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    Kasus

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    angelica glory
    A 55-year-old female patient presented to the clinic with frequent urination but feeling of incomplete emptying. She has a history of similar complaints in the past that resolved spontaneously. She has diabetes for 7 years. On examination, she had suprapubic tenderness. The likely diagnosis is a urinary tract infection based on her symptoms and examination findings. A urinalysis would be needed to confirm the diagnosis and detect any signs of infection like white blood cells or bacteria. Culture of the urine sample would also be required to identify the causative organism and perform antibiotic sensitivity testing to guide treatment. The patient would be treated with antibiotics based on the diagnosis and results of the tests.

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    Kasus

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    angelica glory
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    A 55-year-old female patient presented to the clinic with frequent urination but feeling of incomplete emptying. She has a history of similar complaints in the past that resolved spontaneously. She has diabetes for 7 years. On examination, she had suprapubic tenderness. The likely diagnosis is a urinary tract infection based on her symptoms and examination findings. A urinalysis would be needed to confirm the diagnosis and detect any signs of infection like white blood cells or bacteria. Culture of the urine sample would also be required to identify the causative organism and perform antibiotic sensitivity testing to guide treatment. The patient would be treated with antibiotics based on the diagnosis and results of the tests.

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    A 55-year-old female patient presented to the clinic with frequent urination but feeling of incomplete emptying. She has a history of similar complaints in the past that resolved spontaneously. She has diabetes for 7 years. On examination, she had suprapubic tenderness. The likely diagnosis is a urinary tract infection based on her symptoms and examination findings. A urinalysis would be needed to confirm the diagnosis and detect any signs of infection like white blood cells or bacteria. Culture of the urine sample would also be required to identify the causative organism and perform antibiotic sensitivity testing to guide treatment. The patient would be treated with antibiotics based on the diagnosis and results of the tests.

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    22 views38 pages

    Kasus

    Uploaded by

    angelica glory
    A 55-year-old female patient presented to the clinic with frequent urination but feeling of incomplete emptying. She has a history of similar complaints in the past that resolved spontaneously. She has diabetes for 7 years. On examination, she had suprapubic tenderness. The likely diagnosis is a urinary tract infection based on her symptoms and examination findings. A urinalysis would be needed to confirm the diagnosis and detect any signs of infection like white blood cells or bacteria. Culture of the urine sample would also be required to identify the causative organism and perform antibiotic sensitivity testing to guide treatment. The patient would be treated with antibiotics based on the diagnosis and results of the tests.

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    Kasus:

    • Seorang ♀ 55 thn dtg ke poli dgn BAK sering tp tidak puas. Seblmnya
    psn mengeluhkan hal yang sama kemudian sembuh. DM (+) 7 thn
    • Vital sign : Sens : CM, TD: 120/70 mmHg, nadi: 70 x/i, pernafasan:
    18x/I , suhu : 36,8⁰C,
    • Pemeriksaan fisik : nyeri tekan suprapubik
    • Pertanyaan :
    1. Apakah kemungkinan diagnosa pada pasien ini?
    2. Pemeriksaan penunjang apa yang diperlukan untuk membuktikan
    diagnosa sementara pada pasien tersebut?
    3. Jelaskan pengelolaan pada pasien ini ?
    Division of Nephrology and Hypertension, Department of
    Internal Medicine, Faculty of Medicine,
    Universitas Sumatera Utara
    Definition UTI

    Is a broad term used to described microbial


    contamination of the urine and infection of
    the structure of the urinary tract

    The infection process may involve kidney,


    renal pelvis, ureters, bladder, and urethra
    Lower Urinary Tract Infection

    Cystitis

    Prostatitis

    Urethritis
    Epidemiology

    The risk of UTI in women 10x men.. Why? the shorter distance between anus and meatus urethrae
    externum.
    • ~2% incidence in preschool children females
    • ~5% of school-aged females
    • Large majority of adult cases are females - 30:1
    • Forty percent of all females have at least one episode of a UTI at some time in their lives.
    • The risk of UTI in women increases after menopause
    Women generally don't have many problems with UTI's until they become sexually active.
    Postmenopausal:
    bladder or uterine prolapse
    loss of estrogen that causes a change in the vaginal flora
    loss of lactobacilli in the vaginal flora which results in periurethral colonization
    UTI in men

