Urinary Tract Infection

(Infeksi Saluran Kemih)

dr. Sahala Panggabean, Sp.PD-KGH
Departement of Internal Medicine
FK UKI
May 11, 2011
 Learning Objectives:
After this lectures, participants will be able to:
• Define Urinary Tract Infection
• Recognize Symptoms and Signs of UTI
• Diagnose UTI
• Recognize the Etilogies of UTI
• Recognize the Risk Factors of UTI
• Plan the Tretment of UTI
• Plan the Prevention of UT I
• Understand the Terminologies in relation to UTI
 Introduction and Definition
• Urinary Rract Infection (UTI) is the presence and multiplication of
antimicrobial pathogens within the normally sterile urinery tract.

• UTI can be limited to the bladder (cystitis) can be painful and

annoying. But serious consequences can occur if the infection
spreads to the kidneys (acute pyelonephritis).

• Women are most at risk of developing a UTI. About half of all

women will develop an UTI episode during their lifetimes, and
many will experience more than once.

• UTI is the second most common type of infection in human,

accounts for 8.3 million doctor visits per year.
 Anatomic categoties of UTI

UTI can be subdivided into two general anatomic categories:

1. Lower Tract Infections ( Urethritis and Cystitis )

2. Upper Tract Infection ( Acute Pyelonephritis,
Intrarenal and Perinephric abscesses).
 Types UTI
UTI usually develop first in the lower urinary tract (urethra,
bladder) and, if not treated, progress to the upper urinary
tract (ureters, kidneys).
• Bladder infection (cystitis) is by far the most common UTI.
• Infection of the urethra is called urethritis.
• Kidney infection (pyelonephritis) requires urgent treatment
and can lead to reduced kidney function and possibly even
death in untreated due to septicemia in severe cases.
 Epidemiologic categories of UTI
Epidemiologically UTI’s are sub divided into:
1. Cathether-associated or nosocomial infections
2. Community-aquired infections
Acute community-aquired infections are very common and
account for more than 7 million office visits annually.
Asymptomatic bacteriuria is more common among elderly men and
women.
The Urinary Tract
Bacterial Etiology of UTI
 Pathogenesis of UTI
• The urinary tract can be infected from below, bacteria
entering the urethra and trevelling upwords (ascending
infection).
• Some UTI ocuurs by bacteria entering the kidneys from the
bloodstream (hematogen spread).
• Infection from hematogen spreads are most often seen in
newborns with sepsis and immunocompromized older
patients.
• In older children and adults infection most often starts from
below (ascending infection)
 Pathogenesis ascending infection
• In many cases, bacteria first travel to the urethra from the
perineum. Bacteria multiply and infection can occur.
Infection limited to the urethra is called urethritis.

• If bacteria move to the bladder and multiply, a bladder

infection or cystitis results.

• If the infection is not treated promptly, bacteria may then

travel further up the ureters to multiply and infect the kidneys
result in kidney infection is called acute pyelonephritis.
 Risk Factors for UTI
• A woman's urethra is shorter than a man's, which is one reason why women are
much more likely than men to get UTI's.
• For many women, sexual intercourse seems to trigger an infection.
• Any abnormality of the urinary tract that obstructs the flow of urine;
kidney stones for example sets the stage for an infection.
• Enlarged prostate gland also can slow the flow of urine, thus raising the risk of
infection.
• Common source of infection is catheters, or tubes, placed in the urethra and
bladder.
• People with diabetes have a higher risk of a UTI because of changes in the immune
system.
• According to some reports, about 2 to 4 percent of pregnant women develop a
urinary infection
 Risk Factors for UTI
Conditions affecting Pathogenesis
• Gender and sexual activity
• Pregnancy
• Obstruction
• Neurogenic Bladder Dysfunction
• Vesicoureteral Reflux
• Bacterial Virulence Factors
• Genetic Factors
 Signs and Symptoms in adults
Older children or an adult may experience the following
symptoms with UTI:
– Flank or lower back pain (with a kidney infection)
– Frequent urination
– Inability to produce more than a small amount of urine
at a time
– Incontinensia urinae
– Pain in the pelvic area
– Painful urination (dysuria)
– Cloudy urine or with unusual smell
 Clinical Presentations
Cystitis
• Patients with cystitis usually report dysuria,
frequency, urgency, and suprapubic pain.
• The urine often becomes grossly cloudy and
malodorous, and it is bloody in 30% of cases.
• Physical examination generally reveals only
tenderness of the suprapubic area.
 Clinical Presentations
Acute Pyelonephritis
• Symptoms of acute pyelonephritis generally
develop rapidly over a few hours or a day and
include a fever, shaking chills, nausea, vomiting, and
diarrhea. Besides fever, tachycardia, and generalized
muscle tenderness.
• Physical examination reveals marked tenderness on
deep pressure in one or both costovertebral angles
or on deep abdominal palpation.
 Clinical Presentations
Urethritis

