Dr. Bambang - UrinaryTractInfection

Infeksi Saluran KemihInfeksi Saluran Kemih

Bambang MulyawanBambang Mulyawan

FK UMMFK UMM

IntroductionIntroduction

Pediatric UTIs often signal an underlying Pediatric UTIs often signal an underlying genitourinary tract abnormalitygenitourinary tract abnormality

Can lead to renal scarring with resultant Can lead to renal scarring with resultant hypertension and renal failurehypertension and renal failure

Difficult to diagnose because symptoms Difficult to diagnose because symptoms are non-specific in this age group and are non-specific in this age group and testing is often invasive testing is often invasive

URINARY TRACT INFECTIONURINARY TRACT INFECTION

DEFINITIONDEFINITION:: TISSUE TISSUE

RESPONSE RESPONSE TO THE TO THE PRESENCE OF PRESENCE OF

SIGNIFICANT AMOUNT SIGNIFICANT AMOUNT OF BACTERIA IN THE OF BACTERIA IN THE

URINE URINE

DEFINISIDEFINISI ISKISK : Terdapatnya bakteriuri disertai reaksi : Terdapatnya bakteriuri disertai reaksi inflamasiinflamasi BAKTERIURIBAKTERIURI

- Adanya kuman didalam urin- Adanya kuman didalam urin- Bermakna :- Bermakna : 10 105 5 bakt/mlbakt/ml- Tergantung cara pengambilan sample- Tergantung cara pengambilan sample

- Pada- Pada wanita muda wanita muda urin S.P.P urin S.P.P 10 102 2 bakt/mlbakt/ml- Bisa disertai piuri atau tanpa piuri- Bisa disertai piuri atau tanpa piuri

PIURIPIURI- Adanya lekosit dalam urin - Adanya lekosit dalam urin 5/LPB5/LPB- Bisa - disertai bakteriuri- Bisa - disertai bakteriuri

- steril - steril TBC TBC

DefinitionDefinition

Infection of kidneys, ureters, bladder and uretheraInfection of kidneys, ureters, bladder and urethera

Upper Urinary tract infection - PyelonephritisUpper Urinary tract infection - Pyelonephritis

Lower urinary tract infection- Cystitis, UrethritisLower urinary tract infection- Cystitis, Urethritis

Why ?Why ?

CommonCommon

Difficult to identifyDifficult to identify

Significant complicationsSignificant complications

Guideline for Management ( imaging, prophylaxis and Guideline for Management ( imaging, prophylaxis and prolonged follow up )prolonged follow up )

Which Organism?Which Organism?

Most common organism isMost common organism is

(a) Klebsiella(a) Klebsiella

(b) E. Coli(b) E. Coli

(c) Pseudomonas(c) Pseudomonas

EpidemiologyEpidemiology

One of the most common infections of the childhoodOne of the most common infections of the childhood

Age under one M > F why?Age under one M > F why? Age above one F > MAge above one F > M

4% of boys and 12 % of girls will have had UTI by the age of 4% of boys and 12 % of girls will have had UTI by the age of 16 years16 years

Of these : 4 % will have kidneys scars Of these : 4 % will have kidneys scars

50 % will develop hypertension 50 % will develop hypertension

10% of those scarred will develop renal failure 10% of those scarred will develop renal failure

PATHOGENESISPATHOGENESIS

Upper urinary tract Upper urinary tract infection: infection:

PyelonephritisPyelonephritis

Lower urinary tract Lower urinary tract infection:infection:

Cystitis Cystitis

Pediatric UTIs: Pediatric UTIs: EpidemiologyEpidemiology

PrevalencePrevalence Girls—6.5-8%Girls—6.5-8% Boys—2-3%Boys—2-3%

Uncircumcised boys have a 5-20 X Uncircumcised boys have a 5-20 X increase in UTIs vs circumcised boysincrease in UTIs vs circumcised boys

Occurs in about 7% of children <2 who Occurs in about 7% of children <2 who present with fever without a sourcepresent with fever without a source


Ascending infection Ascending infection most most UTI beyond the newborn UTI beyond the newborn period are the result of period are the result of ascending infectionascending infection

Descending infection Descending infection

4 - 9 percent of children with 4 - 9 percent of children with UTI are bacteremicUTI are bacteremic

Epidemiology Epidemiology (continued)(continued)

Incidence of vesicoureteral reflux (VUR) is 1% in Incidence of vesicoureteral reflux (VUR) is 1% in children < 2 yoa.children < 2 yoa. 50% of kids <1 yoa with UTI have VUR50% of kids <1 yoa with UTI have VUR

Early renal scarring is nearly twice as common in Early renal scarring is nearly twice as common in this age group.this age group.

Incidence of scarring increases with each Incidence of scarring increases with each subsequent UTIsubsequent UTI Scarring occurs in 5-38% of febrile UTI’s.Scarring occurs in 5-38% of febrile UTI’s.

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Infeksi sal.kemihInfeksi sal.kemih

- radang ok adanya mikroorg.di sal.kemihradang ok adanya mikroorg.di sal.kemih- Pada semua usia , wanita > priaPada semua usia , wanita > pria- O.k bakteri, virus, yeast dan jamurO.k bakteri, virus, yeast dan jamur- Tersering o.k bakt.E.coli(50-90%), proteus, Tersering o.k bakt.E.coli(50-90%), proteus,

klebsiela, enterobakter, pseudomonas; inf. klebsiela, enterobakter, pseudomonas; inf. Gram positif lb.jarangGram positif lb.jarang

- Manifestasi dapat berupa asymptomatic Manifestasi dapat berupa asymptomatic significant bacteriuri(ASB), bact.cystitis, significant bacteriuri(ASB), bact.cystitis, abacterial cystitisabacterial cystitis

- Dapat terjadi secara endogen, hematogen, Dapat terjadi secara endogen, hematogen, limfogen, eksogen akibat sistoskopi/kateterlimfogen, eksogen akibat sistoskopi/kateter

PREVALENSI ISK MENURUT USIA & PREVALENSI ISK MENURUT USIA & SEKSSEKSKELOMPOK USIA

PREVALENSI (%)

L : P

NEONATUS 1 1,5 : 1

USIA PRASEKOLAH

2-3 1 : 10

USIA SEKOLAH 1-2 1 : 30

USIA REPRODUKSI

2.5 1 : 50

USIA 65-70 20 1 : 10

USIA 80 30 1 : 2

USIA LANJUT ( 65) DIRAWAT DI R.S.

30 1 : 1

ETIOLOGIETIOLOGI NonspesifikNonspesifik disebabkan disebabkan

- Batang gram (-) aerob : E coli, P mirabilis- Batang gram (-) aerob : E coli, P mirabilis

- Kokus gram (+) : Stafilokok, Enterokus- Kokus gram (+) : Stafilokok, Enterokus

- Anaerob obligate : Bakterioides.- Anaerob obligate : Bakterioides.

- Lain-lain: Chlamidia trachomatis, - Lain-lain: Chlamidia trachomatis, UreaplasmaUreaplasma

SpesifikSpesifik

Disebabkan mikroorganisme spesifik yang Disebabkan mikroorganisme spesifik yang memberikan gejala yang khasmemberikan gejala yang khas

Misal: Tuberkulosis, Gonorrhea, Misal: Tuberkulosis, Gonorrhea, ActinomycosisActinomycosis

Risk FactorsRisk Factors antenatally-diagnosed renal abnormalityantenatally-diagnosed renal abnormality family history of vesicoureteric reflux ? (VUR) or renal diseasefamily history of vesicoureteric reflux ? (VUR) or renal disease history suggesting previous UTI or confirmed previous UTIhistory suggesting previous UTI or confirmed previous UTI recurrent fever of uncertain originrecurrent fever of uncertain origin poor urine flow ( phimosis)poor urine flow ( phimosis) dysfunctional voidingdysfunctional voiding constipation why?constipation why? abdominal mass, evidence of spinal lesionabdominal mass, evidence of spinal lesion poor growthpoor growth high blood pressurehigh blood pressure blood group Lewis antigenblood group Lewis antigen


Host factors: Host factors: • Age Age • Uncircumcised boys Uncircumcised boys • Female infantsFemale infants• Race/ethnicity Race/ethnicity • Genetic factorsGenetic factors• Urinary obstruction Urinary obstruction • Neurogenic Bladder, Dysfunctional eliminationNeurogenic Bladder, Dysfunctional elimination• Vesicoureteral reflux Vesicoureteral reflux • Sexual activitySexual activity• Bladder catheterization Bladder catheterization


Bacterial factors: Bacterial factors:

A variety of virulence factors A variety of virulence factors enable bacteria to ascend enable bacteria to ascend into into the bladder and the bladder and kidneykidney

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Faktor2 predisposisiFaktor2 predisposisi

1.1. Bend.urin: kongenital, batu, oklusi ureterBend.urin: kongenital, batu, oklusi ureter2.2. Refluks vesikoureterRefluks vesikoureter3.3. Rest-urine: BPH, striktur ureter, neurogenic-Rest-urine: BPH, striktur ureter, neurogenic-

bladderbladder4.4. Ggn. Metabolik: hiperkalemia, hipo kalsemia, Ggn. Metabolik: hiperkalemia, hipo kalsemia,

agamaglobulinemiagamaglobulinemi5.5. Manipulasi sal.kemih: kateter, dilatasi uretra, Manipulasi sal.kemih: kateter, dilatasi uretra,

sistoskopisistoskopi6.6. Kehamilan: faktor stasis& bendungan, serta Kehamilan: faktor stasis& bendungan, serta

perubahan pH urineperubahan pH urine

LOKALISASILOKALISASI Upper urinary tract. infectionUpper urinary tract. infection

Ginjal, UreterGinjal, Ureter Lower urinary tract. ifectionLower urinary tract. ifection

Buli, UrethraBuli, Urethra

LAMALAMA AkutAkut Kronis Kronis kurang tepat kurang tepat

- persistent- persistent

- recurrentrecurrent

UTI: ClassifficationUTI: Classiffication

Classification:Classification: Upper tract infectionUpper tract infection

Acute pyelonephritis- fever, bacteriuria, systemic Acute pyelonephritis- fever, bacteriuria, systemic symptomssymptoms

Lower tract infectionLower tract infection UrethritisUrethritis CystitisCystitis Voiding symptoms, little or no fever, no systemic Voiding symptoms, little or no fever, no systemic

symptomssymptoms

KLASIFIKASI ISK (STAMEY KLASIFIKASI ISK (STAMEY 1980)1980)

1. Infeksi pertama (First infection)1. Infeksi pertama (First infection)

- Infeksi pertama kalinya- Infeksi pertama kalinya

- Umumnya uncomplicated, sensitif terhadap - Umumnya uncomplicated, sensitif terhadap ABAB

- Sering pada wanita- Sering pada wanita muda, 1/3 muda, 1/3 recurrensrecurrens

2.2. Unresolved bacteriuriaUnresolved bacteriuria

- Urine tak pernah steril selama terapi- Urine tak pernah steril selama terapi

- Penyebab :- Penyebab :

-- Resisten terhadap AB Resisten terhadap AB -- Reinfeksi Reinfeksi

-- Pasien tidak disiplin Pasien tidak disiplin -- CRF CRF

-- Infeksi campuran Infeksi campuran -- Batu Batu staghorn terinfeksistaghorn terinfeksi

-- Bact. Cepat berubah menjadi resisten Bact. Cepat berubah menjadi resisten

3. Bacterial Persistence3. Bacterial Persistence

Kultur urin steril selama th/Kultur urin steril selama th/ tetapi segera (+) bila th/ tetapi segera (+) bila th/ dihentikan dihentikan sumber infeksi (+) sumber infeksi (+)

Penyebab Penyebab

- Batu infeksi- Batu infeksi - Stump ureter terinfeksi - Stump ureter terinfeksi

- Prostatitis kronis- Prostatitis kronis - Popillary necrosis - Popillary necrosis terinfeksiterinfeksi

- Ginjal atrofi terinfeksi- Ginjal atrofi terinfeksi - Kista urachus terinfeksi - Kista urachus terinfeksi

- Fistel- Fistel - Infected medullary sponge - Infected medullary sponge kidneykidney

- Obstructive nephropathy- Obstructive nephropathy - divertikel urethra - divertikel urethra

- Divertikel pielokaliks - Divertikel pielokaliks - Benda asing - Benda asing

terinfeksiterinfeksi

4. Reinfeksi4. Reinfeksi - Timbul infeksi baru dengan - Timbul infeksi baru dengan patogen yang patogen yang baru baru - Interval dengan infeksi terdahulu - Interval dengan infeksi terdahulu bervariasibervariasi - 80% rekurensi - 80% rekurensi reinfeksi reinfeksi

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Patogenesis Patogenesis

1.1. HematogenHematogen: ok.daya tahan menurun pada : ok.daya tahan menurun pada peny.kronis, tx.imunosupresif, adanya fokus peny.kronis, tx.imunosupresif, adanya fokus infeksi di tulang/kulit/endotel.infeksi di tulang/kulit/endotel.

2.2. Ascending infectionAscending infection::a. kolonisasi uretra&introitus vaginaa. kolonisasi uretra&introitus vaginab. masuknya mikroorg.dlm.sal.kemihb. masuknya mikroorg.dlm.sal.kemihc. multiplikasi bakteri dlm.kd.kemih & c. multiplikasi bakteri dlm.kd.kemih & pertahanan kd.kemih menurunpertahanan kd.kemih menurund. naiknya bakteri kd.kemih ke ginjald. naiknya bakteri kd.kemih ke ginjal

PATOGENESISPATOGENESIS 4 route infeksi4 route infeksi AscendingAscending

Dari : - buli ke ginjal Dari : - buli ke ginjal refluksrefluks - urethra ke prostat, buli- urethra ke prostat, buli

HematogenHematogen Ke : ginjal, prostat, testisKe : ginjal, prostat, testis

LimfogenLimfogen Dari usus, cervix ke buli, ginjalDari usus, cervix ke buli, ginjal

Direct extentionDirect extention Dari usus ke buliDari usus ke buli

FAKTOR-FAKTOR YANG MEMPENGARUHI FAKTOR-FAKTOR YANG MEMPENGARUHI TIMBULNYA I.S.K.TIMBULNYA I.S.K.

1. Faktor virulensi bakteri1. Faktor virulensi bakteri

2. Faktor kepekaan ekstrinsik2. Faktor kepekaan ekstrinsik

2.1. Pada wanita2.1. Pada wanita

2.1.1. Introitus2.1.1. Introitus

2.1.2. Urethra 2.1.2. Urethra pendek pendek

2.2. Pada pria 2.2. Pada pria Prostat mensekresi zat anti Prostat mensekresi zat anti bakteri bakteri bila bila /(-) /(-) Bacterial prostatitis Bacterial prostatitis

3. Faktor kepekaan intrinsik3. Faktor kepekaan intrinsik

Neurogenic bladder, rest urine, batu Neurogenic bladder, rest urine, batu memudahkan infeksi.memudahkan infeksi.