    Males experience a rapid increase in the incidence UTI's sometime in their 50’s -
    benign prostatic hypertrophy
    a UTI in men can be associated with either acute or chronic bacterial prostatitis
    prostatitis or epididymitis may play a part particularly in febrile UTI
    it is advisable to palpate both the prostate and scrotum
    chronic bacterial prostatitis, or at least the retention of bacteria in the prostatic
    ducts, should be suspected in relapses with the same causative bacteria
    UTIs in men (2)
    Afebrile lower urinary tract infection in men:
    🡪if the infection is not associated with urinary stricture or prostatitis,it is
    treated with the same drugs as cystitis in women, but the treatment should
    continue for 7 - 10 days
    🡪nitrofurantoin should not be used in men as adequate prostatic
    concentrations are not achieved (D)

    Febrile urinary tract infection in men is treated with


    🡪a long course of antibiotics with good prostatic and epididymal penetration
    🡪first choice: a fluoroquinolone for 2 weeks
    UTIs in men (3)
    UTI in men associated with acute bacterial prostatitis
    treatment for 4 - 6 weeks (depending how quickly patient responds to
    treatment
    to be followed up with low dose prophylaxis with e.g. trimethoprim or
    nitrofurantoin

    Chronic bacterial prostatitis


    🡪 recurrent UTI’s and calcifications in prostate
    oral quinolones for 2 – 3 months (D)
    to be followed up with prophylactic medication
    Nicole LE .UTI In Lerma EV et al Eds .Nephrology Secrets, Fourth Edition,
    Elsevier 2019
    Pathogenese UTI
    Lower UTI:
    Dysuria
    frequency
    Lower UTI Diagnostic Algorithm
    Prostatitis

    Trauma
    Risk Factor Sexual abstinence
    Dehydration

    Pain in the perineum, lower abdomen, testicles,


    penis, and with ejaculation, bladder irritation,
    Diagnosis
    bladder outlet obstruction, and sometimes blood in
    the semen

    Treatment Trimethoprim/sulfamethoxazole, fluroquinolone


    or other broad spectrum antibiotic
    4-6 weeks of treatment
    Urethritis

    Chlamydia trachomatis

    Frequently asymptomatic in females, but can present with dysuria,


    discharge or pelvic inflammatory disease.
    Do urine culture (if pyuria seen, but no bacteria, suspect chlamydia)
    Pelvic exam – send discharge from cervical or urethral for chlamydia PCR
    Chlamydia screening is now recommended for all females ≤ 25 years
    Treatment:
    Azithromycin – 1 g po x 1
    Doxycycline – 100 mg po BID x 7 days
    Neisseria gonorrhoeae

    May present with dysuria, discharge, PID


    Do urine culture
    Pelvic exam – send discharge samples for gram stain, culture, PCR
    Treatment:
    - Ceftriaxone – 125 mg IM x 1
    - Cipro – 500 mg po x 1
    - Levofloxacin – 250 mg po x 1
    - Ofloxacin – 400 mg po x 1
    - Spectinomycin – 2 g IM x 1
    You should always also treat for chlamydia when treating for gonnorhea!
    Cystitis

    Infection of the urinary tract limited to the bladder, usually


    Definition involving only the mucosal surface.
    Most common type of UTI in the long-term care setting

    Uncomplicated Cystitis

    Classification Complicated Cystitis

    Recurrent Cystitis
    Uncomplicated (Simple ) Cystitis

    🡪 Sexual intercourse
    Risk Factor → May recommend post-coital voiding or prophylactic
    antibiotic use.

