CASE REPORT

URINARY TRACT INFECTION

Prensented by
Miftahul Jannah
C111 12172

Renal & Hypertension Division

Internal Medicine Departement
Medical Faculty of Hasanuddin Univers
 PATIEN
T
IDENTI
TY
Name : Ny. A
Date of birth/ Age : 13-09-1929 / 87 years old
Medical Record : 520863
Study : Junior High School
Date of hospital admission : 03/01/2017
Job : Retired
Marital Status : Married
Address : Pondok Asri Blok C1 8/16
Telp/HP : 081354799403
HISTORY
TAKING

Chief
Complaint
Fever
Present Illness
History
Fever since three days ago. Fever is continuous.
Fever is not affected by time. No chills. No sweat
at night. History of bleeding dinied. Complaints
with a productive cough since five days ago. Not
constantly. Theres sputum (white). No shortness
of breath. No headaches, no dizziness. Theres
blurred vision. No nausea and vomiting.
Complaints accompanied by pain in the waist that
sometimes appear without influenced activity.
Good appetite. No swallowing pain. Less dringking.
No weight loss. Urination swift and yellow,
HISTORY
TAKING

Past Illness
History
History of hypertension since 5 years ago. With a
history of drug consumption amlodipine 10 mg
but not regularly.
History of diabetes mellitus denied
History of heart disease denied
History of lung disease denied
History of kidnay disease dinied
History of smoking and alcohol consumption
denied
History of operating trauma osteoporotic since 3
PHYSICAL
EXAM

General
Status
Mild illness / Well-nourished / Composmentis
Weight : 50 kg
Height : 160 cm
BMI : 19,53 kg/m2

Vital
Status
Blood Pressure : 200/120 mmHg
Heart Rate : 80 bpm
Respiratory rate : 22 rpm
Temperature : 37,1 oC
PHYSICAL
EXAM

Head Ears
Deformity: None Hearing: Within normal limits
Symmetrical face: symmetric Otorrhea: None
Hair: Difficult revoked
Size: Normocephal
Shape: Mesocephal

Eyes Nose
Exophthalmos: None Epistaxis: None
Conjunctiva: anemic (-) Rhinorrhea: None
Cornea: corneal reflex (+)
Enoftalmus: None
Sclera: Jaundice (-)
Pupils: Isokor 2.5 mm / 2.5 mm
PHYSICAL
EXAM

Mouth Neck
Lips: Dry (-) Lymph Nodes: No enlargement
Tongue: Dirty (-) JVP: R + 2 cmH2O
Tonsils: T1-T1 No hyperemia Thyroid: No enlargement
Faring: Not hyperemia Stiff neck: (-)

Chest

Shape: Symmetrical between left and right

Breasts: Symmetrical approximately equal to the right, no
abnormalities
Between the ribs: Symmetrical between left and right
PHYSICAL
EXAM Lung
Palpation : Fremitus symmetrical with the same left-right
Tenderness (-)
Percussion : Limit liver-lung ICS VI dextra
Right behind lung markings ICS IX
Left behind lung markings ICS X
Auscultation : Sounds Breathing: Vesicular
Additional sounds: ronkhi (- / -), wheezing (- / -)

Heart
Inspection : Ictus cordis does not seem
Palpation : Ictus cordis palpable, thrill (-)
Percussion : The upper limit ICS II sinistra
Right border ICS IV linea parasternalis dekstra
ICS left boundary of the left v linea
axilaris anterior
Auscultation : BJ I / II regular pure
Heart murmurs (-)
PHYSICAL
EXAM

Abdomen

Inspection : Flat, follow the motion of breath

Palpation : liver and Lien impalpable
Tumor mass (-), tenderness (-)
Percussion: Timpani (+). Pain of word costovertebra (+)
Auscultation : Peristaltic (+) normal impression

Extremi
ty
No edema pretibial
 LAB
FINDING
TEST RESULT NORMAL VALUE
WBC 6,0 x 103 /uL 4 - 10 x 103 /uL
4,50 6,50 x
RBC 4,03 x 106 /uL
106 /uL
HBG 12,0 g/dl 14 18 /dl
3-1- HCT 37,9 % 40 54 %
2017 MCV 94 80 100
MCH 29.7 pg 27 32 pg
MCHC 31.6 g/dl 32,0 36,0 g/dl
150 - 400 x 103
PLT 116 x 103 /uL
/uL
RDW
13,8 % 11 16 %
CV
PDW 18,8 % 11 16 %
MPV 8,6 6,0 11
PCT 0,0 % 0,15 0,50 %
NEUT 55,9 % 52 75 %
 LAB Test Result Normal value
FINDING
GDS 102mg/dl 140 mg/dl
Ureum 28 mg/dl 10-50 mg/dl
Creatinin 1,09 mg/dl M(<1,3);F(<1,
1) mg/dl
SGOT 37 U/l <38 U/l
3-1-
SGPT 18 U/l <41 U/l
2017
Albumin 4 3,5-5,9 g/L
Globulin 1.9 1.5-5 gr/dl
Natrium 140 136-145
mmol/L
kalium 3.8 3.5-5.1
mmol/L
Klorida 102 97-111 mmol/L
 LAB
FINDING