Surface mucin, GAG, urinary antibody, PH urine.Surface mucin, GAG, urinary antibody, PH urine.

4. Faktor ureter & ginjal4. Faktor ureter & ginjal

Adanya Vesicoureteral reflux, Adanya Vesicoureteral reflux, kualitas pristaltik ureter & kepekaan kualitas pristaltik ureter & kepekaan medula ginjal terhadap infeksi medula ginjal terhadap infeksi

Obstructive uropathy, renal blood Obstructive uropathy, renal blood flow flow & adanya benda asing & adanya benda asing me me (+) kepekaan terhadap infeksi.(+) kepekaan terhadap infeksi.

CLINICAL PRESENTATION CLINICAL PRESENTATION

Younger Younger children:children:

nonspecific nonspecific symptoms and symptoms and signssigns

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Other Less common symptoms of UTI in Other Less common symptoms of UTI in infants includeinfants include

conjugated hyperbilirubinemia (in those conjugated hyperbilirubinemia (in those <28 days)<28 days)

irritability irritability poor feedingpoor feeding failure to thrivefailure to thrive


S & S most helpful in identifying young S & S most helpful in identifying young children with UTI:children with UTI:

History of previous UTIHistory of previous UTI Temperature >40ºCTemperature >40ºC Suprapubic tendernessSuprapubic tenderness Lack of circumcisionLack of circumcision


Older children:Older children:• FeverFever• Urinary symptomsUrinary symptoms• Abdominal pain Abdominal pain • Back painBack pain• New onset urinary incontinenceNew onset urinary incontinence• fever, chills, vomitting and flank pain are fever, chills, vomitting and flank pain are

suggestive of pyelonephritis in older childrensuggestive of pyelonephritis in older children• short stature, poor weight gain, or hypertension short stature, poor weight gain, or hypertension

secondary to renal scarringsecondary to renal scarring• Suprapubic and costovertebral angle tenderness Suprapubic and costovertebral angle tenderness


Older children:Older children:• FeverFever• Urinary symptomsUrinary symptoms• Abdominal pain Abdominal pain • Back painBack pain• New onset urinary incontinenceNew onset urinary incontinence• fever, chills, vomitting and flank pain are fever, chills, vomitting and flank pain are

suggestive of pyelonephritis in older childrensuggestive of pyelonephritis in older children• short stature, poor weight gain, or hypertension short stature, poor weight gain, or hypertension

secondary to renal scarringsecondary to renal scarring• Suprapubic and costovertebral angle tenderness Suprapubic and costovertebral angle tenderness

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Gejala klinis Gejala klinis

- sering tidak khas/ tanpa gejalasering tidak khas/ tanpa gejala- Disuria, polakisuri, nyeri suprapubik, Disuria, polakisuri, nyeri suprapubik,

stranguria, tenesmus, nokturia, enuresisstranguria, tenesmus, nokturia, enuresis- ISK.bawah: nyeri uretra, suprapubikISK.bawah: nyeri uretra, suprapubik- ISK.atas: demam menggigil, nyeri ISK.atas: demam menggigil, nyeri

pinggang malaise, mual, muntah, nyeri pinggang malaise, mual, muntah, nyeri kepalakepala

Signs and Symptoms – Signs and Symptoms – Children 2 months to 2 Children 2 months to 2

yearsyears Fever—usually unexplainedFever—usually unexplained Vomiting and/or diarrheaVomiting and/or diarrhea Abdominal PainAbdominal Pain Failure to thriveFailure to thrive Malodorous urineMalodorous urine Crying on urinationCrying on urination

Signs and Symptoms – Signs and Symptoms – Children >2Children >2

FeverFever Vomiting and/or diarrheaVomiting and/or diarrhea Abdominal painAbdominal pain Malodorous urineMalodorous urine Frequency and/or urgencyFrequency and/or urgency DysuriaDysuria New incontinenceNew incontinence

Clinical PresentationClinical Presentation

Age and gender dependentAge and gender dependent 0 - 2 months:0 - 2 months:

FeverFever 2 mo.– 2 y/o:2 mo.– 2 y/o:

Fever (>38 C)Fever (>38 C) IrritabilityIrritability Vomiting and DiarrheaVomiting and Diarrhea Decrease appetiteDecrease appetite Between 1-2 y/o = crying on urination, foul smelling odorBetween 1-2 y/o = crying on urination, foul smelling odor

Clinical PresentationClinical Presentation

2 y/o – 6 y/o:2 y/o – 6 y/o: Systemic symptomsSystemic symptoms FeverFever Flank or back painFlank or back pain Urgency, urinary incontinence, dysuriaUrgency, urinary incontinence, dysuria Suprapubic or abdominal painSuprapubic or abdominal pain Foul smelling odorFoul smelling odor

> 6 y/o and adolescents:> 6 y/o and adolescents: Same as aboveSame as above

Clinical evaluationClinical evaluation

HISTORYHISTORY history of the acute illness: history of the acute illness: • documentation of the height and duration of feverdocumentation of the height and duration of fever• urinary symptoms (dysuria, frequency, urgency, urinary symptoms (dysuria, frequency, urgency,

incontinence),incontinence),• abdominal pain,abdominal pain,• suprapubic discomfortsuprapubic discomfort• back pain back pain • vomiting vomiting • recent illnessesrecent illnesses• antibiotics administeredantibiotics administered• and sexual activity (if applicable).and sexual activity (if applicable).


HISTORYHISTORY past medical history : past medical history : • Chronic urinary symptoms — Incontinence, lack of proper stream, Chronic urinary symptoms — Incontinence, lack of proper stream,

frequency, urgency, withholding maneuvers frequency, urgency, withholding maneuvers • Chronic constipation Chronic constipation • Previous UTI Previous UTI • Vesicoureteral reflux (VUR) Vesicoureteral reflux (VUR) • Antenatally diagnosed renal abnormality Antenatally diagnosed renal abnormality • Elevated blood pressure Elevated blood pressure • Poor growth Poor growth • In sexually active girls, whether barrier contraception with In sexually active girls, whether barrier contraception with

spermicidal agents is usedspermicidal agents is used• Previous undiagnosed febrile illnesses Previous undiagnosed febrile illnesses family history :family history :• of frequent UTI, VUR, other genitourinary abnormalities and renal of frequent UTI, VUR, other genitourinary abnormalities and renal

failure. failure.

PresentationPresentation

Age Group

Symptoms & SignsMost common → Least common

< 3mths Fever, VomitingLethargy, Irritability

Poor feedingFailure to thrive

Abdominal painJaundiceHaematuriaOffensive urine

>3mthsPreverbal

Fever Abdominal pain,Loin tendernessVomitingPoor feeding

Lethergy, IrritabilityHaematuriaOffensive urineFailure to thrive

>3mthsVerbal

FrequencyDysuria

Abdominal painLoin tendernessDysfunctional voidingChanges to continence

Fever, MalaiseVomitingHaematuriaOffensive/Cloudy urine


PHYSICAL EXAMINATIONPHYSICAL EXAMINATION • Documentation of blood pressure and Documentation of blood pressure and

temperature. temperature. • Growth parameters.Growth parameters.• Abdominal examination for tenderness or Abdominal examination for tenderness or

massesmasses• Assessment of suprapubic and costovertebral Assessment of suprapubic and costovertebral

tenderness. tenderness. • Examination of the external genitalia.Examination of the external genitalia.• Evaluation of the lower back for signs of spina Evaluation of the lower back for signs of spina

bifida occulta.bifida occulta.• Evaluation for other sources of fever.Evaluation for other sources of fever.

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Laborat:Laborat:

1.1. Urinalisis: lekosituri, hematuriUrinalisis: lekosituri, hematuri

2.2. Bakteriologis: mikros., kulturBakteriologis: mikros., kultur

3.3. Tes kimiawi: tes reduksi Griess-nitrateTes kimiawi: tes reduksi Griess-nitrate

4.4. Tes plat-celup (Dip-Slide)Tes plat-celup (Dip-Slide)

Pem.penunjangPem.penunjang: : - mencari kausa : batu, anomali sal.kemihmencari kausa : batu, anomali sal.kemih- IVP, USG, CT-ScanningIVP, USG, CT-Scanning

LABORATORY LABORATORY EVALUATION EVALUATION

Urine:Urine:

DipstickDipstick microscopymicroscopy Culture & Culture &

sensitivitysensitivity


Urine sampling: Urine sampling: How to obtain???How to obtain???

• Midstream clean catchMidstream clean catch• BagBag• CathterizationCathterization• Suprapubic aspirationSuprapubic aspiration


Urine dipstickUrine dipstick

88 % sensitive88 % sensitive

LeukocytesLeukocytes ProteinProtein Red blood cells Red blood cells Leukocyte esteraseLeukocyte esterase Nitrite Nitrite

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Pengelolaan:Pengelolaan:

- Prinsip: eradikasi bakteri dg.Ab. Sesuai, koreksi Prinsip: eradikasi bakteri dg.Ab. Sesuai, koreksi kelainan anatomis& faktor-faktor predisposisi.kelainan anatomis& faktor-faktor predisposisi.

- Cara : dosis tunggalCara : dosis tunggaljangka pendek: 10 – 14 harijangka pendek: 10 – 14 harijangka panjang 4 - 6 minggujangka panjang 4 - 6 minggupengobatan profilaksispengobatan profilaksispengobatan supresifpengobatan supresif

-- antibiotik broadspektrum: amoksisilin, baktrim, antibiotik broadspektrum: amoksisilin, baktrim, asam nalidiksat, asam pipemidat, sefaleksin.asam nalidiksat, asam pipemidat, sefaleksin.


Microscopic examMicroscopic exam

• White Blood Cells: White Blood Cells: in a in a centrifuged sample of centrifuged sample of unstained urine pyuria unstained urine pyuria is defined as ≥5 is defined as ≥5 WBC/high power field , WBC/high power field , or ≥10 WBC/mm3 in an or ≥10 WBC/mm3 in an uncentrifuged sample uncentrifuged sample

• Bacteria:Bacteria: bacteriuria is bacteriuria is the presence of any the presence of any bacteria per hpf.bacteria per hpf.

• Gram stainGram stain

CARA PENGAMBILAN SAMPLECARA PENGAMBILAN SAMPLE

Untuk me (-) kontaminasi terutama pada Untuk me (-) kontaminasi terutama pada wanitawanita

1. Aspirasi supra pubik1. Aspirasi supra pubik

2. Mid Stream2. Mid Stream

Posisi lithotomy, perinum & gen.ext Posisi lithotomy, perinum & gen.ext dibersihkan dibersihkan

dengan sabun.dengan sabun.

3. Kateterisasi (jangan dari urine bag)3. Kateterisasi (jangan dari urine bag)

Untuk mengambil sample urine dari ginjal Untuk mengambil sample urine dari ginjal pakai kateter ureter.pakai kateter ureter.


Urine cultureUrine culture & sensitivity& sensitivity

Urine culture is the gold Urine culture is the gold standard for the diagnosis standard for the diagnosis of UTIof UTI

Urine obtained for culture Urine obtained for culture should be processed as should be processed as soon as possible after soon as possible after collectioncollection


Urine cultureUrine culture • Midstream clean catch Midstream clean catch 10⁵ colony 10⁵ colony

forming unitsforming units• Bag Bag 85% false ve ₊ 85% false ve ₊• Cathterization Cathterization 10⁴ CFU 10⁴ CFU• Suprapubic aspirationSuprapubic aspiration any growth any growth

LABORATORY LABORATORY EVALUATIONEVALUATION

Investigate the fever.Investigate the fever. Markers of inflammation (WBC, ESR, Markers of inflammation (WBC, ESR,

CRP) CRP) Serum creatinineSerum creatinine Blood culture — Blood culture — Bacteremia occurs in 4-9 % of Bacteremia occurs in 4-9 % of

infants with UTI infants with UTI

Lumbar puncture — Lumbar puncture — Infants <1 month of age with Infants <1 month of age with fever and a positive urinalysis; approximately 1 % of fever and a positive urinalysis; approximately 1 % of infants with UTI also have meningitis infants with UTI also have meningitis

Other laboratory testsOther laboratory tests

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Pengobatan:Pengobatan:

1.1. Uretritis/sistitis:Uretritis/sistitis:- Terapi konvensional dg broadspektrum - Terapi konvensional dg broadspektrum antibiotik 3-10 hariantibiotik 3-10 hari- terapi dosis tunggal: amoks. 3 g, baktrim 4 tab., - terapi dosis tunggal: amoks. 3 g, baktrim 4 tab., gentamisin 120 mg im, kanamisingentamisin 120 mg im, kanamisin

2.2. PNA( pielonefritis akut): PNA( pielonefritis akut): - kasus berat MRS dg antib. Parenteral- kasus berat MRS dg antib. Parenteral kombinasi aminoglikosid-ampisilin, sambilkombinasi aminoglikosid-ampisilin, sambil menunggu tes kepekaan; bila perlu diberikanmenunggu tes kepekaan; bila perlu diberikan piperasilin, sefalosporin generasi III.piperasilin, sefalosporin generasi III.- kasus ringan: dg antibiotik broadspektrum- kasus ringan: dg antibiotik broadspektrum

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3. Pielonefritis kronik: diobati bila ada bakteriuri 3. Pielonefritis kronik: diobati bila ada bakteriuri dg antibiotik yg sesuai, koreksi kelainan dg antibiotik yg sesuai, koreksi kelainan anatomis.anatomis.

