated with a ≥ 105 CFU/ml* in women
complicated UTI ≥ 104 CFU/ml* in men or in straight-
catheter urine in women

5 Recurrent UTI (antimicrobial prophylaxis) At least three episodes of uncomplicated infection < 103 CFU/ml* (between episodes)
documented by culture in past 12 mo: women only; no
structural/functional abnormalities
 HOST

• 6x increased risk à 1) urethral meatus located within the vaginal introitus &
close proximity to the anus; 2) much shorter length once entry the urethra
• Presence of bacteria within urine ↮ infection à regular voiding helps
• Use of spermicides or diaphragm, menopause, pregnancy, type 2 diabetes,
genetics à ↑ risk of UTI
• Use of antimicrobials à ↓ level of normal flora à opportunistic uropathogen ↑
 DIAGNOSIS

• Urine dipstick test (leukocytes esterase, nitrate) à pyuria (≥ 10 WBC/mm3)

• Bacterial count (colony-forming units; cfu) à ≥103 cfu/mL (sporadic), ≥105
cfu/mL (asymptomatic)
• Midstream urine culture
• Basic blood samples (hemoglobin, WBC and differential count, C-reactive
protein, S-creatinine)
• Imaging (ultrasound examination, IV pyelogram, CT, cystoscopy
SAFETY OF ANTIBOTICS FOR UTI IN
PREGNANCY
(FDA USA CATEGORY APPROVAL)
 Fosfomycin trometamol– B

Category B
 Penicillins – B
- e.g. Pivmecillinam
 Cephalosporins - B
 Nitrofurantoin – B
 Fluoroquinolones – C
 TMP – C, D first trim
 SMX – C, D last trim

 B : animal studies do not demonstrate or human studies do not confirm fetal risk
 C : animal studies indicate adverse fetal effects not refuted adequately in human studies
 D : positive evidence exists of human fetal risk
 UTI in pregnancy management according to
PNPK
1. Asymptomatic Bacteriuria
Guideline:
Antibiotic treatment according to culture result
E.Coli infection:
1. Fosfomycin trometamol (3 g SD)
2. Nitrofurantoin 100 mg p.o 2x/day (5 days)
3. TMP 300 mg/day (5 days)
*avoid first trimester of pregnancy, folic acid deficiency, orher folic acid antagonist drugs
4. Amoxycillin + clavulanic acid 500+125 mg p.o 2x/day (5 days) * only in <20 weeks of pregnancy

Gram negative bacteria (klebsiella, proteus, enterobacteriaceae, pseudomonas):

1. Norfloxacine 400mg p.o 2x/ay (5 days)
GBS :
1. Pencillin V 500 mg p.o 2x/day (5 days)
2. in labour: benzylpenicillin 3g IV dose as soon as possible and 1.2g IV / 4 hours
3. Allergic to penicillin, alternative: lincomycin 600mg IV/8 h atau azythromycin 500 mg IV /day
 UTI in pregnancy management according to
PNPK
2. Acute Cystitis

Guideline
First line management: oral hydrations
Suprapubic pain and dysuria : mild to moderate analgesia
Antimicrobial therapy:
Fosfomycin trometamol (3 g as a single dose) or
II and III generation of cephalosporin for short term treatment (IIa)

Other antibiotics:
Amoxycilin+Clavulanat 500+125 mg p.0 2x/d (5-7 days)
*if gestational age more than 20 weeks of pregnancy
Nitrofurantoin 50 mg p.o/6 hours (5-7 days)

Nitrofurantoin 50 mg at night for recurrent UTI prophylactic (IIa)

 MANAGEMENT OF ACUTE
PYELONEPHRITIS IN
PREGNANCY
• Parenteral, broad spectrum beta-lactams are the
preferred antibiotics for initial empiric therapy

/ Cefazolin
 FOLLOW UP TREATMENT…

• Once afebrile for 48 hours, switched to oral therapy

guided by culture susceptibility results and
discharged to complete 10 to 14 days of treatment
• Oral trimethoprim-sulfamethoxazole, nitrofurantoin
and fosfomycin are not appropriate for
pyelonephritis due to inadequate tissue levels

Pyelonephritis is not itself an indication for delivery!

 ANTIBIOTICS RESISTANCE PROBLEMS

• Increase resistance on Amoxicillin and cefalosporin

• Resistance increase with duration of treatment.

Single course of Antibiotic with low

resistance is prefered.
 S U G I A N L I S T U D Y, E T A L L
POPULATION-BASED AMR SURVEILLANCE IN INDONESIA
( A N T I B I O T I C R E S I S TA N C E S T U D Y I N R S H A S A N S A D I K I N & R S A D A M M A L I K )

Urology Obstetrics/gynaecology
E. coli K. pneumoniae E. coli K. pneumoniae
(n = 222) (n = 37) (n = 58) (n = 19)
% resistance % resistance % resistance % resistance

Amoxicillin/clavulanic acid 50.5 67.6 36.2 42.1

Ceftriaxone 58.1 78.4 43.1 47.4

Ciprofloxacin 71.6 83.8 48.3 26.3

Levofloxacin 69.4 78.4 41.4 15.8

Trimethoprim/ 56.8 86.5 53.4 57.9

sulfamethoxazole
Nitrofurantoin 13.1 83.8 15.5 63.2

Fosfomycin 0.9 6.7 7.3 0

J. Antimicrobial Chemotherapy,2017
RECCURENT UTI : ≥2 INFECTIONS/6 MO OR
≥ 3 EPISODES/12 MO
 Fever and chills, nausea and vomiting, Frequency, urgency, dysuria, hematuria, pyuria
Algorythm of lumbar pain, Goldflam’s sign positive UC: ≥103 CFU/ml

Management of
yes No
UTI in yes No

Pregnancy Pyelonephritis Cystitis Asymptomatic Bacteriuria

Treatment of 10-14 days of IV/IM Antibiotic treatment according to culture result

antibiotics: 1. Fosfomycin trometamol (3 g SD)
• ceftriaxon/cefazolin 1g/24 h 2. Nitrofurantoin 100 mg p.o 2x/day (5 days)
• Ampicillin 1-2g/6 h plus Gentamicin* 3. TMP 300 mg/day (5 days)
1,5mg/kgBW/ 8 hr *avoid first trimester
• Cefepime 1g/12hr 4. Amoxycillin + clavulanic acid 500+125 mg
p.o 2x/day (5 days) * only in <20 weeks of
Severe Pyelonephritis: pregnancy
• Meropenem 1g/8 hr

Recurrent UTI

Long term Prophylactic Post Coital Prophylactic

• Fosfomycin 3g/10days - Nitrofurantoin 50-100 mg SD
• Nitrofurantoin 50-100 mg/day - TMP-SMX 80/400 mg SD
• Cephalexin 125 mg or 250 mg/day - Cefixime 400 mg SD
TERIMA KASIH