    • Healthy adult woman (over age 12)


    • Non-pregnant
    Symptoms
    • No fever, nausea, vomiting, flank pain

    • if the symptoms are atypical, a strip test urinalysis may be carried out to
    support diagnosis (no culture or lab tests needed)
    Diagnosis • If the strip test is negative, the urine should be cultured and other reasons
    for the symptoms should be considered

    Patient with typical symptoms, not belonging to any of the risk groups, is
    treated without laboratory investigations
    Treatment 🡪 Trimethroprim/Sulfamethoxazole for 3-5 days
    May use fluoroquinolone (ciprofoxacin or levofloxacin) in patient with
    sulfa allergy, areas with high rates of bactrim-resistance
    Antimicrobial management of acute uncomplicated cystitis

    Adapted from Hooton, T.M. Clinical practice. Uncomplicated UTI. NEJM 2012 366, 1028–1037.
    Table 1. Antimicrobial in uncomplicated lower urinary tract

    Antimicrobial dose Duration of treatment

    Trimetoprim-Sulfamethoxazole 160/800 mg q12h 3 days


    Trimetoprim 100 mg q12h 3 days
    ciproflokxacin 100-250 mg q12h 3 days
    Levofloxacin 250 mg q12h 3 days
    cefixime 400 mg q 24h 3 days
    Cefpodoxime proksetil 100 mg q12h 3 days
    Nitrofurantoin macrocrystal 50 mg q6h 7 days
    Nitrofurantoin monohidrat 100 mg q12h 7 days
    macrocrystal
    Amoxicillin/clavulanat 500 mg q 12 hr 7 days
    Complicated Cystitis

    Females with comorbid medical conditions


    All male patients
    Risk Factor
    Indwelling foley catheters
    Urosepsis/hospitalization

    Urinalysis, Urine culture


    Diagnosis Further labs, if appropriate

    Fluoroquinolone (or other broad spectrum antibiotic)


    Treatment 7-14 days of treatment (depending on severity)
    May treat even longer (2-4 weeks) in males with UTI
    Reccurent Cystitis

    Want to make sure urine culture and


    sensitivity obtained.
    Diagnosis May consider urologic work-up to
    evaluate for anatomical abnormality.

    Treatment Treat for 7-14 days


    Prophylaxis of recurrent cystitis with antimicrobial agents

    • prophylaxis should be considered when more than 3


    infections per year
    • prophylaxis to continue for 6 months
    • if infections recur after prophylactic treatment, the
    prophylaxis is re-commenced for 6 – 12 months (D)
    Drugs of choice in UTI prophylaxis
    First choice:
    • trimethoprim 100 mg in the evenings
    • nitrofurantoin 50 - 75 mg in the evenings
    Second choice:
    • methenamine hippurate 1 g twice daily
    • norfloxacin 200 mg daily or on 3 evenings per week
    • nitrofurantoin (not if serum creatinine is above 150 μmol/l)
    • quinolones (in cases where there is no response with other prophylactic
    medication or tolerance to other medications is poor)
    During pregnancy:
    • nitrofurantoin 50 mg daily or
    • methenamine hippurate 1 g daily for the rest of the pregnancy
    • particularly if recurrent bacteriuria is diagnosed in early pregnancy
    Medication to be taken after intercourse

    A single-dose prophylaxis taken after intercourse is effective in women whose


    UTI’s are clearly associated with sexual intercourse (A)

    • First choice:
    – trimethoprim 100-300 mg as a single dose
    – nitrofurantoin 50-75 mg as a single dose
    • Second choice:
    – norfloxacin 200 mg, ofloxacin 100 mg or ciprofloxacin 100-250 mg
    – sulphatrimethoprim (1 single-strength tablet)
    Lower UTIs in children

    • treatment principles are the same as for adults


    • little evidence to support short term treatment in
    children (C)
    • drugs of choice
    – nitrofurantoin 5 mg/kg/day or
    – trimethoprim 8 mg/kg/day
    – treatment to continue for 5 days (C)
    Probable lower UTI with generalised symptoms in children

    • treated so that any possible infection of the kidney is also covered,


    i.e. with antibiotics with high tissue penetrability
    • oral medication acceptable
    • drugs of choice
    – sulphatrimethoprim (trimethoprim 8 mg/kg/day)
    – cefalexin 30 - 50 mg/kg/day in 3 divided doses
    – cefuroxime axetil 20 mg/kg/day in 2 divided doses or
    – mecillinam 20 - 40 mg/kg/day in 3 divided doses
    – treatment to continue for 7 days (C)
    The main quality criteria for the treatment of UTI’s