4. ASB: pada wanita hamil.4. ASB: pada wanita hamil.dosis tunggaldosis tunggal observasi 2-4 mg observasi 2-4 mgjangka pendekjangka pendek obs.; bila rekuren Ab. obs.; bila rekuren Ab. Diteruskan s/d 6 mg/partusDiteruskan s/d 6 mg/partus

5. ISK rekuren: antibiotik profilaksis5. ISK rekuren: antibiotik profilaksiscara pemberian: 3 kali/mg atau tiap hari cara pemberian: 3 kali/mg atau tiap hari selama 6 bulan sampai 3 tahun lebihselama 6 bulan sampai 3 tahun lebih

PEMERIKSAAN RADIOLOGIPEMERIKSAAN RADIOLOGI

Pada simple (uncomplicated) UTI Pada simple (uncomplicated) UTI tidak tidak perlu perlu

IndkasiIndkasi

1. Memerlukan intervensi lain disamping 1. Memerlukan intervensi lain disamping terapi ABterapi AB

2. Persistence bacteriuria2. Persistence bacteriuria

FOTO POLOS ABDOMENFOTO POLOS ABDOMEN

- batu opak- batu opak

- emphysematous pyelonephritis- emphysematous pyelonephritis

RENAL TOMOGRAMRENAL TOMOGRAM

- batu opak/semi opak- batu opak/semi opak

- gas dalam ginjal- gas dalam ginjal

IVPIVP Letak & derajat obtruksiLetak & derajat obtruksi Kelainan kongenital/anatomis : double Kelainan kongenital/anatomis : double

colekting, horse shoe kidneycolekting, horse shoe kidney

VOLDING VOLDING CYSTOURETEROGRAMCYSTOURETEROGRAM

Vesiko ureteral refluxVesiko ureteral reflux Neurogenik bladderNeurogenik bladder Divertikel buli, urachusDivertikel buli, urachus

USGUSG Hidronefrosis Hidronefrosis PionefrosisPionefrosis Perirenal absesPerirenal abses

INFEKSIINFEKSI

TRAK.URINARIUS

TRAK. GENITALIS

SPESIFIK

NON SPESIFIK

- Ginjal

- Ureter

- Buli

- Urethra

- Prostat

- Epididymis- Testis

UrethritisUrethritis

In female infants In female infants Part of a diaper Part of a diaper

dermatitis dermatitis

In adolescent girls In adolescent girls and boys and boys Presenting sign of Presenting sign of

STDSTD

In pre-school and school In pre-school and school age girls age girls Part of “non-specific” Part of “non-specific”

vulvovaginitis vulvovaginitis Generally environmentalGenerally environmental Bubble bathBubble bath Nylon panties (also biker Nylon panties (also biker

shorts, leotards, bathing shorts, leotards, bathing suits)suits)

Poor hygiene (not Poor hygiene (not wiping, wiping back to wiping, wiping back to front)front)

Overzealous hygieneOverzealous hygiene Use of baby powder, Use of baby powder,

perfumesperfumes

Symptoms of urethritisSymptoms of urethritis

DysuriaDysuria Reluctance to voidReluctance to void Perineal discomfort, erythemaPerineal discomfort, erythema May be associated with vaginal irritation May be associated with vaginal irritation

and erythema in girlsand erythema in girls In older boys, urethral dischargeIn older boys, urethral discharge In adolescent girls associated with PID In adolescent girls associated with PID

symptomssymptoms

Risk FactorsRisk Factors

Age <1 yearAge <1 year Female genderFemale gender Uncircumcised Uncircumcised

malesmales ConstipationConstipation Voiding dysfunctionVoiding dysfunction

Improper wipingImproper wiping Genitourinary Genitourinary

abnormalitiesabnormalities Vesicoureteral refluxVesicoureteral reflux ObstructionObstruction

Colonization with Colonization with virulent E. Colivirulent E. Coli

INFEKSI NON SPESIFIK INFEKSI NON SPESIFIK

GINJAL - PielonefritisGINJAL - Pielonefritis

- Abses ginjal- Abses ginjal

- Abses perirenal- Abses perirenal

- Interstitial nephritis- Interstitial nephritis URETER - UreteritisURETER - Ureteritis BULI - Sistitis - AkutBULI - Sistitis - Akut

- Berulang- Berulang URETHRA - urethritis - AkutURETHRA - urethritis - Akut

- kronis- kronis

Akut

Kronis

PIELONEFRITIS AKUTPIELONEFRITIS AKUT Infeksi pada parenkim & pelvis ginjalInfeksi pada parenkim & pelvis ginjal Etiologi : E coli, Proteus, Klebsiella, Strept, Etiologi : E coli, Proteus, Klebsiella, Strept,

Fecalis.Fecalis. PatogenesisPatogenesis Umumnya infeksi “ascending”Umumnya infeksi “ascending” Jarang hematogen atau limfogenJarang hematogen atau limfogen

Temuan KlinisTemuan Klinis Gejala-gejala - demam & menggigil tiba-tibaGejala-gejala - demam & menggigil tiba-tiba

- nyeri menetap pada - nyeri menetap pada pinggangpinggang

- sistitis (frekwensi, nokturia, - sistitis (frekwensi, nokturia, urgensi & disuri)urgensi & disuri)

- malaise, mual, muntah, diare.- malaise, mual, muntah, diare.

• Tanda-tanda - tampak sakitTanda-tanda - tampak sakit - demam (38,5°- 40°C)- demam (38,5°- 40°C)

- takikardia (90x/i - 140x/i)- takikardia (90x/i - 140x/i)

- nyeri ketok pada pinggang- nyeri ketok pada pinggang

- ginjal sukar diraba- ginjal sukar diraba

- distensi abdomen- distensi abdomen

- paralitik ileus- paralitik ileus LaboratoriumLaboratorium

- Leukositosis, BSR - Leukositosis, BSR - Urin : keruh, piuria, bakteriuria, proteinuria - Urin : keruh, piuria, bakteriuria, proteinuria kadang-kadang- kadang hematuria. kadang hematuria.

- Fungsi ginjal : normal- Fungsi ginjal : normal

• RadiologisRadiologis

* BNO - bayangan ginjal tidak jelas* BNO - bayangan ginjal tidak jelas

- batu ginjal- batu ginjal

* IVP - ginjal membesar* IVP - ginjal membesar

- neprogram ber (-)- neprogram ber (-) Diagnosis bandingDiagnosis banding

- Pankreatitis- Pankreatitis

- Basal pneumonia- Basal pneumonia

- Appendisitis, Cholesistitis- Appendisitis, Cholesistitis

- PID- PID

• KomplikasiKomplikasi

- Septikemi- Septikemi Pengobatan Pengobatan

- Segera buat kultur urin dan darah- Segera buat kultur urin dan darah

- Antibiotik : - Aminoglikosid + Ampisilin - Antibiotik : - Aminoglikosid + Ampisilin IV IV

selama 1 minggu selama 1 minggu disambung AB disambung AB sesuai sesuai

kultur.kultur.

- Bed rest- Bed rest

- Analgenik / Antipiretik.- Analgenik / Antipiretik.

CystitisCystitis

Afebrile usuallyAfebrile usually FrequencyFrequency EnuresisEnuresis DysuriaDysuria Reluctance to voidReluctance to void

SISTITIS AKUTSISTITIS AKUT Etiologi : E coli (terbanyak), Staphylococcus Etiologi : E coli (terbanyak), Staphylococcus

saprophyticus, Enterococcussaprophyticus, Enterococcus Umumnya asal infeksi dari urethraUmumnya asal infeksi dari urethra Insidens : lebih sering pada wanita dari pada Insidens : lebih sering pada wanita dari pada

laki-laki.laki-laki. Patologi :Patologi :

Stad awal : mukosa hiperemis, edema.Stad awal : mukosa hiperemis, edema.

Stad lanjut : mukosa rapuh, hemorrhgis, Stad lanjut : mukosa rapuh, hemorrhgis, ulkus ulkus

dangkal yang berisi eksudat.dangkal yang berisi eksudat. Temuan KlinisTemuan Klinis

Gejala-gejala : Gejala-gejala :

- freukwensi, disuri, urgensi, nokturi &- freukwensi, disuri, urgensi, nokturi &

- rasa terbakar pada saat miksi- rasa terbakar pada saat miksi

- urge incontinence, hematuri- urge incontinence, hematuri

- nyeri suprapubik & pinggang- nyeri suprapubik & pinggang

- “ honeymoon cystitis”- “ honeymoon cystitis” Tanda-tanda :Tanda-tanda :

- nyeri ketok suprapubis- nyeri ketok suprapubis

- vagina - vagina - discharge - discharge

- VT - VT adnexa ? adnexa ?

- defisiensi estrogen - defisiensi estrogen pucat pucat

- urethra - urethra tumor, karunkulae. tumor, karunkulae.

PyelonephritisPyelonephritis

Usually associated with fever and Usually associated with fever and systemic signs 2systemic signs 2° ° renal parenchymal renal parenchymal inflammationinflammation

Older children Older children Flank pain or abdominal painFlank pain or abdominal pain

Younger childrenYounger children Fever, irritability, vomiting, poor feedingFever, irritability, vomiting, poor feeding

• LaboratoriumLaboratorium

- Hemogram : lekositosis ringan- Hemogram : lekositosis ringan

- Urinalisa : piuria, bakteriuria, hematuria - Urinalisa : piuria, bakteriuria, hematuria

(mikro/gross)(mikro/gross)

- Kultur urine & tes sensitivitas- Kultur urine & tes sensitivitas Pielografi intravenaPielografi intravena

Indikasi - Th/ A.B Indikasi - Th/ A.B tidak membaik tidak membaik

- Sistitis tanpa piuria, gejala (+)- Sistitis tanpa piuria, gejala (+)

- Sistitis berulang- Sistitis berulang

- Hematuria- Hematuria

• Sistoskopi & kalibrasi urethraSistoskopi & kalibrasi urethra- Indikasi sistoskopi : hematuri, pada IVP - Indikasi sistoskopi : hematuri, pada IVP tidak tidak

ditemukan kelainan pada traktus urinarius ditemukan kelainan pada traktus urinarius

bagian atas.bagian atas.

- Kalibrasi dengan bougie a boule - Kalibrasi dengan bougie a boule snapping snapping

stenosisstenosis PengobatanPengobatan

- A.B. - A.B. sesuai kultursesuai kultur

- Anticholinergic - Anticholinergic Probanthine Probanthine

- Urinary analgesic - Urinary analgesic Pyridium Pyridium

- Stiktur/stenosis - Stiktur/stenosis dilatasi dilatasi

- Karunkulae - Karunkulae ekstirpasi ekstirpasi

URETHRITIS AKUTURETHRITIS AKUT

EtiologiEtiologi

- Ascending : meatus, urethra distal- Ascending : meatus, urethra distal

- Descending : traktus urinarius bagian - Descending : traktus urinarius bagian atas buli atas buli

& prostat& prostat

- Penyebab- Penyebab

* N gonorrhoeae * N gonorrhoeae terbanyak terbanyak

* NGU : Chlamydia trachomatis, U * NGU : Chlamydia trachomatis, U urealyticumurealyticum

PatologiPatologi

- mukosa eritema, edema, eksudat purulen- mukosa eritema, edema, eksudat purulen

- ulserasi- ulserasi

• Temuan klinisTemuan klinis

Gejala-gejala :Gejala-gejala :

- discharge pada urethra- discharge pada urethra

- disuri- disuri

- gatal & rasa terbakar pada urethra- gatal & rasa terbakar pada urethra

- Go - Go masa inkubasi masa inkubasi 1-5 hari1-5 hari discharge discharge

purulent (seperti susu)purulent (seperti susu)

- NGU : masa inkubasi 5-21 hari - NGU : masa inkubasi 5-21 hari discharge discharge

mukoid, disuri bisa (+)/(-)mukoid, disuri bisa (+)/(-)

Tanda-tanda :Tanda-tanda :

- discharge (+)- discharge (+)

- meatus urethra : merah, edematous- meatus urethra : merah, edematous LaboratoriumLaboratorium

- Urin : lekosituria- Urin : lekosituria

- Gram -stained smear- Gram -stained smear

* intracelluler gram (+) cocci * intracelluler gram (+) cocci Go Go

* gram (+) cocci * gram (+) cocci tidak ditemukan tidak ditemukan NGUNGU

- Kultur & tes sentivitas urin- Kultur & tes sentivitas urin

Tanda-tanda :Tanda-tanda :

- discharge (+)- discharge (+)

- meatus urethra : merah, edematous- meatus urethra : merah, edematous LaboratoriumLaboratorium

- Urin : lekosituria- Urin : lekosituria

- Gram -stained smear- Gram -stained smear

* intracelluler gram (+) cocci * intracelluler gram (+) cocci Go Go

* gram (+) cocci * gram (+) cocci tidak ditemukan tidak ditemukan NGUNGU

- Kultur & tes sentivitas urin- Kultur & tes sentivitas urin

• Komplikasi Komplikasi

- infeksi keatas : prostat, ductus - infeksi keatas : prostat, ductus ejaculatorius, ejaculatorius,

vesicula seminalis, vas deferens, vesicula seminalis, vas deferens, epididymis & epididymis &

buli.buli.

- abses periurethral- abses periurethral

- stricture urethra- stricture urethra TerapiTerapi

1. Gonorrhea 1. Gonorrhea infeksi non spesifik infeksi non spesifik

2. NGU 2. NGU sesuai hasil kultur. sesuai hasil kultur.

• A.B. - Tetrasiklin 4x500 mgA.B. - Tetrasiklin 4x500 mg - Doksisiklin 2x100 mg- Doksisiklin 2x100 mg - Minosiklin 2x100 mg- Minosiklin 2x100 mg - Eritromisin 4x500 mg- Eritromisin 4x500 mg - Tmp - sm- Tmp - sm

- lama terapi 7-14 hari- lama terapi 7-14 hari Laki-laki Laki-laki : - pakai kondom : - pakai kondom

- - abstinensiaabstinensia Terapi Terapi sexual partner sexual partner

S/d sembuh

URETERURETER Akibat infeksi descending dari ginjalAkibat infeksi descending dari ginjal Ureter menjadi fibrosis, memendek Ureter menjadi fibrosis, memendek

menjadi lurus, atau strikturmenjadi lurus, atau striktur Muara ureter Muara ureter “golf hole” “golf hole” Akibat stenosis ureter Akibat stenosis ureter hidronefrosis hidronefrosis

autonefrektomiautonefrektomi Striktur Striktur tersering pada uretero - vesikal tersering pada uretero - vesikal RadiologisRadiologis

IVP IVP - gambaran striktur ureter - gambaran striktur ureter single single atau atau

multiplemultiple

- dilatasi ureter- dilatasi ureter

- ureter pendek, lurus- ureter pendek, lurus

BULIBULI Gejala awal Gejala awal irritasi buli irritasi buli

Miksi terasa panas, frekwensi, nokturi Miksi terasa panas, frekwensi, nokturi hematurihematuri

Gejala lanjut Gejala lanjut

- Ulserasi buli - Ulserasi buli nyeri suprapubis nyeri suprapubis

- Contracted bladder - Contracted bladder Frekwensi >> OK Frekwensi >> OK

kapasitas buli kapasitas buli SistoskopiSistoskopi

- tuberkel (+)- tuberkel (+)

- Ulserasi (+)- Ulserasi (+)

- Contrakted bladder- Contrakted bladder SistogramSistogram

- Vesico ureteral reflux- Vesico ureteral reflux

Biopsi

TerapiTerapi

(1) Cycloserine + PAS + INH(1) Cycloserine + PAS + INH

(2) Cycloserine + Ethambutol + INH(2) Cycloserine + Ethambutol + INH

(3) Rifampisin + Ethambutol + INH(3) Rifampisin + Ethambutol + INH

DosisDosis

- Cycloserine- Cycloserine 2x250mg/hr2x250mg/hr

- PAS - PAS 15gr/hr15gr/hr

- INH- INH 300mg/hr300mg/hr

- Ethambutol- Ethambutol 1200mg/hr1200mg/hr

- Rifampisin- Rifampisin 600mg/hr600mg/hr Lama terapiLama terapi

Gow (1979) Gow (1979) 6 bulan 6 bulan

AntibioticsAntibiotics

DON’T : Treat asymptomatic bacteuriaDON’T : Treat asymptomatic bacteuria

Use antibiotic prophylaxis routinely after 1Use antibiotic prophylaxis routinely after 1stst UTI UTI

DO : Use different antibiotic, not a higher dose of same antibiotic, for children who are already on prophylactic antibiotic

A Cochrane systematic review suggests that treatment for 2-4 days seems to be as effective as treatment for 7 - 14

days foreradicating lower tract UTI in children.

