Term of Reference (TOR) Workshop

Rasionalisasi Penggunaan Antibiotik di RSUD AWS

HOW TO MANAGE:
URINARY TRACT INFECTION
Ricky Agave Ompusunggu
DEFINITIONS
DEFINITIONS
➤ UTI: inflammatory response of urothelium to bacterial
invasion that usually associated with bacteriuria or pyuria.
DEFINITIONS
➤ UTI: inflammatory response of urothelium to bacterial
invasion that usually associated with bacteriuria or pyuria.

presence of bacteria in the urine,

which is normally free of bacteria.
Asymptomatic bacteuria (ABU)
Symptomatic bacteuria
DEFINITIONS
➤ UTI: inflammatory response of urothelium to bacterial
invasion that usually associated with bacteriuria or pyuria.
DEFINITIONS
➤ UTI: inflammatory response of urothelium to bacterial
invasion that usually associated with bacteriuria or pyuria.

presence of white blood cells

(WBCs) in the urine, is generally
indicative of infection and/or an
inflammatory response of the
urothelium to the bacterium,
stones, or other indwelling foreign
body
DEFINITIONS
➤ UTI: inflammatory response of urothelium to bacterial
invasion that usually associated with bacteriuria or pyuria.

IMPORTANT!!!
Bacteriuria without pyuria = bacterial colonization without infection of the urinary tract.
Pyuria without bacteriuria = evaluation for tuberculosis, stones, or cancer
DEFINITIONS
➤ UTI: inflammatory response of urothelium to bacterial
invasion that usually associated with bacteriuria or pyuria.
DEFINITIONS

➤ Define by anatomical site: cystitis, pyelonephritis

DEFINITIONS

➤ Define by terms of the anatomic or functional status of the

urinary tract and the health of the host :
➤ UNCOMPLICATED
➤ COMPLICATED
DEFINITIONS

➤ COMPLICATED
DEFINITIONS
DEFINITIONS
DEFINITIONS
➤ European Association of Urology (EAU)
DEFINITIONS
➤ European Association of Urology (EAU)
DEFINITIONS
➤ European Association of Urology (EAU)
ASYMPTOMATIC BACTERIURIA (ABU)
ASYMPTOMATIC BACTERIURIA (ABU)
➤ Bacteria +, but ASYMPTOMATIC
ASYMPTOMATIC BACTERIURIA (ABU)
➤ Bacteria +, but ASYMPTOMATIC
➤ Mid-stream sample of urine, bacterial growth ≥ 105 cfu/mL in
TWO consecutive samples in women and in ONE single
sample in men
ASYMPTOMATIC BACTERIURIA (ABU)
➤ Bacteria +, but ASYMPTOMATIC
➤ Mid-stream sample of urine, bacterial growth ≥ 105 cfu/mL in
TWO consecutive samples in women and in ONE single
sample in men
➤ ABU may protect against superinfecting symptomatic UTI
ASYMPTOMATIC BACTERIURIA (ABU)
➤ Bacteria +, but ASYMPTOMATIC
➤ Mid-stream sample of urine, bacterial growth ≥ 105 cfu/mL in
TWO consecutive samples in women and in ONE single
sample in men
➤ ABU may protect against superinfecting symptomatic UTI
➤ Treatment of ABU should be performed only in cases of
proven benefit for the patient to avoid the risk of selecting
antimicrobial resistance and eradicating a potentially
protective ABU strain
ASYMPTOMATIC BACTERIURIA (ABU)
ASYMPTOMATIC BACTERIURIA (ABU)

