INFEKSI SALURAN KEMIH URINARY TRACT INFECTION ISK / UTI dr.Yudi Andre Marpaung,M.Ked(PD),SpPD dr.Joseph Sibarani dr.Leonardo Dairi,SpPD-KGEH

Invasi mikroorganisme pada salah satu atau beberapa bagian saluran kemih URETHRA URETHRITIS KANDUNG KEMIH CYSTITIS URETER URETERITIS JARINGAN GINJAL PYELONEPHRITIS PROSTAT PROSTATITIS

Keadaan adanya infeksi ( ada perkembangbiakan bakteri ) dalam saluran kemih, meliputi infeksi di parenkim ginjal sampai infeksi di kandung kemih dengan jumlah bakteriuria yang bermakna. > 100.000 per ml urine segar

Faktor resiko : Kerusakan / kelainan anatomi saluran kemih berupa obstruksi internal oleh jaringan parut, pemasangan kateter urin yang lama, endapan obat intratubular, refluks, instrumentasi saluran kemih, konstriksi arteri-vena Hipertensi Analgetik Ginjal polikistik Kehamilan DM Pengaruh obat-obat estrogen

PYELONEPHRITIS URETERITIS CYSTITIS URETHRITIS PROSTATITIS

Mikroorganisme penyebab ISK BAKTERI : Escherichia coli * Staphylococcus sp Proteus sp * Streptococcus sp Klebsiella sp Pseudomonas sp Enterobacter sp JAMUR : Candida sp. VIRUS : = Papovavirus = Herpes simplex = Adenovirus

Usually suspected in women----> also called Common Cold of Urology. In England---> 62.5% of GP patients; woman : man= 10 : 1 to 50 : 1. UTI can occur in both sexes, babies, and elders. Mostly found asymptomatic in sexually active women 3-10%, and men <1%. At the age of 80: woman --> 20%, man--> 5-20% In elder man, the accident of UTI also depends on the degree of urinary tract obstruction because of the prostate gland.

Mekanisme pertahanan tubuh Against micro organism invation: The forming of anti bodies  activity of neutrophil and macrophage. Reccurent mixtie  fresh urine production. Kidney  cortex resistention > medullae  blood flow speed >>, oxygenation >>. Ureter peristaltic & in vesico – ureterik pathway.

Lower UTI UTI that occurs in urinary bladder or lower part of urinary tract, and not yet ascending to the upper urinary tract. Cystitis -Pollakisuria, urgency -Dysuria -Hematuria -Heavy pain at upper pubic

Upper UTI UTI GET TO THE PYELUM, CALYCES & KIDNEY TISSUES, MOSTLY MEDULLAE  OFTEN CALLED: PYELONEPHRITIS  - ACUTE (APN) - SUB ACUTE - CHRONIC (CPN) APN - Low back pain - Fever - Bacterimia - Polysuria - Hematuria, nausea, vomitting

ISK ASIMTOMATIS (ISKA) Jenis ISK ISK ASIMTOMATIS (ISKA) ISK SIMTOMATIS (ISKS) ISK BERULANG - ULANG (ISKU) RELAPSE : OLEH STRAIN YANG SAMA REINFEKSI : OLEH SPECIES BERBEDA PERSISTENT : KARENA KEGAGALAN TERAPI KELAINAN PADA SALURAN KEMIH → ISKU VUR (Vesico Urethral Reflux) PENYUMBATAN KELAINAN KONGENITAL SALURAN KEMIH

ISK ASIMPTOMATIS ( ISKA ) Without symptoms In pregnant woman and elder Pregnant woman 5-10%  causing acute pyelonephritis and born underweight babies.

PEMERIKSAAN PENUNJANG PEMERIKSAAN FISIK Febris Nyeri tekan supra-pubik Nyeri ketok sudut kostovertebra PEMERIKSAAN PENUNJANG DPL, tes resistensi kuman, tes fungsi ginjal, gula darah Kultur urin (+) : bakteriuria >105/ml urin Foto BNO-IVP ( bila perlu ) USG Ginjal ( bila perlu )

DIAGNOSTIK UTI Culture of urine  micro organism > 100.000/ml. Mostly found  E. coli. Maintain proper urine sampling  sterile,mid stream urine.

DIAGNOSIS BANDING Keganasan kandung kemih Nonbacterial cystitis Interstitial cystitis Pelvic Inflammatory Disease Pyelonephritis Akut Urethritis Vaginitis

ACUTE PYELONEPHRITIS Upper UTI  infection at kidney tissues, often in medullae. Predispotition Obstruction : - Stricture Prostate/Hypertrophy Stone Retroperitoneal fibrosis Sexual trauma in woman. Urine stasis during pregnancy. Metabolic : - D M - Hypokalemia - Analgesic

CHRONIC PYELONEPHRITIS Contracted kidney Kidney obstruction hydronephrosis Rough surface because of fibrosis Reddish at pelvic wall Microscopic Plasma cells and limphocyte infiltration at the parenchyme + pelvic inflammatory reaction. Sometimes acute by the presence of Pus cells in kidney tubules. Colloid casts in kidney tubules. Glomeruli Bowmann capsule surrounded by fibrotic connective tissue. Plasma cells infiltration End-arteritis

PROSTATITIS Prostate gland inflammation and the cause of reccurent UTI in men. Urgency Frequency Dysuria Nycturia Perineal pain Muscle and ligament pain

RT  painful feel at the prostate gland (acute). Prostate massage  hemorrhagic secret  culture: - Staphylococcus - E. coli - Pseudomonas - Enterobacter - Klebsiella - Neisseria gonorrhoe Terapi : Aminoglikosida

TATALAKSANA Non Farmakologis Banyak minum bila fungsi ginjal masih baik Menjaga higiene genitalia eksterna Farmakologis Antimikroba berdasarkan pola kuman yang ada Bila hasil tes resistensi kuman sudah ada, pemberian antimikroba disesuaikan

TABEL 1. Antimikroba pada ISK bawah Anti mikroba Dosis Lama terapi Trimetoprim-Sulfametoksazol 2x160/800mg 3 hari Trimetoprim 2x100mg 3 hari Siprofloksasin 2x100-250mg 3 hari Levofloksasin 2x250mg 3 hari Sefiksim 1x400mg 3 hari Sefpodoksim proksetil 2x100mg 3 hari Nitrofurantoin makrokristal 4x50mg 7 hari Nitrofurantoin monohidrat 2x100mg 7 hari Amoksisilin / klavulanat 2x500mg 7 hari

TABEL 2. Antimikroba pada ISK atas Anti mikroba Dosis Sefepim 2x1 gram Siprofloksasin 2x400 mg Levofloksasin 1x500 mg Ofloksasin 2x400 mg Gentamisin (+ampisilin) 1x3-5 mg/kgBB 3x1 mg/kgBB Ampisilin (+gentamisin) 4x1-2 gram Tikarsilin-klavulanat 3x3,2 gram Piperasilin-tazobaktam 3-12x3,375 gram Imipenem-silastatin 3-4x250-500 mg

KOMPLIKASI PROGNOSIS Batu saluran kemih Obstruksi saluran kemih Sepsis Infeksi kuman yang multiresisten Gangguan fungsi ginjal PROGNOSIS ISK tanpa kelainan anatomis → prognosis lebih baik bila diobati pd fase akut yg adekuat, disertai pengawasan thdp kemungkinan infeksi berulang.

TERIMA KASIH