PrognosisPrognosis

Most recover quickly and completely with antibiotic Most recover quickly and completely with antibiotic treatment.treatment.

Recurrence of urinary tract infection is more likely in:Recurrence of urinary tract infection is more likely in:

Younger children i.e. aged less than 6 monthsYounger children i.e. aged less than 6 months

Girls compared to boysGirls compared to boys

Vesicoureteral refluxVesicoureteral reflux

Vesicoureteric reflux (VUR) is found in about 1% of normal Vesicoureteric reflux (VUR) is found in about 1% of normal infants and normally resolves over several years.However, infants and normally resolves over several years.However, it is a risk factor for pyelonephritis, which can cause renal it is a risk factor for pyelonephritis, which can cause renal scarring, which can lead to hypertension & impaired renal scarring, which can lead to hypertension & impaired renal function.function.

MANAGEMENTMANAGEMENT


GOALS:GOALS: Elimination of infection and prevention of Elimination of infection and prevention of

urosepsis urosepsis Relief of acute symptomsRelief of acute symptoms Prevention of recurrence and long-term Prevention of recurrence and long-term

complicationscomplications


Decision to hospitalize:Decision to hospitalize:• Age <2 months Age <2 months • Clinical urosepsis or potential bacteremia Clinical urosepsis or potential bacteremia • Immunocompromised patient Immunocompromised patient • Vomiting or inability to tolerate oral Vomiting or inability to tolerate oral

medication medication • Lack of adequate outpatient follow-upLack of adequate outpatient follow-up• Failure to respond to outpatient therapyFailure to respond to outpatient therapy


ANTIBIOTIC THERAPY:ANTIBIOTIC THERAPY:• Choice of agent: Choice of agent: provide adequate coverage provide adequate coverage

for E. coli. for E. coli. • Oral therapy: Oral therapy: Cefixime, amoxicillin-clavulanate.Cefixime, amoxicillin-clavulanate.• Parenteral therapyParenteral therapy: Third- or fourth-generation : Third- or fourth-generation

cephalosporins and aminoglycosides are cephalosporins and aminoglycosides are appropriate first-line agents for empiric appropriate first-line agents for empiric treatment of UTI in children.treatment of UTI in children.

• In children receiving antibiotic prophylaxis. In children receiving antibiotic prophylaxis.


ANTIBIOTIC THERAPYANTIBIOTIC THERAPY Duration of therapy:Duration of therapy: 5-14 days 5-14 days Response to therapy:Response to therapy:

Clinical responseClinical response

Repeat urine cultureRepeat urine culture

MANAGEMENTMANAGEMENT FURTHER INVESTIGATIONSFURTHER INVESTIGATIONS

Indications:Indications:

1.1. Girls younger than 3 years of age with a first Girls younger than 3 years of age with a first UTIUTI

2.2. Boys of any age with a first UTI Boys of any age with a first UTI

3.3. Children of any age with a febrile UTI Children of any age with a febrile UTI

4.4. Children with recurrent UTIChildren with recurrent UTI

5.5. First UTI in a child of any age with a family First UTI in a child of any age with a family history of renal disease, abnormal voiding history of renal disease, abnormal voiding pattern, poor growth, hypertensionpattern, poor growth, hypertension

PROGNOSISPROGNOSIS

Recurrent UTIRecurrent UTI 14 percent of children younger than 6 14 percent of children younger than 6

years with UTI have a subsequent UTIyears with UTI have a subsequent UTI associated with a higher risk of UTI associated with a higher risk of UTI

recurrencerecurrence

-white race -white race

-age 3 to 5 years -age 3 to 5 years

-VUR of grade IV to V-VUR of grade IV to V

PROGNOSISPROGNOSIS

Long-term sequelae Long-term sequelae Approximately 40 percent Approximately 40 percent

had VUR had VUR

Renal scars developed in Renal scars developed in approximately 8 % of approximately 8 % of patients, 15 % of those had patients, 15 % of those had abnormal DMSA scan at abnormal DMSA scan at the time of diagnosis.the time of diagnosis.

URINARY TRACT URINARY TRACT INFECTIONINFECTION

WHY IMPORTANT????WHY IMPORTANT????

May lead to renal scarringMay lead to renal scarring

RENAL SCARRINGRENAL SCARRING• The loss of renal parenchyma between the calyces and The loss of renal parenchyma between the calyces and

the renal capsule, a potential complication of UTI. the renal capsule, a potential complication of UTI.

• Long-term consequences include hypertension, Long-term consequences include hypertension, decreased renal function, proteinuria, and end-stage decreased renal function, proteinuria, and end-stage renal diseaserenal disease

• The development of renal scarring has been associated The development of renal scarring has been associated with:with:

-Recurrent febrile UTI-Recurrent febrile UTI -Delay in treatment of acute infection-Delay in treatment of acute infection -Dysfunctional elimination-Dysfunctional elimination -Obstructive malformations -Obstructive malformations -VUR-VUR

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Sindroma nefritik akutSindroma nefritik akut

Batasan: SNA (glomerulonefritis akut) Batasan: SNA (glomerulonefritis akut) adalah sidroma klinik yg ditandai oliguri, adalah sidroma klinik yg ditandai oliguri, kelainan urinalisis (proteinuri < 2 g/hr), kelainan urinalisis (proteinuri < 2 g/hr), hematuria,azotemia, hipertensi, hematuria,azotemia, hipertensi, bendungan sirkulasi, kenaikan tek.vena bendungan sirkulasi, kenaikan tek.vena jugularis, hepatomegali, edema.jugularis, hepatomegali, edema.

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Glomerulopathy Glomerulopathy - adalah proses inflamasi glomerulusadalah proses inflamasi glomerulus- Terjadi akibat berbagai sebab yg berbeda Terjadi akibat berbagai sebab yg berbeda

etiologi, patofisiologi ataupun etiologi, patofisiologi ataupun patogenesanyapatogenesanya

- Dulu dikenal dg istilah glomerulonephritisDulu dikenal dg istilah glomerulonephritis- Peyebab utama Gagal GinjalPeyebab utama Gagal Ginjal- Manifestasi klinis bisa tanpa gejala sampai Manifestasi klinis bisa tanpa gejala sampai

gejala yang berat gejala yang berat - Terpenting:menghambat progresifitas Terpenting:menghambat progresifitas

kerusakan kerusakan

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Klasifikasi glomerulopathyKlasifikasi glomerulopathy

1.1. Klasifikasi klinisKlasifikasi klinis

2.2. Klasifikasi lesi histopatologi Klasifikasi lesi histopatologi

3.3. Klasifikasi berdasar etiologi&patogenesisKlasifikasi berdasar etiologi&patogenesis

4.4. Klasifikasi berdasar proses imunologiKlasifikasi berdasar proses imunologi

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Klasifikasi klinis:Klasifikasi klinis:1.1. Kelainan urine tanpa keluhanKelainan urine tanpa keluhan

2.2. Sindroma nefrotikSindroma nefrotik

3.3. Sindroma nefritik akutSindroma nefritik akut

4.4. Sindroma nefritik kronikSindroma nefritik kronik

5.5. Sindroma RPGN (Rapid Progressive Sindroma RPGN (Rapid Progressive Glomerulonephritis)Glomerulonephritis)

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Klasifikasi lesi Klasifikasi lesi histopatologishistopatologis

a.a. Lesi minimalLesi minimalb.b. Lesi glomerulosklerosis fokal segmentalLesi glomerulosklerosis fokal segmentalc.c. Lesi mesangioproliferatif (IgM)Lesi mesangioproliferatif (IgM)d.d. Lesi mesangioproliferatif (IgA) (penyakit Lesi mesangioproliferatif (IgA) (penyakit

Berger)Berger)e.e. Lesi proliferatif akutLesi proliferatif akutf.f. Lesi membranoproliferatifLesi membranoproliferatifg.g. Lesi membranosaLesi membranosah.h. Lesi bulan sabit (crescentic)Lesi bulan sabit (crescentic)i.i. Lesi glomerulosklerosis.Lesi glomerulosklerosis.

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Klasif. Etiologi& patogenesaKlasif. Etiologi& patogenesa

a.a. Kelainan imunologiKelainan imunologib.b. Kelainan metabolik:Kelainan metabolik:

- nefropati diabettik- nefropati diabettik- nefropati as. Urat- nefropati as. Urat- amiloidosis primer/sekunder- amiloidosis primer/sekunder

c.c. Kelainan vaskulerKelainan vaskulerd.d. Disseminated Intravascular Coagulopathy Disseminated Intravascular Coagulopathy

(DIC)(DIC)e.e. Kel. Herediter: sindr.Alport, peny.FabryKel. Herediter: sindr.Alport, peny.Fabryf.f. Patogenesis tak diketahui: lipoid nefrosisPatogenesis tak diketahui: lipoid nefrosis

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Klasif. imunologiKlasif. imunologia.a. peny. Kompleks immun:peny. Kompleks immun:

1. Circulating immune complex:1. Circulating immune complex:Nephropathy BergerNephropathy BergerHenoch-Schonlein PurpuraHenoch-Schonlein PurpuraNefritis Lohlein (endokar.bakteri)Nefritis Lohlein (endokar.bakteri)

2. Pembentukan komplek imun insitu:2. Pembentukan komplek imun insitu:Glom. Post Streptococcus Glom. Post Streptococcus

infectioninfectionGlom. Membranosa Glom. Membranosa

b.b. peny.AGBM: sindroma Goodpasteur.peny.AGBM: sindroma Goodpasteur.

FUNGSI GINJALFUNGSI GINJAL

FUNGSI UTAMA : MEMBERSIHKAN PLASMA DARAH FUNGSI UTAMA : MEMBERSIHKAN PLASMA DARAH DARI ZAT-ZAT YANG TIDAK DIPERLUKAN TUBUH, DARI ZAT-ZAT YANG TIDAK DIPERLUKAN TUBUH, TERUTAMA HASIL-HASIL METABOLISME PROTEIN.TERUTAMA HASIL-HASIL METABOLISME PROTEIN.

Secara keseluruhan dapat dibagi 2 golongan : Secara keseluruhan dapat dibagi 2 golongan : I. I. Fungsi ekskresi Fungsi ekskresi : sisa metabolisme, regulasi volume : sisa metabolisme, regulasi volume cairan tubuh, menjaga keseimbangan asam basa. cairan tubuh, menjaga keseimbangan asam basa. II. Fungsi II. Fungsi endokrin :endokrin : partitipasi dalam eritropoesis ( pembentukan partitipasi dalam eritropoesis ( pembentukan eritrosit ), pengaturan tekanan darah, keseimbangan eritrosit ), pengaturan tekanan darah, keseimbangan kalsium dan fosforkalsium dan fosfor

Faal GinjalFaal Ginjal

A. Faal glomerulus, yaitu filtrasi darahA. Faal glomerulus, yaitu filtrasi darah B. Faal tubulus, yaitu mengatur aliran dan B. Faal tubulus, yaitu mengatur aliran dan

konsentrasi urine. Mengatur konsentrasi urine. Mengatur keseimbangan asam basa dengan keseimbangan asam basa dengan pertukaran ion hidrogen, produksi amonia pertukaran ion hidrogen, produksi amonia dan reabsorpsi bikarbonat; mengatur dan reabsorpsi bikarbonat; mengatur pengeluaran elektrolit, asam amino dan pengeluaran elektrolit, asam amino dan asam organik,asam organik,

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Etiologi :Etiologi :

1. Glomerulopati (GP)idiopatik /primer1. Glomerulopati (GP)idiopatik /primera. GP akut proliferatifa. GP akut proliferatifb. GP mesangioproliferatif (IgA)b. GP mesangioproliferatif (IgA) (penyakit Burger)(penyakit Burger)c. GP membranoproliferatif.c. GP membranoproliferatif.

2.2. GP post-infeksi:GP post-infeksi:a. post-infection streptococcus a. post-infection streptococcus haemolitikhaemolitikb. endokarditis bakterialis (nefritis Lohlein)b. endokarditis bakterialis (nefritis Lohlein)c. stphylococcus albus ( shunt nephritis)c. stphylococcus albus ( shunt nephritis)d. abses viscerald. abses viscerale. hepatitis Be. hepatitis B

105

3. Disseminated Lupus Erythematosus 3. Disseminated Lupus Erythematosus (DLE)(DLE)

4. Vaskulitis:4. Vaskulitis:

a. poliarteritis nodosaa. poliarteritis nodosa

b. Wagener Granulomatosisb. Wagener Granulomatosis

c. henoch-Schonlein purpurac. henoch-Schonlein purpura

d. Krioglobulinemiad. Krioglobulinemia

5. Nephritis herediter.5. Nephritis herediter.

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Patofisiologi Patofisiologi

1. Kel.urinalisis: ok. Kerusakan dd. Kapiler 1. Kel.urinalisis: ok. Kerusakan dd. Kapiler glomerulus glomerulus selektif proteinuri < 2g/hr, selektif proteinuri < 2g/hr, hematuria disertai silinder eritrosit.hematuria disertai silinder eritrosit.

2. LFG menurun, disertai reabsorbsi Na. dan 2. LFG menurun, disertai reabsorbsi Na. dan air sehingga terjadi oliguri ,edema, air sehingga terjadi oliguri ,edema, edema paru dan hipertensiedema paru dan hipertensi

107

Gejala klinis:Gejala klinis:

1. 90% G/ subklinis ,kelainan urinalisis 1. 90% G/ subklinis ,kelainan urinalisis + + hipertensi.hipertensi.

2. 10% dg G/klinik:2. 10% dg G/klinik:

a. sindroma nefrotik (4%)a. sindroma nefrotik (4%)

b. sindroma RPGN (1%)b. sindroma RPGN (1%)

c. sindr.nefritik akut (5%)c. sindr.nefritik akut (5%)

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Klinis:Klinis:

1.1. Riwayat infeksi streptokokRiwayat infeksi streptokok2.2. Oliguri dan hematuri tanpa rasa sakit.Oliguri dan hematuri tanpa rasa sakit.3.3. Hipertensi terutama pada anak2Hipertensi terutama pada anak24.4. Sembab & bendungan sirkulasi:Sembab & bendungan sirkulasi:

- kardiomegali- kardiomegali- bendungan paru akut- bendungan paru akut- kenaikan tek.vena jugularis.- kenaikan tek.vena jugularis.- hepatomegali- hepatomegali

5.5. bradikardibradikardi

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Pemeriksaan & diagnosisPemeriksaan & diagnosis

1.1.diagnosis: diagnosis:

a. kelainan urinalisis: proteinuri, hematuria. kelainan urinalisis: proteinuri, hematuri

b. foto thorax: kardiomegali&bend.parub. foto thorax: kardiomegali&bend.paru

c. ECG: voltase rendah, T inverted, QT >c. ECG: voltase rendah, T inverted, QT >

2. Diagnosis perjalanan penyakit:2. Diagnosis perjalanan penyakit:

a. faal ginjal kenaikan BUN & kreatina. faal ginjal kenaikan BUN & kreatin

b. elektrolit serum: Na.turun, K naik.b. elektrolit serum: Na.turun, K naik.

c. protein darah tetap/turun, profil lemak normalc. protein darah tetap/turun, profil lemak normal

d. ggn.faktor pembekuan: fibrinogen, F.VII, fibrinolitikd. ggn.faktor pembekuan: fibrinogen, F.VII, fibrinolitik

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Diagnosis etiologiDiagnosis etiologi

A.A. pem.serologi: - ASO titerpem.serologi: - ASO titer

- kompleks imun - kompleks imun

- antiimunoglobulin- antiimunoglobulin

- serum komplemen- serum komplemen

B.B. pem.histopatologi.pem.histopatologi.