What is the most effective

management for people with
asymptomatic bacteriuria?
ASYMPTOMATIC BACTERIURIA (ABU)
UNCOMPLICATED UTI
UNCOMPLICATED UTI
➤ Uncomplicated cystitis
UNCOMPLICATED UTI
➤ Uncomplicated cystitis
➤ acute, sporadic or recurrent cystitis LIMITED to non-
pregnant women, pre-menopausal women with no
known relevant anatomical and functional abnormalities
within the urinary tract or comorbidities
UNCOMPLICATED UTI
➤ Uncomplicated cystitis
➤ acute, sporadic or recurrent cystitis LIMITED to non-
pregnant women, pre-menopausal women with no
known relevant anatomical and functional abnormalities
within the urinary tract or comorbidities
➤ Risk factors: sexual intercourse, use of spermicide, new
sexual partner, a mother with a history of UTI and a history
of UTI during childhood.
UNCOMPLICATED UTI
➤ Uncomplicated cystitis
➤ acute, sporadic or recurrent cystitis LIMITED to non-
pregnant women, pre-menopausal women with no
known relevant anatomical and functional abnormalities
within the urinary tract or comorbidities
➤ Risk factors: sexual intercourse, use of spermicide, new
sexual partner, a mother with a history of UTI and a history
of UTI during childhood.
➤ Most common causative agent: E.coli, followed by
Staphylococcus saprophyticus, Klebsiella pneumoniae and
P. mirabilis
UNCOMPLICATED UTI
UNCOMPLICATED UTI (CYSTITIS CONT.)
UNCOMPLICATED UTI (CYSTITIS CONT.)
UNCOMPLICATED UTI (CYSTITIS CONT.)
UNCOMPLICATED UTI (CYSTITIS CONT.)
➤ Suggested regimens for antimicrobial therapy in
uncomplicated cystitis
UNCOMPLICATED UTI (CYSTITIS CONT.)
UNCOMPLICATED UTI
UNCOMPLICATED UTI
➤ Uncomplicated pyelonephritis
UNCOMPLICATED UTI
➤ Uncomplicated pyelonephritis
➤ fever (> 38°C), chills, flank pain, nausea, vomiting, or
costovertebral angle tenderness, with or without the typical
symptoms of cystitis
UNCOMPLICATED UTI
➤ Uncomplicated pyelonephritis
➤ fever (> 38°C), chills, flank pain, nausea, vomiting, or
costovertebral angle tenderness, with or without the typical
symptoms of cystitis
➤ vital to differentiate as soon as possible between
uncomplicated and complicated mostly obstructive
pyelonephritis.
UNCOMPLICATED UTI
➤ Uncomplicated pyelonephritis
➤ fever (> 38°C), chills, flank pain, nausea, vomiting, or
costovertebral angle tenderness, with or without the typical
symptoms of cystitis
➤ vital to differentiate as soon as possible between
uncomplicated and complicated mostly obstructive
pyelonephritis.
➤ Urinalysis and urine culture mandatory
UNCOMPLICATED UTI
➤ Uncomplicated pyelonephritis
➤ fever (> 38°C), chills, flank pain, nausea, vomiting, or
costovertebral angle tenderness, with or without the typical
symptoms of cystitis
➤ vital to differentiate as soon as possible between
uncomplicated and complicated mostly obstructive
pyelonephritis.
➤ Urinalysis and urine culture mandatory
➤ Imaging: USG, CT or excretory urography if febrile >72 hrs
after Tx.
UNCOMPLICATED UTI
UNCOMPLICATED UTI (PYELONEPHRITIS CONT.)
UNCOMPLICATED UTI (PYELONEPHRITIS CONT.)
➤ Suggested regimens for empirical ORAL antimicrobial therapy
in uncomplicated pyelonephritis
UNCOMPLICATED UTI (PYELONEPHRITIS CONT.)
UNCOMPLICATED UTI (PYELONEPHRITIS CONT.)
➤ S u g g e s t e d r e g i m e n s f o r e m p i r i c a l PA R E N T E R A L
antimicrobial therapy in uncomplicated pyelonephritis
COMPLICATED UTI
COMPLICATED UTI
➤ Occurs in an individual in whom factors related to the host or
specific anatomical or functional abnormalities related to the
urinary tract.
COMPLICATED UTI
➤ Occurs in an individual in whom factors related to the host or
specific anatomical or functional abnormalities related to the
urinary tract.
COMPLICATED UTI
➤ Occurs in an individual in whom factors related to the host or
specific anatomical or functional abnormalities related to the
urinary tract.
➤ Dysuria, urgency, frequency, flank pain, costovertebral angle
tenderness, suprapubic pain and fever. BUT, ALL OF THESE
SYMPTOMS NOT ONLY CAUSED BY UTI
COMPLICATED UTI
➤ Occurs in an individual in whom factors related to the host or
specific anatomical or functional abnormalities related to the
urinary tract.
➤ Dysuria, urgency, frequency, flank pain, costovertebral angle
tenderness, suprapubic pain and fever. BUT, ALL OF THESE
SYMPTOMS NOT ONLY CAUSED BY UTI
➤ Urine culture !!! E. coli (60-75%), Proteus spp., Klebsiella
spp., Pseudomonas spp., Serratia spp. and Enterococcus spp.
are the most common species found in cultures
