MUH.

AKBAR BAHAR

INFEKSI SALURAN KEMIH

(ISK)

PENDAHULUAN
Saluran kemih : salah satu lokasi infeksi tersering

setelah saluran pernapasan

Sering ditemukan, sekitar 1-2 % dari pasien yang
berobat ke dokter umum.
Kasus ISK paling sering terjadi pada wanita (10:1),
insidensinya mencapai 0,5/wanita tiap tahun.
ISK dibagi atas ISK komplikasi dan non-komplikasi
Biasanya
disebabkan
oleh
bakteri
(E.coli,
S.saprophyticus, Proteus sp., Klebsiella sp.,
S.aureus, dan S.epidermidis)

URINARY TRACT INFECTION

Urinary

tract infections are thought of as

complicated and uncomplicated. Generally this
refers to presence or absence, respectively, of
functional or structural abnormalities within the
urinary tract.
The majority (85%) of uncomplicated UTIs are
caused by Escherichia coli. The remaining 15%
are caused by Klebsiella spp., Staphylococcus
saprophyticus, Enterococcus spp., Proteus
spp.,and other organisms.
Symptoms of lower UTIs including dysuria,
urgency, frequency, nocturia

URINARY TRACT INFECTION

Symptoms of upper UTIs include fever, nausea,

vomiting, and often severe flank pain.

Uncomplicated UTIs may be managed with 3-day
or even 1-day regimens, while complicated UTIs
should be treated for at least 7 days,and
sometimes up to 2 weeks.

Gambaran Klinis
Gejala sistemik

Demam, kaku otot, confusion

Gejala Lokal

Disuria, Frekuensi, Urgency, Nyeri

suprapubis, Nyeri lipat paha, Hematuria, Urin
berbau menyengat.

Pemeriksaan mikroskopik dan kultur urin

Infeksi Bakteri
> 105 bakteri/ mL + > 100 leukosit /L

Piuria Steril
Tdk ada organisme (yaitu, < 105 bakteri/ mL ) + >
100 leukosit /L.
TB, Nefritis interstisial, Nekrosis papiler, kanker,
batu ginjal/batu saluran kemih.

Penatalaksanaan dugaan isk

Kultur urin dan pemeriksaan mikroskopik
Atasi dgn AB dan asupan air ditingkatkan
Atur AB sesuai dgn sensitivitas.

Apabila infeksi rekuren/relaps pada wanita dan pria

Lakukan pemeriksaan penunjang.

Pemeriksaan penunjang
Tes dipstik urin
Pemeriksaan mikroskopik dan kultur spesimen

dari spesimen urin identifikasi penyebab dan

pola resistensi AB.
Pencitraan saluran ginjal abnormalitas struktur
ginjal/saluran kemih : usg , IVU
Fungsi ginjal : kreatinin
Diabetes : glukosa

Routes of Infection
Ascending Pathway
Hematogenous Pathway
Lymphatic Pathway

Ascending Pathway
The ascending pathway occurs when bacteria colonizing

the urethra subsequently travel upwards,or ascend the

urethra to the bladder and cause cystitis (Fig.761).
The ascending route may help to explain why urinary
tract infections occur more commonly in women than in
men. Women have a shorter urethra than men, and
colonization of the female urethra is likely due to its
proximity to the perirectal area. It is also known that the
use of spermicidal agents increases the colonization of
the vagina with uropathogens.
Additionally,massage of the urethra in women as well as
sexual intercourse may lead to bacteria gaining entrance
into the bladder. Once in the bladder, bacteria are not
limited to causing cystitis.These bacteria may continue to
ascend the urinary tract via the ureters and cause more
complicated infections, such as pyelonephritis.

Hematogenous Pathway
The hematogenous route occurs through the

seeding of the urinary tract with pathogens

carried by the blood supply.
These pathogens represent an infection at
some other primary site in the body.
Staphylococcus
aureus bacteremia, for
example,can cause renal abscesses via the
hematogenous route,and pyelonephritis can
be experimentally produced by intravenous
injection
of
Salmonella,Mycobacterium
tuberculosis,or even yeast (Candidaspp.)

Lymphatic Pathway
The

lymphatic system,also known as the

secondary circulatory system, connects the
bladder to the kidney and may represent a way
for bacteria to be transported and subsequently
cause infection.