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Penatalaksanaan:Penatalaksanaan:

1.1. Pengobatan darurat.Pengobatan darurat.

2.2. Pengobatan suportifPengobatan suportif

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Pengobatan darurat:Pengobatan darurat:

1.1. Mengatasi bendungan sirkulasi dan paru:Mengatasi bendungan sirkulasi dan paru:a. posisi tidur setengah duduka. posisi tidur setengah dudukb. oksigenb. oksigenc. diuresis paksa : lasix intravenac. diuresis paksa : lasix intravenad. morfin d. morfin e. obat antihipertensi orale. obat antihipertensi oralf. hemodialisis: bila tx 24 jam gagal/GGAf. hemodialisis: bila tx 24 jam gagal/GGA

2.2. Ensefalopati hipertensi akut :Ensefalopati hipertensi akut :a. hidralazin 20 mg I.V. & diuretik furosemida. hidralazin 20 mg I.V. & diuretik furosemidb. nifedipin im. /sublingual dan furosemidb. nifedipin im. /sublingual dan furosemid

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Pengobatan suportifPengobatan suportif

1.1. Diet: a. tinggi kalori 35 kal./kgBB/hrDiet: a. tinggi kalori 35 kal./kgBB/hr

b. lemak tak jenuhb. lemak tak jenuh

c. rendah protein c. rendah protein 0,5-0,75/kgBB/hr0,5-0,75/kgBB/hr

d. elektrolit: Na.&K. dibatasid. elektrolit: Na.&K. dibatasi

Ca. 600-1000 Ca. 600-1000 mg/hrmg/hr

2.2. Cairan: harus dibatasi untuk menjaga Cairan: harus dibatasi untuk menjaga keseimbangan cairan tubuh.keseimbangan cairan tubuh.

S U K S E SS U K S E S

Selamat belajarSelamat belajar

&&

Urinary Tract Infection:Urinary Tract Infection:Guidelines to assessment, Guidelines to assessment, treatment, and prevention treatment, and prevention

in the older adultin the older adult

33:610 Gerontological Nursing33:610 Gerontological NursingUniversity of Massachusetts LowellUniversity of Massachusetts Lowell

Mary Ellen Powers, BSN, RNMary Ellen Powers, BSN, RN

March 30, 2006March 30, 2006

Urinary Tract InfectionUrinary Tract Infection

The Agency for Healthcare Research and The Agency for Healthcare Research and Quality (AHRQ) and the U.S. Preventive Quality (AHRQ) and the U.S. Preventive Services Task Force (USPSTF)Services Task Force (USPSTF)

MissionMission

Improve quality, efficiency and effectiveness of Improve quality, efficiency and effectiveness of healthcare for all Americanshealthcare for all Americans

Supports health services research that will Supports health services research that will improve the quality of healthcare & promote improve the quality of healthcare & promote evidence-based decision makingevidence-based decision making


GNP’s RoleGNP’s Role

Develop and implement evidence-based Develop and implement evidence-based health promotion strategies, as well as health promotion strategies, as well as prevention and treatment criteria in UTI prevention and treatment criteria in UTI management of the older adult, both in the management of the older adult, both in the community and long-term care settingcommunity and long-term care setting


Prevalence

Community-dwelling elders – 25% Community-dwelling elders – 25% Swart, Soler & Holman, 2004Swart, Soler & Holman, 2004

Long-term care elders 25-50% of women Long-term care elders 25-50% of women (chronically bacteriuric) 15-40% of men(chronically bacteriuric) 15-40% of men

Juthani-Mehta et al., 2005Juthani-Mehta et al., 2005

Marked increases in women & men after age 65Marked increases in women & men after age 65Wagenlehner, Naber & Weidner, 2005Wagenlehner, Naber & Weidner, 2005

}

Urinary Tract Infection DefinedUrinary Tract Infection Defined

DefinitionDefinition

Women:Women: Presence of at least 100,000 colony-Presence of at least 100,000 colony-forming units (cfu)/mL in a pure forming units (cfu)/mL in a pure culture of voided clean-catch urineculture of voided clean-catch urine

Men:Men: Presence of just 1,000 cfu/mLPresence of just 1,000 cfu/mLindicates urinary tract infectionindicates urinary tract infection

**Some labs do not routinely identify & determine the Some labs do not routinely identify & determine the

sensitivity of organisms for specimens with <10,000sensitivity of organisms for specimens with <10,000 cfu/mL. May have to special request.cfu/mL. May have to special request.

Swart, Soler & Holman, 2004Swart, Soler & Holman, 2004


Urinary tract infection—most common source of Urinary tract infection—most common source of bacteremia, a dangerous systemic infection in bacteremia, a dangerous systemic infection in long-term care facilitieslong-term care facilities

Bacteremia—40 times more likely to occur in Bacteremia—40 times more likely to occur in catheterized than non-catheterized residentscatheterized than non-catheterized residents

Bacteremia leads to significant morbidity and Bacteremia leads to significant morbidity and mortality in the vulnerable elderlymortality in the vulnerable elderly

Nicolle, 2005Nicolle, 2005

Physiologic changes with aging in the urinary tract

Age-Related Changes Men Women

Decreased bladder capacity and increased Decreased bladder capacity and increased urine production (especially at night)urine production (especially at night)

Decreased voided volumeDecreased voided volume

Decreased estrogen w/menopause leads to Decreased estrogen w/menopause leads to thinning of vaginal & urethral mucosathinning of vaginal & urethral mucosa

Decreased lower urinary tract sensory Decreased lower urinary tract sensory thresholdthreshold

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√√Palmer, 2004Palmer, 2004

Urinary Tract InfectionUrinary Tract InfectionPhysiologic ChangesPhysiologic Changes

Physiologic changes with aging in the urinary tract

Age-Related Changes Men Women

Problems of urinary storage & emptyingProblems of urinary storage & emptying

↑↑incidence of overflow incontinence from incidence of overflow incontinence from urethral obstruction or strictureurethral obstruction or stricture

Decreased estrogen levels leads to pH Decreased estrogen levels leads to pH changes in vagina, favoring colonization of changes in vagina, favoring colonization of E. coliE. coli, , ↑risk of UTI↑risk of UTI

Prostatic enlargement can lead to urinary Prostatic enlargement can lead to urinary obstruction, increased residual urine & obstruction, increased residual urine & infectioninfection

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Palmer, 2004Palmer, 2004

UTI—Physiologic ChangesUTI—Physiologic Changes

Age-Related Changes in the Age-Related Changes in the Urinary SystemUrinary System

StructureStructure ChangeChange ImpactImpact

GlomeruliGlomeruli ↓↓numbernumber

↑↑surface areasurface area

↓ ↓filtration of bloodfiltration of blood ↓ ↓glomerular filtration rate by 30-40%glomerular filtration rate by 30-40%

TubulesTubules thickened membranethickened membrane

fatty degenerationfatty degeneration

shorteningshortening

↓↓tubule transporttubule transport ↓↓urine-concentrating capacityurine-concentrating capacity ↓↓Na conservationNa conservation ↓↓renal acidificationrenal acidification

Renal Renal vasculaturevasculature

stiffeningstiffening

narrowingnarrowing

↓ ↓blood flowblood flow ↓ ↓efficiency in removal of waste efficiency in removal of waste productproduct

Connective Connective tissuetissue

↓↓expandability & expandability & compressibility of compressibility of bladderbladder

↓ ↓bladder capacitybladder capacity ↑ ↑residual urine volume after voidingresidual urine volume after voiding

Palmer, 2004Palmer, 2004

History & Physical ExaminationHistory & Physical Examination

Age-related Risk Factors for UTIAge-related Risk Factors for UTI

Advanced AgeAdvanced Age Fecal incontinence/impactionFecal incontinence/impaction Incomplete bladder emptying or neurogenic bladderIncomplete bladder emptying or neurogenic bladder Vaginal atrophy/estrogen deficiencyVaginal atrophy/estrogen deficiency Pelvic prolapse/cystocelePelvic prolapse/cystocele Insufficient fluid intake/dehydrationInsufficient fluid intake/dehydration Indwelling foley catheter or urinary catheterization or Indwelling foley catheter or urinary catheterization or

instrumentation proceduresinstrumentation procedures

H & P, cont’dH & P, cont’d

Age-related Risk Factors for UTIAge-related Risk Factors for UTI

Diabetes or immunosuppressionDiabetes or immunosuppression Benign prostatic hypertrophyBenign prostatic hypertrophy Bladder or prostate cancerBladder or prostate cancer Urinary tract obstructionUrinary tract obstruction Spinal cord injurySpinal cord injury

Mahan-Buttaro, Aznavorian & Dick, 2006Mahan-Buttaro, Aznavorian & Dick, 2006

Farms

note: these are key indicators you must consider in eliciting a athorough history & ROS to determine risk for each elder

H & PH & P, , cont’dcont’d

Age GroupAge Group

(years)(years)

FemaleFemale


MaleMale


50-7050-70 Estrogen deficiencyEstrogen deficiency

DiabetesDiabetes

Gynecological diseases—Gynecological diseases—cystocele & related surgical cystocele & related surgical proceduresprocedures

Prostatic obstructionProstatic obstruction

DiabetesDiabetes

Urological/surgical proceduresUrological/surgical procedures

Female vs. Male Complicating FactorsFemale vs. Male Complicating Factors

H & P, cont’dH & P, cont’d

Age GroupAge Group

(years)(years)

FemaleFemale


MaleMale


>70>70 Estrogen deficiencyEstrogen deficiency

DiabetesDiabetes

Gynecological diseases (cystocele Gynecological diseases (cystocele & related surgical procedures)& related surgical procedures)

Urological diseases (incontinence, Urological diseases (incontinence, residual urine, cystopathy) & residual urine, cystopathy) & related surgical proceduresrelated surgical procedures

Urinary catheterUrinary catheter

Reduced mental statusReduced mental status

Co-morbid diseasesCo-morbid diseases

Immunological changesImmunological changes

Prostatic obstructionProstatic obstruction

DiabetesDiabetes

Urological/surgical Urological/surgical proceduresprocedures

Urinary catheterUrinary catheter

Reduced mental statusReduced mental status

Co-morbid diseasesCo-morbid diseases

Immunological changesImmunological changes

Wagenlehner, et al., 2005Wagenlehner, et al., 2005

Female vs. Male Complicating FactorsFemale vs. Male Complicating Factors

Complicated vs Uncomplicated UTIComplicated vs Uncomplicated UTI UTI’s in elderly men are UTI’s in elderly men are always always consideredconsidered

complicatedcomplicated UTI’s in women are UTI’s in women are complicatedcomplicated when: when:

Hx of recurrent UTIHx of recurrent UTI Secondary to structural abnormalitiesSecondary to structural abnormalities CathetersCatheters StonesStones Urinary retentionUrinary retention Abscess formation or urosepsisAbscess formation or urosepsis

Primary diagnostic and treatment focus in Primary diagnostic and treatment focus in research studies have been related to the research studies have been related to the elderly elderly femalefemale population population


Complicated vs Uncomplicated UTIComplicated vs Uncomplicated UTI

RecurrentRecurrent UTI’sUTI’s—culture-confirmed UTI’s—culture-confirmed UTI’s

** >3 in 1 year or >3 in 1 year or

** > 2 in 6 months > 2 in 6 months

Relapse UTI—Relapse UTI— occurs within 2 weeks of occurs within 2 weeks of RxRx

of an earlier UTIof an earlier UTI same same pathogenpathogen

Re-infection UTI—Re-infection UTI— occurs >4 weeks afteroccurs >4 weeks afterearlier UTIearlier UTI

different different pathogenpathogen


Causative PathogensCausative Pathogens

UTI in WomenUTI in Women Escherichia coliEscherichia coli—gram (-) etiologic agent —gram (-) etiologic agent

in in ~ ~ 80% of all UTI’s80% of all UTI’s Research indicates primary source of Research indicates primary source of

microbial invasion is retrograde microbial invasion is retrograde colonization by intestinal pathogenscolonization by intestinal pathogens

Other factors influencing colonization: Other factors influencing colonization: vaginal pH, urethral length, capacity of vaginal pH, urethral length, capacity of bacteria to adhere to urotheliumbacteria to adhere to urothelium

Osborne, 2004Osborne, 2004

=

Causative Pathogens, cont’dCausative Pathogens, cont’d

Polymicromial bacteriuria Polymicromial bacteriuria

Contamination most frequent cause of Contamination most frequent cause of multiple microorganismsmultiple microorganisms

25-33% in LTCF’s may be polymicrobic 25-33% in LTCF’s may be polymicrobic due to fistulas, urinary retention, infected due to fistulas, urinary retention, infected stones, or cathetersstones, or catheters

Midthun, 2004Midthun, 2004

Causative Pathogens, cont’dCausative Pathogens, cont’dAge/Type Specific PathogensAge/Type Specific Pathogens

Younger patients, rare in Younger patients, rare in elderly—Staphylcoccuselderly—Staphylcoccus,, saprophyticussaprophyticus (gram pos.) (gram pos.) –– 10-15% 10-15%

Elderly diabeticsElderly diabetics KlebsiellaKlebsiella species (gram neg.) most common species (gram neg.) most common

LTCF elderlyLTCF elderly E. coli E. coli ~ 30%~ 30% Proteus Proteus species (part of host flori in GI tract) ~ 30%species (part of host flori in GI tract) ~ 30% Staphylcoccus aureusStaphylcoccus aureus, , KlebsiellaKlebsiella, , PseudomonasPseudomonas

(gram neg.) and (gram neg.) and Enterococcus (gram pos.) ~ 40%Enterococcus (gram pos.) ~ 40%


Symptoms versus Symptoms versus Asymptomatic BacteriuriaAsymptomatic Bacteriuria

Asymptomatic Bacteriuria (ASB)Asymptomatic Bacteriuria (ASB) Defined as the presence of bacteria in Defined as the presence of bacteria in

urine of patients who do urine of patients who do notnot have dysuria, have dysuria, urinary frequency, urgency, fever, flank urinary frequency, urgency, fever, flank pain, or other symptoms related to pain, or other symptoms related to irritation of the urethra, bladder, or kidneyirritation of the urethra, bladder, or kidney


Strictly defined—exists when 2 urine Strictly defined—exists when 2 urine cultures done with clean-catch specimens cultures done with clean-catch specimens are positive in a patient who has are positive in a patient who has nono urinary tract symptomsurinary tract symptoms

Foxman, 2003Foxman, 2003

Symptomatic vs Asymptomatic Symptomatic vs Asymptomatic Bacteriuria, cont’dBacteriuria, cont’d

ASBASB Frequent in elderly, even > prevalent in Frequent in elderly, even > prevalent in

residents of LTCF: residents of LTCF:

elderly >70 yrs oldelderly >70 yrs old

women: 16-18%women: 16-18%

men: 6%men: 6%

Symptomatic vs. Asymptomatic Symptomatic vs. Asymptomatic Bacteriuria, cont’dBacteriuria, cont’d

Asymptomatic Bacteriuria (ASB)Asymptomatic Bacteriuria (ASB)

Most ASB in the elderly is associated with Most ASB in the elderly is associated with complicating complicating factors factors such as:such as: Hormonal:Hormonal: post-menopausal womenpost-menopausal women Anatomical:Anatomical: prostatic obstruction in men, cystocele in prostatic obstruction in men, cystocele in

womenwomen Functional:Functional: CNS, i.e., P.D. & dementiaCNS, i.e., P.D. & dementia Metabolic:Metabolic: diabetics (ASB females with Type 2 diabetes—diabetics (ASB females with Type 2 diabetes—

29%)29%) Immunological:Immunological: ↑’s in inflammatory mediators (cytokines, acute↑’s in inflammatory mediators (cytokines, acute

phase proteins)phase proteins) Instrumental:Instrumental: indwelling catheter→always bacteriuric indwelling catheter→always bacteriuric

ssymptomsymptoms

Wagenlehner, Naber & Weidner, 2005Wagenlehner, Naber & Weidner, 2005

UTI Signs and Symptoms in UTI Signs and Symptoms in ElderlyElderly

Very difficult to Very difficult to assessassess and and recognizerecognize, even when present in the , even when present in the older adult.older adult.