Urinalisis

TEST RESULT NORMAL VALUE

Color Yellow Clear Yellow
PH 6.0 4.5-8.0
SG <= 1.005 1.005-1.035
PRO Trace Negative
GLU Neg Negative
BIL Neg Negative
UBG Normal Normal
KET Neg Negative
NIT Neg Negative
BLD 2+ Negative
LEU Neg Negative
VC 0.6 Negative
Bact 30 0-1 Hpf
RADIOLOGI
FINDING

Imaging : - cardiomegaly with pulmonary

hypertension
- Dilatatio, elongatio et
atherosclerosis aortae

EKG
FINDING
Sinus rhythm
HR: 76 bpm
Reguler
Normoaxis
DIAGNOSIS

- Urinary Trac Infection

- Hypertension grade II (JNC VII) on
treatment
- Cardiomegaly ec Hypertension
 PROBLEM
LIST
No Problem Planni Treatment
. ng
1. Urinary Tract Infection Kultur Non Pharmacological :
Urin - Education (Wiping
Based on : techniques, Drink lots of
- Fever water every day and more)
- Hematuri (Blood +2) Pharmacological :
- Bacteriuria 30 Hpf - Paracetamol 500mg/8
- pain in the waist. jam/oral (PRN)
- Less dringking -Ciprofloxacin 250 mg/12
- pain during urination jam/oral.
- Pain of word costovertebra
(+)

2. Hypertension grade II Non Pharmacological :

(JNC 7) on Treatment - Diet low salt
- lifestyle modification
Based on : Pharmacological :
TD: 200/120 mmhg - Amlodipin 10 mg/24
hour/oral (at night)
- Micardis 80 mg/ 24
PROBLEM
LIST

N Problem Plannin Treatment

o. g
3. Cardiomegaly ec Echocard Non Pharmacological :
Hypertension iografy - Education
- Lifestyle Modification
Based on : Pharmacological
- TD : 200/120 - Amlodipin 10 mg/24
mmhg hour/oral (at night)
- Radilogy imaging: - Micardis 80 mg/ 24
cardiomegaly with hour/oral (at morning)
pulmonary
hypertension
Discussion
DEFINITION

Urinary Tract Infection is the state of infection in the

urinary tract, including infections in the renal
parenchyma to the infection in the bladder with a
number of significant bacteriuria.
Significant bacteriuria: the growth of microorganisms
pure> 105 cfu / ml in the bacterial culture.
Bacteriuria asymptomatik: significant bacteriuria
without clinical presentation of UTI.
Meaningful symptomatic bacteriuria: significant
bacteriuria + clinical presentation of UTI
Significant pyuria: neutrophils> 10 per visual field.
EPIDEMIOLO
GI
>
Recurrent UTIs in rarely found
prevalence of asymptomatic
bacteriuria is more common in women
The prevalence of asymptomatic
infection increased to 30% ~
predisposing
EPIDEMIOLO
GI
Predisposing factors precipitating UTI:
lithiasis
Urinary Tract Obstruction
Polycystic Kidney Disease
papillary necrosis
DM after kidney transplantation
analgesic nephropathy
Sickle-cell disease
Pregnancy and FP with progesterone tablets
Catheterization
EPIDEMIOLO
GI
Factors causing false negatives in
patients with UTI:
The patient had received antimicrobial
therapy
diuretic therapy
drink plenty
Sampling time is not right
The role of bacteriophages
 ETIOLOGI

Gram-negative bacteria (80%):

Escherichia coli, Proteus sp., Klebsiella
sp., Enterobacter sp.,
Gram-positive bacteria (10-15%):
Enterococcus sp., Staphylococcus
aureus., Staphylococcus epidermidis.,
Others: Pseudomonas sp., And Seratia
~ procedures urology and urinary tract
obstruction
CLASIFICATI
ON

urinary tract infection can be divided

anatomically into two categories:
Lower UTI (Sisititis, Acute Urethral
Syndrome)
(cystitis, prostatitis, Epidimidis,
urethritis)
Upper UTI : Acute pyelonephritis (APN)
Chronic pyelonephritis (CPN)
CLASIFICATI
ON

