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URINARY TRACT INFECTION

Prof Dr dr Jazanul Anwar SpFK


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Anatomi:
Bagian bawah (superficial):
uretra
kandung kemih
Bagian atas (lebih dalam):
prostat
ginjal: acute pyelonephritis


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Urinary Tract Infection
Upper urinary tract Infections:
Pyelonephritis
Lower urinary tract infections
Cystitis (traditional UTI)
Urethritis (often sexually-transmitted)
Prostatitis


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Urinary Tract Infection (UTI)
Background
1. Bacterial infections of urinary tract are a very common
reason to seek health services
2. Common in young females and uncommon in males under
age 50
3. Common causative organisms
a. Escherichia coli (gram-negative enteral bacteria) causes
most community acquired infections
b. Staphylococcus saprophyticus, gram-positive organism
causes 10 15%
c. Catheter-associated UTIs caused byA gram-negative
bacteria: Proteus, Klebsiella, Seratia, Pseudomonas
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Urethritis
Chlamydia trachomatis
Frequently asymptomatic in females, but can present with
dysuria, discharge or pelvic inflammatory disease.
Send UA, Urine culture (if pyuria seen, but no bacteria,
suspect Chlamydia)
Pelvic exam send discharge from cervical or urethral os 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

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Neisseria gonorrhoeae
May present with dysuria, discharge, PID
Send UA, 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!

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Urinary Tract Infection (UTI)
Medications
a. Short-course therapy: 3 day course of antibiotics for
uncomplicated lower urinary tract infection; (single dose
associated with recurrent infection)
b. 7 10 days course of treatment: for pyelonephritis,
urinary tract abnormalities or stones, or history of previous
infection with antibiotic-resistant infections; clients with
severe illness may need hospitalization and intravenous
antibiotics
c. Antibiotics commonly used for short and longer course
therapy include trimethoprim-sulfamethoxazole (TMP-SMZ),
or quinolone antibiotic such as ciprofloxacin (Cipro)
d. Intravenous antibiotics used include ciprofloxacin,
gentamycin, ceftriaxone (Rocephin), ampicillin
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Final thoughts!
Antibiotic choice and duration are determined by
classification of UTI.
Biggest bugs for UTI are E. Coli, Staph. Saprophyticus,
Proteus mirabilis, Enterococci and gram-negatives
Dont use moxifloxacin for UTI!
Chlamydia screening is now recommended for all
women 25 years and under since infection is
frequently asymptomatic, and risk for PID/infertility
is high!
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Principles of management of acute severe urinary tract infections
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ANTIBIOTIC THERAPY - PRINCIPLES OF MANAGEMENT

Ideal antibiotic
Achieve high renal tissue and urine levels
Bactericidal
Broad spectrum of activity
Common drugs :
gentamicin, ciprofloxacin,
trimethoprim/sulfamethoxazole, amoxicillin and the
cephalosporins.
Chlamydiae and mycoplasmas :
Tetracyclines and erythromycin.
Trichomonas vaginalis :
Metronidazole.
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Gentamicin
Most suitable antimicrobial
Bactericidal activity
Combination with -lactams and vancomycin
Added advantage of synergistic activity.
Increase the diffusion of gentamicin across bacterial cell
membranes thereby improving efficacy.
Post-antibiotic effect with a large once daily dose producing
bacteriostasis several hours after dosage.
pregnancy, diabetes mellitus, anatomical variation,
urolithiasis, neuropathy, renal impairment, hepatic
impairment, immunosuppression and age.
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Bacterial antibiotic resistance
Three mechanisms
1.Natural resistance occurs with the absence of any drug-
sensitive strains prior to the initiation of therapy.
2.Resistant mutants - up to 10% , within 48 h of antibiotic
treatment.
Bacterial transport molecules and molecules aiding the
binding of antibiotics to bacterial proteins, eg. 30S
ribosomal subunit binding to gentamicin.
3.Plasmid-mediated resistance (R-factor)
Most important mechanism of bacterial resistance -
transfer of multidrug resistance (MDR) genes leading to the
production of 'killer' enzymes.
Important to obtain periodic advice from regional clinical
microbiologists/infectious diseases physician if empiric treatment
of UTIs is contemplated.
Choice of antimicrobials, adjustments in dosage and length of
treatment by coexisting conditions

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Antibiotics used in the management of urinary tract infections
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Fungal
Urinary Tract Infections
Diagnosis and Management
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Candida species - saprophytes of the skin, oropharyx
,gasrointestinal tract and genital regions.
Blastomyces, Histoplasmosis, Coccidoides
Mucormycosis

Apergillosis
Fungus yang sering sebagai penyebab UTI
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Treatment
Bladder irrigation with Amphotericin B 50mg/1L
water x10-14 d
Effective in 80-92% of patients
Nystatin and Miconazole useful. -poor colloid
dispersion in Nystatin-limits use
Surgical intervention may be required in the form
of mucosal debridement
Removal of large fungal bezoars if present.


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Treatment
Localized
Amphotericin
B irrigation for infection of the collecting system..