SignsSigns && Symptoms that indicate Symptoms that indicate further evaluationfurther evaluation for UTI for UTI elicited from H&P:elicited from H&P:

NewNew or i or increasedncreased urgency, frequency, dysyuria: urgency, frequency, dysyuria: > in younger patients, still can be present in elderly> in younger patients, still can be present in elderly These complaints can be common & chronic without These complaints can be common & chronic without

bacteriuriabacteriuria Requires careful interpretation—may not be due to UTIRequires careful interpretation—may not be due to UTI

ChangeChange inin character character ofof urineurine One study found cloudy, bloody, or malodorous urine in One study found cloudy, bloody, or malodorous urine in

>85% symptomatic UTI’s>85% symptomatic UTI’s Others less predictiveOthers less predictive


Signs and Symptoms, cont’dSigns and Symptoms, cont’d Clarity of urine Clarity of urine

Clear Clear → no bacteria; → no bacteria; cloudy, milky or turbid cloudy, milky or turbid → bacteriuria→ bacteriuria Cloudiness, however, can occur in normal urine—mucus, epithelial cellsCloudiness, however, can occur in normal urine—mucus, epithelial cells Cloudy character, alone or with (+) dipstick analysis Cloudy character, alone or with (+) dipstick analysis → further lab → further lab

analysisanalysis Study by Loeb et al. (2001) as consensus criteria—cloudy urine Study by Loeb et al. (2001) as consensus criteria—cloudy urine notnot an an

indication for antibioticsindication for antibiotics

BloodyBloody Hematuria not always indicative of infection; possiblyHematuria not always indicative of infection; possibly irritation or medication relatedirritation or medication related

Malodorous Malodorous Not a Not a validvalid indicator—may be caused by bacteria, but indicator—may be caused by bacteria, but could be hygiene-relatedcould be hygiene-related Often considered an indicator, howeverOften considered an indicator, however


Signs and Symptoms, Signs and Symptoms, cont’dcont’d Elevated temperatureElevated temperature—(vital signs)—(vital signs)

Elderly require > time to present with fever, may not have any Elderly require > time to present with fever, may not have any increase in temperature increase in temperature → may even be hypothermic→ may even be hypothermic

Elderly at Elderly at ↑’d risk for masked or absent fever response due to ↑’d risk for masked or absent fever response due to antipyretics, corticosteroids, chemo Rx, alcoholism, antipyretics, corticosteroids, chemo Rx, alcoholism, hypothyroidism, malnutrition and renal insufficiency hypothyroidism, malnutrition and renal insufficiency

Studies indicate fever is a marker for Studies indicate fever is a marker for seriousserious infection & most infection & most important clinical indicator for antibiotic treatmentimportant clinical indicator for antibiotic treatment

Other studies, fevers can resolve without treatment; Other studies, fevers can resolve without treatment; antibiotics did not improve outcomes in elderlyantibiotics did not improve outcomes in elderly

Not always due to UTI—consider differential diagnoses: Not always due to UTI—consider differential diagnoses: pulmonary or skin infectionspulmonary or skin infections

Lack of fever may delay diagnosis Lack of fever may delay diagnosis Midthun, 2004Midthun, 2004

Signs and Symptoms, cont’dSigns and Symptoms, cont’d

PainPainDespite limitations of assessment in the elderly, suprapubic,Despite limitations of assessment in the elderly, suprapubic,flank or CVA pain can indicate UTI flank or CVA pain can indicate UTI (abdominal, rectal & vaginal exam)(abdominal, rectal & vaginal exam)Agitation, irritability, restlessness, decreased appetite,Agitation, irritability, restlessness, decreased appetite,increased confusion, or even falls may indicate pain increased confusion, or even falls may indicate pain (Neuro & GI exam)(Neuro & GI exam)Cultural differences in interpretation of pain, symptomsCultural differences in interpretation of pain, symptoms

IncontinenceIncontinenceMay be caused by UTI or the altered mental status thatMay be caused by UTI or the altered mental status thatthat occurs with the elderly that occurs with the elderly Commonly caused by Commonly caused by other other conditions conditions Symptom and a risk factor of UTISymptom and a risk factor of UTI



Decline or Sudden Change in Mental Status Decline or Sudden Change in Mental Status

(Neuro, MMSE)(Neuro, MMSE) Hallmark symptom of UTI in elderly in most studies Hallmark symptom of UTI in elderly in most studies Altered mental status, lethargy & confusion are the most Altered mental status, lethargy & confusion are the most

common indicators of bacteremia in elderly UTIcommon indicators of bacteremia in elderly UTI

FallsFalls Not specific to UTI, but may indicate a change in status, Not specific to UTI, but may indicate a change in status,

evaluate clinical picture evaluate clinical picture

Appearance—(Appearance—(general survey) general survey) Vague assessmentVague assessment General decline in statusGeneral decline in status Listen to family and staff that know the patient wellListen to family and staff that know the patient well



Other Possible Signs & Symptoms of UTI Other Possible Signs & Symptoms of UTI Signs of sepsis other than fever or decline in M.S.Signs of sepsis other than fever or decline in M.S.

HypotensionHypotension TachycardiaTachycardia TachypneaTachypnea RalesRales Respiratory distressRespiratory distress Anorexia, nausea, vomitingAnorexia, nausea, vomiting Abdominal tenderness Abdominal tenderness


Diagnostic CriteriaDiagnostic Criteria

PyuriaPyuria A host response to infecting bacteria causing an increase of A host response to infecting bacteria causing an increase of

white blood cells or pus in the urinewhite blood cells or pus in the urine Associated with presence of both Associated with presence of both symptomaticsymptomatic and and

asymptomaticasymptomatic UTI’s in elderly UTI’s in elderly Level of pyuria is Level of pyuria is ↑ when infected with a gram negative ↑ when infected with a gram negative

organismorganism Most research finds this is so common that it has questionable Most research finds this is so common that it has questionable

value in UTI detection and as an indicator for Rx in the value in UTI detection and as an indicator for Rx in the absence of clinical symptomsabsence of clinical symptoms McGeer et al. (one of the most commonly used consensus criteria in McGeer et al. (one of the most commonly used consensus criteria in

LTCF for UTI detection in Canada) rejects it as being a LTCF for UTI detection in Canada) rejects it as being a reliablereliable predictor predictor of bacteriuria or symptomatic infectionof bacteriuria or symptomatic infection


Juthani-Mehta,, 2005Juthani-Mehta,, 2005

Screening/DiagnosisScreening/Diagnosis

Asymptomatic BacteriuriaAsymptomatic Bacteriuria

No universally accepted criteria for the No universally accepted criteria for the diagnosis, treatment, or surveillance of UTI, diagnosis, treatment, or surveillance of UTI, specifically in LTCF residentsspecifically in LTCF residents

Treatment of ASB is associated with Treatment of ASB is associated with ↑ adverse ↑ adverse antimicrobial effects, antimicrobial effects, re-infectionre-infection with organisms with organisms or increasing or increasing resistanceresistance

Nicolle, et al., 2005Nicolle, et al., 2005

Screening/DiagnosisScreening/Diagnosis

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

specimen (specimen (** important to minimize contamination) important to minimize contamination)

WomenWomen:: bacteriuria = 2 consecutive voided urine bacteriuria = 2 consecutive voided urine samples samples w/isolation of same strain in cfu/mL w/isolation of same strain in cfu/mL >100,000>100,000

MenMen:: bacteria = single, clean-catch specimen bacteria = single, clean-catch specimen with 1with 1

bacterial species isolated in bacterial species isolated in >> 100,000 100,000 cfu/mLcfu/mL

BothBoth:: single catheterized urine specimen with 1 single catheterized urine specimen with 1 bacterial bacterial species isolated in a count of species isolated in a count of >> 1,000 1,000 cfu/mLcfu/mL

Infectious Disease Society of America:Infectious Disease Society of America:Guidelines for Dx & Rx of ASB in adultsGuidelines for Dx & Rx of ASB in adults

Screening/DiagnosisScreening/DiagnosisGuidelines, continuedGuidelines, continued

2.2. Pyuria accompanying ASB not an indication for Pyuria accompanying ASB not an indication for antimicrobial Rx (A-2)antimicrobial Rx (A-2)

3.3. Pregnant women should be screened in early Pregnant women should be screened in early pregnancy, at least once & treated if positive (A-1)pregnancy, at least once & treated if positive (A-1)

4.4. Screening of ASB & Rx if positive before these Screening of ASB & Rx if positive before these urological procedures: urological procedures:

Transurethral resection of prostate (A3) Transurethral resection of prostate (A3) Procedures anticipated to cause possible mucosal Procedures anticipated to cause possible mucosal

bleeding (A-3)bleeding (A-3)

Screening/DiagnosisScreening/DiagnosisGGuidelines, continueduidelines, continued

5.5. No No screening for ASB: (A-1 & A-2 strongly recommended screening for ASB: (A-1 & A-2 strongly recommended via research evidence)via research evidence)

Pre-menopausal, non-pregnant women (A-1) Pre-menopausal, non-pregnant women (A-1) Diabetic women (A-1)Diabetic women (A-1) Community older adults (A-2)Community older adults (A-2) Institutionalized elderly (A-1)Institutionalized elderly (A-1) Spinal cord injury (A-2)Spinal cord injury (A-2) Indwelling-catheterized patients (A-1)Indwelling-catheterized patients (A-1)

6.6. Antimicrobial Rx of asymptomatic women with catheter-Antimicrobial Rx of asymptomatic women with catheter-acquired bacteriuria persisting 48 hrs after removed, should acquired bacteriuria persisting 48 hrs after removed, should be considered (B-1/good)be considered (B-1/good)

7.7. No screening or Rx of ASB No screening or Rx of ASB → renal transplant or solid → renal transplant or solid organ transplant recipients (C-3/weak)organ transplant recipients (C-3/weak)

Infectious Disease Society of America, Infectious Disease Society of America, 20052005Nicolle et al. 2005Nicolle et al. 2005

www.guideline.gov/summary/summary

http://www.guideline.gov/summary/summary

Screening/DiagnosisScreening/DiagnosisGuidelines, continuedGuidelines, continued

Guide to Clinical Preventive Services, 2005Guide to Clinical Preventive Services, 2005 Similar consensus of IDSA recommendationsSimilar consensus of IDSA recommendations Clinical considerationsClinical considerations

Dipstick analysis & direct microscopy have poor Dipstick analysis & direct microscopy have poor positive & negative predictive value for detecting ASBpositive & negative predictive value for detecting ASB

Urine culture = gold standard, but expensive for Urine culture = gold standard, but expensive for routine screening in populations of low prevalence routine screening in populations of low prevalence

New enzymatic urine screening test (UriscreenNew enzymatic urine screening test (UriscreenTMTM) ) showed 100% sensitivity & specificity of 81%showed 100% sensitivity & specificity of 81%

No clinical benefit to No clinical benefit to screenscreen individuals other than individuals other than pregnant women—did not improve clinical outcomes.pregnant women—did not improve clinical outcomes.

Guide to Clinical Preventive ServicesGuide to Clinical Preventive Services , 2005, 2005http://www.ahrq.gov/clinic/ppcletgp/geps2b.htm#bacteriaria

http://www.ahrq.gov/clinic/ppcletgp/geps2b.htm

Screening & DiagnosisScreening & DiagnosisGuideline Criteria for TreatmentGuideline Criteria for Treatment

The following are a recommended minimum set of criteria adapted from the McGeer The following are a recommended minimum set of criteria adapted from the McGeer (1991) and Loeb et al. (2001) studies necessary to initiate diagnostics and AB Rx.(1991) and Loeb et al. (2001) studies necessary to initiate diagnostics and AB Rx.

Indwelling catheter presentIndwelling catheter present: :

two of the following must be mettwo of the following must be metCatheter is not presentCatheter is not present: :

three of the following must be metthree of the following must be met

Fever (>38Fever (>38°C/100.4°F) or increase of 1.5°C °C/100.4°F) or increase of 1.5°C (2.4°F) above baseline temperature.(2.4°F) above baseline temperature.

ChillsChills New costovertebral angle tendernessNew costovertebral angle tenderness New suprapubic pain, flank pain or New suprapubic pain, flank pain or

tendernesstenderness Decreased mental or functional status Decreased mental or functional status

(delirium)(delirium) New-onset hematuria, foul-smelling urine, New-onset hematuria, foul-smelling urine,

or amount of sedimentor amount of sediment

Acute dysuria alone (key indicator) or fever Acute dysuria alone (key indicator) or fever (>38(>38°C/100.4°F) or increase of 1.5°C (2.4°F) °C/100.4°F) or increase of 1.5°C (2.4°F) above baseline temperatureabove baseline temperature

ChillsChills FrequencyFrequency UrgencyUrgency New costovertebral angle tendernessNew costovertebral angle tenderness Decreased mental or functional status (may be Decreased mental or functional status (may be

new or increased incontinence related) new or increased incontinence related) ** New-onset hematuria, foul-smelling urine or New-onset hematuria, foul-smelling urine or

(+) sediment(+) sediment New suprapubic pain, flank pain or tendernessNew suprapubic pain, flank pain or tenderness

Farms

how do cogn-impaired patients express pain?