UTI based on the clinical picture:

Simple Type UTI (uncomplicated UTI)
UTI complicated (complicated UTI)
PATOGENSIS

Pathogenesis of Urinary Pathogens

1. The role of bacterial pathogenicity
The role of bacterial attachment of
mucosa
The role of virulence factors other
Virulence factors phase variations
2. The role of host factors (host)
Factors predisposing precipitating ISK
Immunological status of patients (host)
PATOFISIOLOGI

Port d 'entre
Defense mechanisms:
Risk factor : comes from the
1. Cleaning bacteria at VU 1. Gender
urethra ~
2. Sexual Activity
2. The content of urea infection
3. Pregnancy
and high urine osmolarity
4. obstruction assendens
3. Sekresi cytokines and
chemokines in epithelial 5. The use of
antibiotics towards VU and
VU
renal parenchymal
CLINICAL MANIFESTASI

Acute pyelonephritis (ANP) : high fever

(39.5-40.5), chills and pain (often preceded by
symptoms of cystitis).
Cystitis : suprapubic pain, polakisuria, nocturia,
dysuria, stranguria.
Acute Urethral Syndrome (SUA): dysuria and
frequent urination, <105 cfu / ml (cystitis
abakterialis)
Recurrent UTI:
Re-infection
Relapsing
 SUPPORTING
INVESTIGATION
Urinalisa : pyuria, bacteriuria,
hematuria, nitrites (+), leukocytes>
5 / LPB
Urine culture (urine midstream)
Blood cultures : patients with high
fever or suspected complications
Imaging : Ultrasound Kidney, CT Scan
Abdomen, sistografi
 SUPPORTING
INVESTIGATION
Indications of further investigation after UTI:
UTI relapse (relapsing infection)
pasein men
Symptoms urologik: renal colic, pyuria,
hematuria
persistent hematuria
MO rare: Pseudomonas spp and Proteus spp
Recurrent UTIs with an interval of <= 6
weeks
iteria for diagnosis of significant bacteriuria

Symptomatic women :
102 coliform organisms/ml urine plus pyuria, or
105 of any pathogenic organism/ml urine, or
Any growth of a pathogenic organism from urine obtained by
suprapubic aspiration

Symptomatic men :
103 pathogenic organism/ml urine
Asymptomatic patients :
105 pathogenic organism/ml urine in two
consecutive samples
APY
Non-Pharmacological Therapy
Fluid intake
Regular replacement of catheters in patients who
use it
Prevention of Recurrence of UTI: Maintain the
cleanliness and hygiene of the urethra and
surrounding area
Y Pharmacological Therapy
Non complicated acute The choice of antibiotic orally, among others:
cystitis 1. Cotrimoxazole 2x960 mg 3 days
2. Ciprofloxacin 2x250 mg 3 days
3. Nitrofurantoin 2x100 mg 7 days
4. Co-amoxiclav 2x625 mg 7 days
Acute recurrent cystitis in Required antibiotic prophylaxis for prevention:
women 1. Nitrofurantoin 50 mg / day
2. Cotrimoxazole 240 mg / day or 3 times a week
3. If the infection occurs amid prophylaxis period, can be
given ciprofloxacin 125 mg / day
Non complicated acute 1. Indications care: signs of systemic toxicity, is not
pyelonephritis capable of taking oral antibiotics. Parenteral Antibiotic
selection: 1x1 g ceftriaxone or 4x500mg levofloxacin or
ciprofloxacin 2x400 mg for 7-14 days
2. Mild symptoms: ciprofloxacin 2x250 mg for 7 days
3. Severe symptoms: ciprofloxacin 2x250 mg for 14 days.
UTI on Man Cotrimoxazole and ciprofloxacin for 7 days
asymptomatic bacteriuria system implementation is only given to pregnant women,
before surgery urology, and after a kidney transplant.
UTI On Pregnant Women 1. Co-amoxiclav, nitrofurantoin, oral cephalosporin, or a
single dose fosfomycin
2. Pyelonephritis: IV antibiotics until pasein afebrile for 24
hours followed by oral therapy of 10-14 days
3. Antibiotics are contraindicated: sulfonamides and
quinolones
UTI In Diabetes Patients Treated with medical and surgical therapy.
PROGNOSIS

Urinary Tract Infection without any

anatomical abnormalities have a
better prognosis if treatment with the
acute phase of adequate supervision
of the possibility of repeated infections