• Approximately 30% of women with acute dysuria,

frequency, and pyuria have midstream urine cultures that
show either no growth or insignificant bacterial growth.

• In this situation, a distinction should be made between

women infected with sexually transmitted pathogens, such
as C. trachomatis, N. gonorrhoeae, or herpes simplex virus,
and those with low-count E. coli or staphylococcal infection
of the urethra and bladder.
 Complications of UTI
• The most serious consern in a UTI is if to avoid its
progress to acute pyelonephritis.

• This can result in scarring and damage to the kidney

tissue and Sepsis

• Fortunately acute uncomplicated pyelonephritis in

adults rarely progresses to renal functional
impairment and chronic renal disease.
 Diagnostic Testing
• Proteinuria, pyuria, hematuria microskopis and/or
macroskopis are ususally found in urinalysis. Glomerular
cast is a sign for kidney infection (pyelonephritis)
• Determination of the number and type of bacteria in the
urine with the urine culture is an important diagnostic
procedure.
• Microscopic bacteriuria which is best assessed with Gram-
stained urine seiment, is found in 90% of specimens from
patients whose infections are associated with colony
counts of at least 105/mL, and this finding is very specific.
• Urine culture and antimicrobial susceptibility testing.
• Ultrasound exam to look for stones and obstruction.
• BNO – IVP to look for structural abnormality.
 TREATMENT-1
• Severely ill patients with vomiting should
be hospitalized and given the IVFD until
they can take fluids and drugs orally.

• Drinking plenty of water helps cleanse

the urinary tract of bacteria.
 TREATMENT-2
Following principles underlie the treatment of UTIs:
• Except in acute uncomplicated cystitis in women,
quantitative urine culture should be oredered to
confirm infection before empirical treatment is
begun.
• When culture results become available,
antimicrobial sensitivity testing should be used to
further direct therapy.
• Factors predisposing to infection, such as
obstruction and calculi, should be identified and
corrected if possible.
 Treatment-3
Oral regimen for acute uncomplicated cystitis:
 Treatment-4
Parenteral regimens for acute uncomplicated and
complicated UTI
 PREVENTIONS-1
• Women who experience frequent symptomatic UTIs (3 per
year on average) are candidates for long-term administration
of low-dose antibiotics directed at preventing recurrences.
• Such women should be advised to avoid spermicide use and
to void soon after intercourse. Daily or thrice-weekly
administration of a single dose of TMP-SMX (80/400 mg).
• Prophylaxis should be initiated only after bacteriuria has been
eradicated with a full-dose treatment regimen.
• All pregnant women should be screened for bacteriuria in the
first trimester and should be treated if bacteriuria is
demonstrated.
 Preventions-2
• Drink plenty of liquids, especially water.
• Wipe from front to back. Doing so after urinating
and after a bowel movement helps prevent bacteria
in the perineum from spreading to the vagina and
urethra.
• Voiding as soon as possible after intercourse
• Avoid potentially irritating feminine products.
 References:
• Thomas Hooton: Urinary Tract Infection in Adults.
In Richard Johnson and John Feehally (eds.):
Comprehensive Clinical Nephrology. Mosby, New York,
2nd.ed. 2003; 695-729.

• Lindsay Nicole: Urinary Tract Infection.

In: Arthur Greenberg (Ed.) Primer on Kidney Diseases.
National Kidney Foundation, 4th.ed. 2005; 411-417.