Laboratory AnalysisLaboratory Analysis

Dipstick TestingDipstick Testing

Used in primary care & LTC settings. But for institutionalized adults, Used in primary care & LTC settings. But for institutionalized adults, urinalysis is preferable.urinalysis is preferable.

Chemically impregnated reagent strips (UA Chemstrip Screen) provideChemically impregnated reagent strips (UA Chemstrip Screen) provide preliminary/quick determinations of:preliminary/quick determinations of:

pHpH bilirubinbilirubinproteinprotein bloodbloodglucoseglucose **nitritenitriteketonesketones **leukocyte esteraseleukocyte esteraseurobilinogenurobilinogen specific gravityspecific gravity

Fischback, 2004Fischback, 2004

Fairly reliable, although U.S. Preventive Services Task Force (USPSTF) Fairly reliable, although U.S. Preventive Services Task Force (USPSTF) report from research studies these have “poor positive & negative report from research studies these have “poor positive & negative predictive value” for detecting bacteriuria in asymptomatic patients.predictive value” for detecting bacteriuria in asymptomatic patients.

www.ahrq.gov/clinic (2005)(2005)

http://www.ahrq.gov/clinic

Laboratory Analysis, continuedLaboratory Analysis, continued

Routine Urinalysis—Key Indicators of InfectionRoutine Urinalysis—Key Indicators of Infection

Urine collectionUrine collection 11stst morning specimen is best morning specimen is best

Straight catherization for those incontinent, functionally or cognitively Straight catherization for those incontinent, functionally or cognitively impairedimpaired

Specific gravitySpecific gravity Measure of kidney’s abiltiy to concentrte urineMeasure of kidney’s abiltiy to concentrte urine

Range of SG depends on state of hydrationRange of SG depends on state of hydration

AppearanceAppearance Cloudy, may not indicate WBC’sCloudy, may not indicate WBC’s

Could indicate a change in urine pH Could indicate a change in urine pH → causes precipitation→ causes precipitation

Alkaline urine → phosphates → cloudyAlkaline urine → phosphates → cloudy

Acid urine → urates → cloudyAcid urine → urates → cloudy

ColorColor Pale yellow to amberPale yellow to amber

Variations can be caused by medications, disease processes (*nl urine Variations can be caused by medications, disease processes (*nl urine darkens on standing 30 min. after voiding—oxidation of urobilinogen to darkens on standing 30 min. after voiding—oxidation of urobilinogen to urobilin)urobilin)

OdorOdor nl nl → faint odor when freshly voided→ faint odor when freshly voided

Foul-smelling—often presence of bacteria which splits urea to form Foul-smelling—often presence of bacteria which splits urea to form ammoniaammonia

Fischbach, 2004Fischbach, 2004


Routine Urinalysis, continuedRoutine Urinalysis, continued

pHpH Acid or base—measures free HAcid or base—measures free H+ + ion concentration in urine 7.0—neutral. ion concentration in urine 7.0—neutral. Indicates kidney functionIndicates kidney function

Determines if systemic acid-base disorders of metabolic/resp. originDetermines if systemic acid-base disorders of metabolic/resp. origin control of pH control of pH → manages bacteriuria, renal calculi & drug Rx→ manages bacteriuria, renal calculi & drug Rx bacteria from a UTI → produce alkaline urinebacteria from a UTI → produce alkaline urine

Blood or Blood or HemoglobinHemoglobin

Always an indicator of kidney/UT damageAlways an indicator of kidney/UT damage

Protein (Albumin)Protein (Albumin) Single most important indication of renal diseaseSingle most important indication of renal disease

MicroalbuminuriaMicroalbuminuria Below dipstick range of detectionBelow dipstick range of detection

Detects deteriorating renal function in diabetic patients (standard Detects deteriorating renal function in diabetic patients (standard screener)screener)



Routine Urinalysis, continuedRoutine Urinalysis, continued

**Nitrite (Bacteria)Nitrite (Bacteria) Dipstick - rapid, indirect method to detect bacteriaDipstick - rapid, indirect method to detect bacteria common gram-negative organisms contain enzymes common gram-negative organisms contain enzymes → reduce → reduce nitratenitrate

in urine to in urine to nitrite nitrite somesome UTI’s are caused by organisms that do UTI’s are caused by organisms that do not not convert convert nitratenitrate to to nitritenitrite

(e.g., (e.g., staphylococcus, streptococcistaphylococcus, streptococci))

**Leukocyte Leukocyte

EsteraseEsterase

Esterase is released by leukocytes (WBC’s) in urineEsterase is released by leukocytes (WBC’s) in urine

Microscopic exam & chemical testMicroscopic exam & chemical test

____________________

**U/A testing positive for nitrite & leukocyte esterase should be cultured for bacterial pathogenU/A testing positive for nitrite & leukocyte esterase should be cultured for bacterial pathogen


Urine Culture and SensitivityUrine Culture and Sensitivity

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

Bacterial identification from urine C&S, Bacterial identification from urine C&S, keykey in in males and females with males and females with complicatedcomplicated UTI’s. UTI’s.

Other Laboratory TestsOther Laboratory Tests

Complete Blood Count with DifferentialComplete Blood Count with Differential Indicated to R/O bacterial infection supports Indicated to R/O bacterial infection supports

treatment plantreatment plan Careful evaluation of WBC & differential (left shift)Careful evaluation of WBC & differential (left shift)

ElectrolytesElectrolytes R/O dehydration & if IV fluids replacement neededR/O dehydration & if IV fluids replacement needed

BUN, CreatinineBUN, Creatinine Determine ↓ renal function for nephrotoxic Determine ↓ renal function for nephrotoxic

medicationsmedications

Blood CultureBlood Culture Identify bacteremic organism in suspected urosepsisIdentify bacteremic organism in suspected urosepsis

Treatment PlanTreatment Plan Early detection/Rx Early detection/Rx → goal is to prevent systemic infection, → goal is to prevent systemic infection,

bacteremiabacteremia Initiation of antibiotic treatment is recommended for a Initiation of antibiotic treatment is recommended for a

clinicallyclinically-diagnosed UTI. Adjust medication when urine C&S -diagnosed UTI. Adjust medication when urine C&S is final is final

Selection of antibiotic must be individualized and consider:Selection of antibiotic must be individualized and consider: Side effect profileSide effect profile CostCost Bacterial resistanceBacterial resistance Likelihood of compliance (convenience, fewer pills/day ↑’s Likelihood of compliance (convenience, fewer pills/day ↑’s

compliance)compliance) Effect of impaired renal function on dosingEffect of impaired renal function on dosing Possible adverse drug reactions ↑ in elderly (multiple drugs, co-Possible adverse drug reactions ↑ in elderly (multiple drugs, co-

morbidities.morbidities.Osborne, 2004Osborne, 2004

Swart et al. 2004Swart et al. 2004

Treatment PlanTreatment PlanRecommended Treatment Regimens for Acute, Uncomplicated UTI’s in the ElderlyRecommended Treatment Regimens for Acute, Uncomplicated UTI’s in the Elderly

TreatmentTreatment Dosage/DurationDosage/Duration Bacterial Coverage/ Bacterial Coverage/ ResistanceResistance

Common Side Common Side EffectsEffects

Compliance/Compliance/ConvenienceConvenience

Cost Cost I/EI/E

MenMen WomenWomen

SulfonamideSulfonamide Trimethoprim-Trimethoprim-SulfamethoxazoleSulfamethoxazoleTMP-SMXTMP-SMX

160/800 mg po bid x 3-14160/800 mg po bid x 3-14** days days**available in a syrupavailable in a syrupIfIf CrCl <15-30 mL/min, ↓in halfCrCl <15-30 mL/min, ↓in half

((E. coli E. coli 20%) 20%) ↑ ↑ resistanceresistanceLess effectiveLess effective

nausea, rashnausea, rash Fair/GoodFair/Good

longer duration of longer duration of bid ↓ compliancebid ↓ compliance

II √√ √√

FluoroquinolonesFluoroquinolonesCiprofloxacin (2Ciprofloxacin (2ndnd gen) gen)

Levofloxacin (3Levofloxacin (3rdrd gen) gen)

100- 250 mg po bid x 3-14100- 250 mg po bid x 3-14** days daysIf CrCL <30mL/min ↓ by half If CrCL <30mL/min ↓ by half

250 mg po daily x 10 days250 mg po daily x 10 days(complicated upper and lower (complicated upper and lower UTI)UTI)

gram (-) effectivegram (-) effectivegram (+) only fairgram (+) only fair

headache, headache, dizziness, nausea, dizziness, nausea, diarrheadiarrhea

Good/GoodGood/Goodbid, longer duration bid, longer duration ↓ compliance↓ complianceExcellentExcellent

EE √√ √√

FosfomycinFosfomycin 3 g powder, dissolved in water3 g powder, dissolved in water**single dosesingle dose

gram (-) effectivegram (-) effectivegram (+) less effectivegram (+) less effective

diarrhea, vaginitis, diarrhea, vaginitis, nausea, rhinitisnausea, rhinitis

ExcellentExcellent VE, often VE, often not on not on formulariesformularies

√√ √√

NitrofurantoinNitrofurantoin(Macrobid)(Macrobid)

100 mg po bid x 7 days100 mg po bid x 7 daysIf CrCL <40 mL/minIf CrCL <40 mL/min not recommendednot recommended

Narrow spectrumNarrow spectrumgram (-) effectivegram (-) effectivegram (+) effectivegram (+) effective

nausea, vaginitis,nausea, vaginitis,diarrheadiarrhea↑ ↑ rate of severe rate of severe pulmonary & pulmonary & hepatotoxicityhepatotoxicity

FairFair7-day regimen &7-day regimen & bid, bid, ↓ compliance↓ compliance

II ProstatitisProstatitisNRNR

√√

MiscellaneousMiscellaneousBeta Lactam AB’s:Beta Lactam AB’s:Cephalosporins (Cefuroxime, cefpodoxime)Cephalosporins (Cefuroxime, cefpodoxime)Penicillins (ampicillin), Carbapenems (imipenem)Penicillins (ampicillin), Carbapenems (imipenem)Phenazopyridine (Pyridium)—not appropriate Phenazopyridine (Pyridium)—not appropriate for elderly or patients with renal insufficiencyfor elderly or patients with renal insufficiency

↑ ↑ resistance 2° Beta resistance 2° Beta Lactamase enzymes in Lactamase enzymes in resistant bacteriaresistant bacteria22ndnd/3/3rdrd gen Cephalosporins gen Cephalosporins>resistant to beta >resistant to beta lactamaselactamase

PCN-anaphylaxisPCN-anaphylaxisAbdominal cramping Abdominal cramping diarrheadiarrhea

Fair for bid dosingFair for bid dosing II ProstatitisProstatitisNRNR

√√

Data adapted from Swart et al. (2004), Osborne (2004), Wagenlehner et al. (2005), Mahan-Buttaro et al. (2006) and Evercare Corp (2004) I = inexpensive; E = expensive; VE = very expensive; NR = not recommended **Longer duration for complicated UTI per individual’s clinical statusLonger duration for complicated UTI per individual’s clinical status

Treatment PlanTreatment PlanDuration of Antibiotic Therapy: Ongoing DebateDuration of Antibiotic Therapy: Ongoing DebateResearchResearchVogel et al., 2004Vogel et al., 2004 Double-blind randomized controlled trial compared 3-and Double-blind randomized controlled trial compared 3-and

7-day courses of oral ciprofloxacin, 250mg bid.7-day courses of oral ciprofloxacin, 250mg bid.

183 elderly women 183 elderly women >> 65 yrs old. Acute, uncomplicated 65 yrs old. Acute, uncomplicated UTI.UTI.

*Outcome—bacterial eradiation @ 2 days, Rx was 98% *Outcome—bacterial eradiation @ 2 days, Rx was 98% in 3-day group; 93% in 7 day group.in 3-day group; 93% in 7 day group.

3-day course not inferior to 7 day3-day course not inferior to 7 day Better toleratedBetter tolerated Rates of relapse & re-infection 6 weeks later, both Rates of relapse & re-infection 6 weeks later, both

groups similargroups similar

Brumfitt et al./Brumfitt et al./

Stromm et al., 1980Stromm et al., 1980

Proposed long term prophylaxis of recurrent UTI—Proposed long term prophylaxis of recurrent UTI—demonstrated benefits from low dose, long term Rx with demonstrated benefits from low dose, long term Rx with nitrofurantoin macrocrystals 100 mg po at bedtime. nitrofurantoin macrocrystals 100 mg po at bedtime. There was minimal/no association w/development of There was minimal/no association w/development of resistance in susceptible strains.resistance in susceptible strains.

Treatment PlanTreatment Plan

AB Rx for at AB Rx for at leastleast 10 days for institutionalized 10 days for institutionalized

elderly, as short-term therapy may elderly, as short-term therapy may notnot be as be as

effective. effective.

Ten-14 days, if indicated, for complicated UTI.Ten-14 days, if indicated, for complicated UTI.

(recommended for males)(recommended for males)Evercare, 2004Evercare, 2004

Conventional regimen of 7-10 days duration isConventional regimen of 7-10 days duration is

usually recommended.usually recommended.Wagenlehner et al. 2005Wagenlehner et al. 2005

Treatment PlanTreatment Plan

Complicated UTIComplicated UTI Can be common in LTC patientsCan be common in LTC patients Associated with azotemia, obstruction, or indwelling foleyAssociated with azotemia, obstruction, or indwelling foley Can lead to bacteremia, life-threatening systemic infectionCan lead to bacteremia, life-threatening systemic infection

Recommended Treatment for Acute Complicated UTIRecommended Treatment for Acute Complicated UTIIV antibiotic therapy--*consider renal & hepatic elimination, IV antibiotic therapy--*consider renal & hepatic elimination, creatinine clearance for dosage adjustmentcreatinine clearance for dosage adjustment

33rdrd generation cephalosporin (Ceftriaxone = Rocephin) Rx 1 generation cephalosporin (Ceftriaxone = Rocephin) Rx 1 gram IV every 24 hoursgram IV every 24 hours

Or if fluoroquinolones (Levofloxacin = Levaquin) 250-500 mg IV Or if fluoroquinolones (Levofloxacin = Levaquin) 250-500 mg IV every 24 hoursevery 24 hours

Continue until afebrile, minimum of 48 hrs, then start oral Continue until afebrile, minimum of 48 hrs, then start oral therapy and fluids x 14 days.therapy and fluids x 14 days.

Mahan-Buttaro et al., 2006Mahan-Buttaro et al., 2006

Prevention & Treatment PlanPrevention & Treatment Plan

Recommendations/Considerations/PreventionRecommendations/Considerations/Prevention

Indwelling-CatheterizationIndwelling-CatheterizationFoley catheterization should be avoided if at all possibleFoley catheterization should be avoided if at all possible

Most effective means of UTI prevention is limitation of Most effective means of UTI prevention is limitation of chronic indwelling catheters.chronic indwelling catheters.

