DIAGNOSIS

ISK

dr Shahrul Rahman, Sp.PD

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
DIAGNOSA
ANAMNESE

ISK ATAS ISK BAWAH

 NYERI PINGGANG  POLAKISURIA
 DEMAM  DISURIA
 MENGGIGIL  NYERI SUPRA PUBIK
 MUAL
 MUNTAH
 HEMATURI
PEMERIKSAAN FISIS

 FEBRIS
 NYERI TEKAN SUPRA PUBIK
 NYERI KETOK SUDUT KOSTOVERTEBRA
UTI Signs and Symptoms in Elderly
Very difficult to assess and recognize, even when present in the older adult.
Signs & Symptoms that indicate further evaluation for UTI elicited from H&P:

 New or increased urgency, frequency, dysyuria:

> in younger patients, still can be present in elderly
These complaints can be common & chronic without bacteriuria
Requires careful interpretation—may not be due to UTI
 Change in character of
urine
One study found cloudy, bloody, or malodorous urine in >85%
symptomatic UTI’s
Others less predictive
Midthun, 2004
Signs and Symptoms, cont’d

 Clarity of urine
 Clear → no bacteria; cloudy, milky or turbid → bacteriuria
Cloudiness, however, can occur in normal urine—mucus, epithelial cells
Cloudy character, alone or with (+) dipstick analysis → further lab analysis
Study by Loeb et al. (2001) as consensus criteria—cloudy urine not an indication
for antibiotics
 Bloody
 Hematuria not always indicative of infection; possibly
irritation or medication related
 Malodorous
 Not a valid indicator—may be caused by bacteria, but
could be hygiene-related
 Often considered an indicator, however
Midthun, 2004
Diagnostic Criteria
Pyuria
A host response to infecting bacteria causing an increase of
white blood cells or pus in the urine
Associated with presence of both symptomatic and
asymptomatic UTI’s in elderly
Level of pyuria is ↑ when infected with a gram negative
organism
Most research finds this is so common that it has questionable
value in UTI detection and as an indicator for Rx in the absence
of clinical symptoms
McGeer et al. (one of the most commonly used consensus criteria in LTCF
for UTI detection in Canada) rejects it as being a reliable predictor of
bacteriuria or symptomatic infection
Midthun, 2004
Juthani-Mehta,, 2005
 Screening/Diagnosis

Asymptomatic Bacteriuria

 No universally accepted criteria for the diagnosis,

treatment, or surveillance of UTI, specifically in LTCF
residents

 Treatment of ASB is associated with ↑ adverse

antimicrobial effects, re-infection with organisms or
increasing resistance
Nicolle, et al., 2005
Screening/Diagnosis
Infectious Disease Society of America:
Guidelines for Dx & Rx of ASB in adults

1. ASB Dx based on results of a culture from clean-catch

specimen (* important to minimize contamination)
Women: bacteriuria = 2 consecutive voided urine samples
w/isolation of same strain in cfu/mL >100,000
Men: bacteria = single, clean-catch specimen with 1
bacterial species isolated in > 100,000 cfu/mL
Both: single catheterized urine specimen with 1 bacterial
species isolated in a count of > 1,000 cfu/mL
Screening/Diagnosis
Guidelines, continued

2. Pyuria accompanying ASB not an indication for

antimicrobial Rx (A-2)
3. Pregnant women should be screened in early pregnancy, at
least once & treated if positive (A-1)
4. Screening of ASB & Rx if positive before these urological
procedures:
Transurethral resection of prostate (A3)
Procedures anticipated to cause possible mucosal
bleeding (A-3)
Screening/Diagnosis
Guidelines, continued

5. No screening for ASB: (A-1 & A-2 strongly recommended via research
evidence)
Pre-menopausal, non-pregnant women (A-1)
Diabetic women (A-1)
Community older adults (A-2)
Institutionalized elderly (A-1)
Spinal cord injury (A-2)
Indwelling-catheterized patients (A-1)
6. Antimicrobial Rx of asymptomatic women with catheter-acquired bacteriuria
persisting 48 hrs after removed, should be considered (B-1/good)
7. No screening or Rx of ASB → renal transplant or solid organ transplant
recipients (C-3/weak)
Infectious Disease Society of America, 2005
Nicolle et al. 2005
www.guideline.gov/summary/summary
Mid Stream Urina (MSU) / Urine Pancaran Tengah (UPT)

WANITA
-Telanjang badan bagian bawah
-Jongkok dengan kaki terbuka lebar
-Bersihkan Genitalia dgn kapas basah pakai air hangat
3x dari depan ke belakang
-Buka labia
-Ambil aliran tengah

PRIA
- 1, 2 idem
-Buka preputium
-Cuci glans penis dan orificium urethra sda
-Ambil aliran tengah
 Urine Culture and Sensitivity

 Traditional gold standard for significant bacteriuria

>100,000 cfu/mL of urine. Some argue criteria for
bacteriuria is only 100 cfu/mL of a uropathogen in
symptomatic females or 1,000 in symptomatic males.

 Bacterial identification from urine C&S, key in males and

females with complicated UTI’s.
 Other Laboratory Tests
Complete Blood Count with Differential
 Indicated to R/O bacterial infection supports treatment plan
 Careful evaluation of WBC & differential (left shift)
Electrolytes
 R/O dehydration & if IV fluids replacement needed
BUN, Creatinine
 Determine ↓ renal function for nephrotoxic medications
Blood Culture
 Identify bacteremic organism in suspected urosepsis