    • urine sample to be collected appropriately when infection is suspected


    • unnecessary culturing of urine samples to be avoided
    • the investigation and treatment of asymptomatic bacteriuria to be
    reserved for risk groups
    • diagnosing structural anomalies of the urinary tract in children
    • rational use of antibiotics
    Antimicrobial therapy in UTI

    Reserve drugs:
    • Quinolones (norfloxacin, ofloxacin or ciprofloxacin) for 3 days
    – if first choice drugs are not suitable or
    – if the infection has not responded to first choice drugs or
    – recurrent infection within 4 weeks
    – if there is a relapse, urine must be cultured and the treatment should be continued for 7
    days
    • In special cases:
    – cefalexin or cefadroxil for 5 days (if the above are contraindicated)
    – sulphatrimethoprim (SMZ-TM) for 3 days (particularly if the level of infection is unclear)
    – amoxicillin for 5 days (particularly in enterococcal infections)
    Single-dose therapy

    • single-dose therapy is slightly less effective than conventional therapy


    • effective in infections caused by E. coli, but less so in S. saprophyticus infections
    • recommended particularly when practical reasons warrant its use (e.g. self-care)
    • Preparations:
    – phosphomycin 3 g
    – norfloxacin 800 mg
    – ciprofloxacin 500 - 750 mg
    – ofloxacin 200 mg as a single dose
    Antimicrobial therapy in association with a urinary catheter

    • the treatment of UTI in a catheterised patient should always be based on the


    identity and sensitivity of the causative microbe
    • the catheter should always be removed, at least for the duration of treatment,
    as otherwise the bacteria will not be eradicated
    • if this is not feasible, the recommendation is to continue treatment for 7 - 10
    days even in lower UTI’s
    Antimicrobial therapy in association with a urinary catheter

    In the following patient groups antibiotics can prevent serious infective complications caused by
    long-term catheterisation :
    • after renal transplant (for 3 months)
    • granulocytopenic patients and possibly in diabetics
    • it is recommended that drugs which could be of benefit in serious infections (beta-lactamases and
    fluoroquinolones) are not used for prophylaxis

    Antibiotic prophylaxis is not recommended:


    • for repeat catheterisations

    • for the insertion of long-term catheter

    • for pyuria and bacteriuria in a patient with a long-term catheter but no obvious infection
    Antimicrobial therapy in association with a urinary catheter

    Fungal bladder infection in a catheterised patient:


    • systemic fluconazole is slightly more effective than topical amphotericin B
    • removal of the catheter will improve the eradication of the microbe during
    therapy

    Suprapubic catheter:
    • its use is associated with a lower incidence of bacteriuria in postoperative care
    • any infections are treated as any other infections associated with urinary
    catheters
    Follow-up after Uncomplicated Cystitis or Pyelonephritis

    • a urine culture is unnecessary if symptoms have resolved, except in pregnant women


    (for whom treatment of persistent asymptomatic bacteriuria is recommended)
    • In women with recurrent uncomplicated cystitis or pyelonephritis, routine urologic
    evaluation (with the use of ultrasonography or computed tomography) has a low
    diagnostic yield and is not recommended.
    • However,it should be considered in women who have persistent hematuria or
    multiple early recurrences of cystitis involving the same strain of bacteria.
    • In women with pyelonephritis who have severe or worsening illness, persistent
    fever 48 to 72 hours after the initiation of appropriate antimicrobial treatment, or
    symptoms suggestive of a stone, abscess, or obstruction, urologic evaluation should
    be performed to rule out these latter abnormalities.

    • It is also reasonable to perform imaging studies in women who have two or more
    recurrences of pyelonephritis
    Other preventive regiments

    ▪ Drink sufficient fluid to void 2 ltr per day

    ▪ Void 2 – 3 hourly with double micturition if reflux present

    ▪ Avoid bubble baths and chemical additives in bath water

    ▪ Avoid constipation which may impair bladder emptying

    36
    Thank you

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