Wagenlehner et al. 2005Wagenlehner et al. 2005

Prevention & TreatmentPrevention & TreatmentRecommendations/Considerations/PreventionRecommendations/Considerations/Prevention

Research Research StudiesStudies

FindingsFindings

Wilde & Carrigan Wilde & Carrigan (2003)(2003)

Patients with indwelling catheters, maintaining urine flow was a key finding in Patients with indwelling catheters, maintaining urine flow was a key finding in preventing UTIpreventing UTI

Muder et al. (2006)Muder et al. (2006) Urinary catheterization is a major risk factor for Urinary catheterization is a major risk factor for S. aureusS. aureus bacteriuria in long-term bacteriuria in long-term care patientscare patients, so reducing prevalence of indwelling catheters is key. Majority of , so reducing prevalence of indwelling catheters is key. Majority of these cases are methicillin-resistant these cases are methicillin-resistant S. aureusS. aureus, which can lead to bacteremia, which can lead to bacteremia

Need for optimal infection-control measures & limit unnecessary AB admin. in LTCF.Need for optimal infection-control measures & limit unnecessary AB admin. in LTCF. Focus on urine as potential infection reservoir, may be effective preventive strategyFocus on urine as potential infection reservoir, may be effective preventive strategy

Nicolle ( 2005)Nicolle ( 2005) Study focused on catheter-related UTI.Study focused on catheter-related UTI.Catheter infection rate of 5%/dayCatheter infection rate of 5%/day**Formation of biofilm on catheters leads to infection as this protects pathogens fromFormation of biofilm on catheters leads to infection as this protects pathogens from antimicrobials & host immune responseantimicrobials & host immune response

Johnson et al (2006)Johnson et al (2006) Studied efficacy of antimicrobial urinary catheters in hospitalized patients.Studied efficacy of antimicrobial urinary catheters in hospitalized patients. prevent or delay onset of catheter-associated bacteriuriaprevent or delay onset of catheter-associated bacteriuria

Alternative Therapies in UTI PreventionAlternative Therapies in UTI Prevention

Old adage: “An ounce of prevention is worth a pound of cure.”Old adage: “An ounce of prevention is worth a pound of cure.”

CranberryCranberry ( (VacciniumVaccinium macrocarponmacrocarpon, , fruit)fruit)

Leading cranberry juice cocktail: juice Leading cranberry juice cocktail: juice sweetener, water & added Vit. Csweetener, water & added Vit. C

Central in folk medicine beneficial effects on urinary Central in folk medicine beneficial effects on urinary tract health.tract health.

Longstanding Rx for UTI prophylaxisLongstanding Rx for UTI prophylaxis

Well-tolerated, key factor with older adultsWell-tolerated, key factor with older adults

MechanismMechanism Cranberry prevents bacterial (Cranberry prevents bacterial (E. coliE. coli & other gram- & other gram-negative uropathogens) binding to host cell surface negative uropathogens) binding to host cell surface membranesmembranes

19841984—Sobota demonstrated a mode of action in —Sobota demonstrated a mode of action in cranberry juice that interferes with the adherence of cranberry juice that interferes with the adherence of E. coliE. coli and other bacteria to uroepithelial cells and other bacteria to uroepithelial cells

Scientific RationaleScientific Rationale E. coli E. coli & other bacteria have different types of & other bacteria have different types of adhesins on their adhesins on their fimbriae fimbriae that allow the organism that allow the organism to adhere to epithelial cells & proliferate. to adhere to epithelial cells & proliferate. Cranberries unique compound, proanthocyanidins Cranberries unique compound, proanthocyanidins (PAC’s) adhesins inhibit this process(PAC’s) adhesins inhibit this process

Prevention & TreatmentPrevention & TreatmentRecommendations/Considerations/PreventionRecommendations/Considerations/Prevention

Post-menopausal women w/recurrent infection may Post-menopausal women w/recurrent infection may require estrogen replacement to restore atrophic require estrogen replacement to restore atrophic vaginal mucosa, vaginal mucosa, ↓ vaginal pH (topical creams)↓ vaginal pH (topical creams)

Always adjust antibiotic dosage for renal Always adjust antibiotic dosage for renal impairment/insufficiency using the Cockcroft-Gault impairment/insufficiency using the Cockcroft-Gault equation:equation:

(140-Age) x weight in Kg (0.85 if female)(140-Age) x weight in Kg (0.85 if female)

72 x serum creatinine 72 x serum creatinine http://www.fhea.com/op/ch14.htm

Ensure adequate hydrationEnsure adequate hydration Recommended 2.5 L/day in patients with recurrent UTIRecommended 2.5 L/day in patients with recurrent UTI Often signs & symptoms similar to UTI in elderly are actually Often signs & symptoms similar to UTI in elderly are actually

caused by dehydrationcaused by dehydration

X

http://www.fhea.com/op/ch14.htm

Alternative Therapies for Prevention Alternative Therapies for Prevention Cranberry juice, dried cranberries, raisinsCranberry juice, dried cranberries, raisins

Research StudiesResearch Studies Findings/EvidenceFindings/Evidence

Greenberg et al. (2005)Greenberg et al. (2005) Boston pilot-study on 5 subjects. Boston pilot-study on 5 subjects. Some evidence of anti-adherence activity using dried cranberry Some evidence of anti-adherence activity using dried cranberry consumption.consumption.Raisins—none Raisins—none Small studySmall study

Jepson et al (2004)Jepson et al (2004) Cochrane Database 2004 Reviews—Cochrane Database 2004 Reviews—Some evidence from RCT’s to show cranberries (juice & capsules) can Some evidence from RCT’s to show cranberries (juice & capsules) can prevent prevent recurrent infections in women (especially older women). No recurrent infections in women (especially older women). No significant difference between juice or capsules. Safe & well-toleratedsignificant difference between juice or capsules. Safe & well-tolerated

McHarg et al. (2005)McHarg et al. (2005) May alter or even prevent formation of calcium oxalate kidney stones vs. May alter or even prevent formation of calcium oxalate kidney stones vs. just water consumption (upper UT)just water consumption (upper UT)

Multiple studiesMultiple studies Pilot, double-blind crossover design, prospective, RCT’s.Pilot, double-blind crossover design, prospective, RCT’s. All support a moderately All support a moderately preventive preventive role for cranberry juice or capsule role for cranberry juice or capsule

concentrates against UTIconcentrates against UTI No significant findings or support inNo significant findings or support in treatment treatment of bacteriuria of bacteriuria

Key Points in Cranberry Therapy, cont’dKey Points in Cranberry Therapy, cont’d

InteractionsInteractions No significant herb-drug reactions reportedNo significant herb-drug reactions reported

DosageDosage Varies. Cranberry extract tablets/capsules: 1 tablet (300-Varies. Cranberry extract tablets/capsules: 1 tablet (300-400mg) twice daily. CranMax—500mg once daily (potent 400mg) twice daily. CranMax—500mg once daily (potent cranberry supplement)cranberry supplement)

CostCost Tablets: $10-$15/30-day supplyTablets: $10-$15/30-day supply

Unsweetened juice: variesUnsweetened juice: varies

**Safe botanical alternative, effective in UTI prophylaxisSafe botanical alternative, effective in UTI prophylaxis

Other Alternative Therapies in UTI ManagementOther Alternative Therapies in UTI ManagementGrapefruit SeedsGrapefruit Seeds Case study by Oyelami et al (2005)—4 middle-aged patients Case study by Oyelami et al (2005)—4 middle-aged patients

treated w/seeds x 2 weeks upon dx of UTI.treated w/seeds x 2 weeks upon dx of UTI.

Concluded: adequate clinical responseConcluded: adequate clinical response

5-6 seeds every 8 hrs comparable to antibacterials5-6 seeds every 8 hrs comparable to antibacterials

Oral LactuloseOral Lactulose May reduce rate of UTIs in elderly.May reduce rate of UTIs in elderly.

Possible mechanism: increase in fecal Possible mechanism: increase in fecal LactobacillusLactobacillus organisms organisms & avoidance of constipation& avoidance of constipation

Urinary Tract Infections in the Elderly:Urinary Tract Infections in the Elderly:Guidelines for Assessment, Diagnosis, Treatment and Guidelines for Assessment, Diagnosis, Treatment and

PreventionPrevention

AssessmentAssessment Key DeterminantsKey Determinants EvaluationEvaluation

Past medical historyPast medical history

Personal & Social Personal & Social historyhistory

Age-related changes and risk factorsAge-related changes and risk factors

Co-morbidities (diabetes, cancer, GU Co-morbidities (diabetes, cancer, GU dx)dx)

PregnanciesPregnancies

Urological & gynecological proceduresUrological & gynecological procedures

History of UTI, recurrent UTIHistory of UTI, recurrent UTI

Medication/allergiesMedication/allergies

Cultural S&S interpretationCultural S&S interpretation

Indwelling catheter present (2 S&S)Indwelling catheter present (2 S&S):: Fever (>38Fever (>38°C/100.4°F) or increase of 1.5°C (2.4°F) above °C/100.4°F) or increase of 1.5°C (2.4°F) above

baseline temperature.baseline temperature. ChillsChills New CVA tendernessNew CVA tenderness New suprapubic/flank pain or tendernessNew suprapubic/flank pain or tenderness Decreased mental or functional status (delirium)Decreased mental or functional status (delirium) New-onset hematuria, foul-smelling urine, or (+) sedimentNew-onset hematuria, foul-smelling urine, or (+) sediment

Catheter is not present (3 S&S)Catheter is not present (3 S&S):: Acute dysuria alone (key indicator) or fever (>38Acute dysuria alone (key indicator) or fever (>38°C/100.4°F)°C/100.4°F)

or increase of 1.5°C (2.4°F) above baseline temperatureor increase of 1.5°C (2.4°F) above baseline temperature ChillsChills FrequencyFrequency Urgency Urgency New costovertebral angle tendernessNew costovertebral angle tenderness Decreased mental or functional status (may be new or Decreased mental or functional status (may be new or

increased incontinence related) *increased incontinence related) * New-onset hematuria, foul-smelling urine or (+) sedimentNew-onset hematuria, foul-smelling urine or (+) sediment New suprapubic/flank pain or tendernessNew suprapubic/flank pain or tenderness

Review of SystemsReview of Systems

Physical Physical ExaminationExamination

**General appearanceGeneral appearance

Skin/hydrationSkin/hydration

**Fever, vital signsFever, vital signs

Cardiac-Cardiac-↑BP, AP, arrhythmias↑BP, AP, arrhythmias

Pulmonary-lung sounds, DOEPulmonary-lung sounds, DOE

**CVA tendernessCVA tenderness

Appetite, Appetite, **abdominal pain, bowel abdominal pain, bowel patternpattern

**Urine—color, character, odor, catheter, Urine—color, character, odor, catheter,

continence changes, dysuriacontinence changes, dysuria

**Mental status—cognition, memory,Mental status—cognition, memory,

reporting reliability, declinereporting reliability, decline, , ↑ ↑ confusion, agitation/restlessnessconfusion, agitation/restlessness

UTI in the Elderly: Guidelines—Diagnosis, Treatment & Prevention UTI in the Elderly: Guidelines—Diagnosis, Treatment & Prevention

Clinical PlanClinical Plan Key DeterminantsKey Determinants RationaleRationale

UrinalysisUrinalysis

Lab urinalysis Lab urinalysis w/microscopic examw/microscopic exam

Indirect dipstick U/A for bacteriuria (+) nitriteIndirect dipstick U/A for bacteriuria (+) nitrite

Leukocyte esteraseLeukocyte esterase

Pyuria—WBC’s in urinePyuria—WBC’s in urine

Useful for screening asymptomatic individualsUseful for screening asymptomatic individualsR/o’s urinary source of infection/less reliable R/o’s urinary source of infection/less reliable Indicates inflammatory response, not used as Indicates inflammatory response, not used as

indicator to treat ASBindicator to treat ASBPyuria alone not specific for infectionPyuria alone not specific for infection

Urine C&SUrine C&S Identifies organisms in urine and antimicrobial Identifies organisms in urine and antimicrobial sensitivitysensitivity

Organisms count must be sufficient to r/o contaminationOrganisms count must be sufficient to r/o contamination

Identify antimicrobial effective against organismIdentify antimicrobial effective against organism

CBC w/DiffCBC w/DiffEvaluate WBC & DiffEvaluate WBC & Diff

ElectrolytesElectrolytes

BUN, CrBUN, Cr

Blood cultureBlood culture

Suspect bacterial infectionSuspect bacterial infectionElevated WBC with left shiftElevated WBC with left shift

Current statusCurrent status

Current renal statusCurrent renal status

Identify organism in suspected bacteremiaIdentify organism in suspected bacteremia

To support treatment decisionTo support treatment decision

R/o dehydration, ? need for fluid replacementR/o dehydration, ? need for fluid replacement

Baseline for nephrotoxic medsBaseline for nephrotoxic meds

Documents urosepsisDocuments urosepsisAB Rx determinationAB Rx determination

Treatment Treatment **See guidelines for empirical RxSee guidelines for empirical Rx Other supports:Other supports: hydration/fluid replacement/IV therapyhydration/fluid replacement/IV therapy fever—treat if presentfever—treat if present pain, discomfort—relieve symptomspain, discomfort—relieve symptoms

Asymptomatic bacteriuriaAsymptomatic bacteriuriaRx not indicated due to risk of AB resistanceRx not indicated due to risk of AB resistance

Confirm with 2Confirm with 2ndnd urine specimen urine specimen

Monitor clinical status, assess for contributing factors, urinary Monitor clinical status, assess for contributing factors, urinary incontinenceincontinence

Calculate CrCl:Calculate CrCl: (140-Age) x weight in Kg (0.85 if female) (140-Age) x weight in Kg (0.85 if female)

72 x serum creatinine72 x serum creatinine

Prevention StrategiesPrevention Strategies cranberry extract tablets, 300-400 mg po bid and/or juice, cranberry extract tablets, 300-400 mg po bid and/or juice,

minimum of 240 mL/dayminimum of 240 mL/day ensure hydration of 2.5 L/dayensure hydration of 2.5 L/day strict hand and perineal hygiene strict hand and perineal hygiene Staff ed r/t early detection of UTI S&SStaff ed r/t early detection of UTI S&S

GNP ImplicationsGNP Implications

Overuse of antibiotics is problematic in UTI management Overuse of antibiotics is problematic in UTI management in elderlyin elderly

Careful individualized assessment & evaluation of elder. Careful individualized assessment & evaluation of elder. Must consider differential diagnoses before treatment, Must consider differential diagnoses before treatment, even when urine culture is positive. even when urine culture is positive.

Identification of subtle, atypical symptoms of UTI is Identification of subtle, atypical symptoms of UTI is critical. Listen to family and staffcritical. Listen to family and staff

UTI most common nosocomial infection in LTCF’s. UTI most common nosocomial infection in LTCF’s. Opportunity to educate staff and implement preventative Opportunity to educate staff and implement preventative measures to measures to ↓ incidence. ↓ incidence.

Lack of consensus criteria related to UTI management in Lack of consensus criteria related to UTI management in elderly emphasizes need for further research in urinary elderly emphasizes need for further research in urinary health promotion. health promotion. BeBe proactive!proactive!