COMPLICATED UTI
COMPLICATED UTI (CONT.)
COMPLICATED UTI (CONT.)
➤ Principles of Tx:
COMPLICATED UTI (CONT.)
➤ Principles of Tx:
➤ Appropriate management of underlying factors.
COMPLICATED UTI (CONT.)
➤ Principles of Tx:
➤ Appropriate management of underlying factors.
➤ Optimal antimicrobial Tx: severity of illness, local
resistance patterns, host factors, result of urine culture.
COMPLICATED UTI (CONT.)
➤ Principles of Tx:
➤ Appropriate management of underlying factors.
➤ Optimal antimicrobial Tx: severity of illness, local
resistance patterns, host factors, result of urine culture.
CATHETER ASSOCIATED UTI
CATHETER ASSOCIATED UTI
➤ UTIs occurring in a person whose urinary tract is currently
catheterised or has been catheterised within the past 48 hours
CATHETER ASSOCIATED UTI
➤ UTIs occurring in a person whose urinary tract is currently
catheterised or has been catheterised within the past 48 hours
➤ Urine culture: microbial growth of ≥ 103 cfu/mL of one or
more bacterial species in a single catheter urine specimen or
in a mid-stream voided urine specimen from a patient whose
urethral, suprapubic, or condom catheter has been removed
within the previous 48 hours
CATHETER ASSOCIATED UTI
➤ UTIs occurring in a person whose urinary tract is currently
catheterised or has been catheterised within the past 48 hours
➤ Urine culture: microbial growth of ≥ 103 cfu/mL of one or
more bacterial species in a single catheter urine specimen or
in a mid-stream voided urine specimen from a patient whose
urethral, suprapubic, or condom catheter has been removed
within the previous 48 hours
CATHETER ASSOCIATED UTI (CONT.)
CATHETER ASSOCIATED UTI (CONT.)
URETHRITIS
URETHRITIS
URETHRITIS (CONT.)
URETHRITIS (CONT.)
➤ Suggested regimens for antimicrobial therapy for urethritis
EPIDIDYMITIS-ORCHITIS
 EPIDIDYMITIS-ORCHITIS
➤ TESTICULAR TORSION!!!
EPIDIDYMITIS-ORCHITIS (CONT.)
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
➤ A fluoroquinolone active against C. trachomatis orally once daily for ten to
fourteen days. OR
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
➤ A fluoroquinolone active against C. trachomatis orally once daily for ten to
fourteen days. OR
➤ Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for
ten to fourteen days plus an antibiotic active against Enterobacteriaceae
for ten to fourteen days
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
➤ A fluoroquinolone active against C. trachomatis orally once daily for ten to
fourteen days. OR
➤ Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for
ten to fourteen days plus an antibiotic active against Enterobacteriaceae
for ten to fourteen days
➤ likely gonorrhoeal
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
➤ A fluoroquinolone active against C. trachomatis orally once daily for ten to
fourteen days. OR
➤ Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for
ten to fourteen days plus an antibiotic active against Enterobacteriaceae
for ten to fourteen days
➤ likely gonorrhoeal
➤ Ceftriaxone 500 mg intramuscularly single dose plus Doxycycline 200 mg
initial dose by mouth and then 100 mg twice daily for ten to fourteen days
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
➤ A fluoroquinolone active against C. trachomatis orally once daily for ten to
fourteen days. OR
➤ Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for
ten to fourteen days plus an antibiotic active against Enterobacteriaceae
for ten to fourteen days
➤ likely gonorrhoeal
➤ Ceftriaxone 500 mg intramuscularly single dose plus Doxycycline 200 mg
initial dose by mouth and then 100 mg twice daily for ten to fourteen days
➤ non-sexually active men
 EPIDIDYMITIS-ORCHITIS (CONT.)
➤ Empiric antibiotic regimens
➤ low risk of gonorrhoea (e.g. no discharge)
➤ A fluoroquinolone active against C. trachomatis orally once daily for ten to
fourteen days. OR
➤ Doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for
ten to fourteen days plus an antibiotic active against Enterobacteriaceae
for ten to fourteen days
➤ likely gonorrhoeal
➤ Ceftriaxone 500 mg intramuscularly single dose plus Doxycycline 200 mg
initial dose by mouth and then 100 mg twice daily for ten to fourteen days
➤ non-sexually active men
➤ Appropriate option is a fluoroquinolone by mouth once daily for ten to
fourteen days
REFERENCES
➤ Bonkat et al.(2019). EAU Guidelines on Urological Infections.
Arnheim: The EAU Guidelines Office.
➤ Campbell-Walsh Urology 11th Ed.