Host Defense Mechanisms

Urine, although not an antimicrobial it self, does possess

characteristics that are less than ideal for bacterial

growth.
Some of these characteristics include low pH, significant
urea concentration, and high osmolality. Also, specifically
in men, it isknown that prostatic fluid secretions inhibit
bacterial growth.
When they enter the bladder, bacteria stimulate anurge to
urinate. This is yet another host defense mechanism
targeted at preventing a bladder infection.
There are several other host factors present that should
be mentioned that inhibit what are known as bacterial
virulence factors. In general, these virulence factors are
mechanisms that bacteria utilize to cause infection and/or
ensure their survival.

Host Defense Mechanisms

The first is glycosaminoglycan, a compound

produced by the body that coats the epithelial

cells of the bladder. This compound essentially
separates the bladder from the urine by forming
a protective layer against bacterial adhesion.
A second compound known as Tamm-Horsfall
protein (uromodulin) is secreted into the
urine,and prevents E. coli from binding to
receptors present on the surface of the bladder.
Other factors implicated in contributing to host
defense mechanisms include immunoglobulins,
specifically IgA, and lactobacilli,bacteria that are
part of the normal vaginal flora.

Uncomplicated Cystitis (Lower

UTI)
E. coli is the most frequent (85%) of causal

organisms in this setting,but in a minority of

cases may be caused by S. saprophyticus, K.
pneumoniae, P. mirabilis, Enterococcus spp.,
and a small percentage of others.
One significant benefit oftreatment in the
setting of uncomplicated cystitis is that
treatment duration can be less than 7
days,and often may be 3 days or even 1 day.

Acute Pyelonephritis (Upper UTI)

In contrast to patients that present with lower tract

UTIs,those that present with pyelonephritis will have

high-grade fever[greater than 38.3C (100.9F)] and
severe flank pain.
Select patients with pyelonephritis may be treated in
the outpatient setting; however, patients whose
infection
is
severe
enough
to
cause
vomiting,decreased food intake,and dehydration
should be treated in an inpatient hospitalized setting.
These patients will receive intravenous antibiotics at
first before being switched to oral therapy.

Acute Pyelonephritis (Upper UTI)

Patients with pyelonephritis are traditionally given 14 days of

therapy;however,there are limited data showing success in treating

acute uncomplicated pyelonephritis for 7 to 10 days. Gram stain and
culture are important in ensuring appropriate antimicrobial coverage
is selected.
Women who present with mild cases of pyelonephritis (defined as
low-grade fever and a normal to slightly elevated peripheral white
blood cell count, without nausea or vomiting) may be treated as
outpatients.
Those women who exhibit more severe signs and symptoms will
need to be admitted to an acute care setting for appropriate
treatment.The same holds true for antibiotic selection in these
patients.
Those who are treated in an outpatient setting can be treated with
trimethoprim sulfamethoxazole, fluoroquinolones, or even lactam/-lactamase inhibitors, such amoxicillin-as.clavulanate.
In those patients that are admitted to the hospital,antibiotic therapy is
usually broader in nature,especially in patients suspected of having
bacteremia or urosepsis. These patients will typically receive
intravenous therapy such as a fluoroquinolone, or a -lactam plus an
aminoglycoside.

Pregnant Women
7%

of pregnant women have an asymptomatic

bacteriuria that may progress to pyelonephritis,screening
is
necessary.In
patients
with
significant
bacteriuria,whether symptomatic or asymptomatic.
In the majority of patients, a sulfonamide (not in the third
trimester due to concerns for hyperbilirubinemia),
amoxicillin, amoxicillin clavulanate, cephalexin, or
nitrofurantoin are effective treatment options.
Tetracyclines and fluoroquinolones should be avoided
due to risk of teratogenicity and ability to inhibit cartilage
and bone development, respectively. Follow-up usually
consists of a urine culture 1 to 2 weeks after completion
of therapy,and afterwards monthly until birth.

UTIs in Men
Although UTIs in men are not always complicated by

definition,due to the relative infrequency ofUTIs in men

compared to women, an abnormality (structural or
functional) should be suspected and therefore treated as
a probable complicated infection until proven otherwise.
For this reason,men should not be treated with a single
dose or short course of therapy if diagnosed with a UTI.
Typically these patients will receive 2 weeks of
therapy,and in situations of failure may be treated up to 6
weeks,
particularly if a prostatic source of infection is
suspected.Prostatic
enlargement,as
previously
mentioned,is a risk factor in men,