Systemic or multifocal infection
IV Ampho B 6mg/kg (Gold Standard) , Fluconazole
100mg BID x 10 days
5-FC- 150mg/kg- high resistance


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Cryptococosis
Tx: Adrenal-Amphotericin B
Renal- IV Amphotericin B
Prostate-Fluconazole 200-600mg/d
x 4 wks
Penis- Resection followed by
systemic Ampho B

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Apergillosis
Predisposition: abraded skin, wounds, cornea,
ext. ear and sinuses, immunocompromised
GU involvement: Renal- DM, malignancy or
AIDS
(Fever, CVAT, obstructive uropathy)
Prostate and Genital-DM, Met colon ca, steroid
use & AIDS
DX:Isolation from urine,semen or tissue.



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Dx- Identification of organism in
urine,semen or tissue. Culture or skin test.
Tx- IV Amphotericin B(>2g) total dose
followed by long term Itraconazole
200mg/d x12 wks
Surgical management- Surgical excision or
drainage of prostate abscess.





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Blastomyces

Organism: Blastomyces dermatitidis
Properties: Dimorphic, m












old in soil, yeast in tissue
Broad-based budding
Epidemiology: North and Central America, also
Africa. Grows in moist soil.





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Mucormycosis


Manifestations- primarily rhino cerebral, sinusitis
and brain hemorrhage
GU- Primarily fever and flank pain
Dx- biopsy showing mold with nonseptate hyphae
Tx-IV amphotericin B >1gram for 1 month






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Dasar-dasar pengobatan keradangan saluran kemih
Keradangan saluran kemih biasanya diobati dengan
antibiotika atau khemoterapetika selama 10-14 har dengan
konsentrasi tinggi didalam urin untuk dapa menghasikan
yang efektif.
Obat antibiotika atau khemoterapetika yang bekerja dalam
konsentrasi tinggi didalam urin lebih lemah dibandingkan
obat-obat yang konsentrasinya lebih tinggi didalam darah
Cystitis yang tidak melibatkan sel-sel parenchym mudah
diobati dengan obat-obat yang yang banyak terdapat dalam
urin
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Kriteria keberhasilan pengobatan setelah 48 jam urin itu
steril, hilangnya lekosit, , hilangnya nyeri waktu buang air
kecil dan di pinggul, jumalh sel-sel darah putih normal
Ketidak berhasilan pengobatan UTI terjadi oleh n amyak hal,
seperti terjadinya mixed infection, salah diagnosis
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A. Keradangan saluran kemih akut
Obat yang paling manjur untuk UTI
adalahamoxycillin atau cotimozasol. Lamanya
pengobatan paling kurang 10-14 hari.
Pembetian satu dosis perhari.
Pengobatan yang tak diketahui kuman
patogennya, harus dimula waaupun belum
diketahui penyebabnya. Dimulai pemberian
amoxycillin, bacampicillin atau co-trimoxazols.
Cefotaxime atau suatu turunan minglikosida
efektif juga.
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B. Pengobatan Pyelonefritis
neys

Pyelonefritis ditandai demam dan lekositosis, nyeri
panggul bila di perkusi dapat menyebabkan
septikemia.
Penyebabnya adalah mekanikal ( batu, obstruksi)
Amoxicillin
Cephalosporin
Levofloxacin and ciprofloxacin
Sulfa drugs such as /trimethoprim
In acute cases, you may receive a 10- to 14-day
course of antibiotics.
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2. Cystitis
Acute cystitis is a bacterial infection of the
bladder or lower urinary tract
Commonly used antibiotics include
trimethoprim-sulfamethoxazole,
amoxicillin, Augmentin, doxycycline, and
fluoroquinolones. Your doctor will also
want to know whether you are pregnant.
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3. Urethritis
Urethritis is inflammation of the urethra
Pain with urination is the main symptom of urethritis.
Urethritis is commonly due to infection by bacteria. It
can typically be cured with antibiotics.
E. coli and other bacteria present in stool.
Gonococcus. It is sexually transmitted and causes
gonorrhea.
Chlamydia trachomatis. It is sexually transmitted
and causes chlamydia.
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4. Prostatitis,, orchitis
There are four types of prostatitis:
acute bacterial prostatitis
chronic bacterial prostatitis
chronic prostatitis without infection
asymptomatic inflammatory prostatitis
Acute bacterial prostatitis treatment
Treatment for acute bacterial prostatitis is a prescription for
antibiotics by mouth, usually ciprofloxacin (Cipro) or tetracycline
(Achromycin). Home care includes drinking plenty of fluids,
medications for pain control, and rest.

Chronic prostatitis without infection treatment
Chronic prostatitis without infection treatment addresses chronic
pain control and may include physical therapy and relaxation
techniques as well as tricyclic antidepressant medications.

prostatitis
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epididymitis
Epididymitis is infection or less frequently, inflammation
of the epididymis (the coiled tube on the back of the
testicle). because of a bacterial infection.
Ceftriaxone (Rocephin): As a single dose either in an IM
(intramuscular) shot or through an IV line and 1 dose of
azithromycin (Azithromycin 3 Day Dose Pack, Azithromycin 5 Day
Dose Pack, Zithromax, Zithromax TRI-PAK, Zithromax Z-Pak, Zmax)
Doxycycline (Vibramycin): Pills twice a day for 10 days in addition
to the shot of ceftriaxone
The CDC guidelines recommend ceftriaxone (Rocephin) 250 IM in a
single dose plus doxycycline 100 mg orally twice a day for 10 days.
Ciprofloxacin (Cipro): Pills twice a day for 10-14 days
Ofloxacin (Floxin): Pills twice a day for 10-14 days
Sulfamethoxazole and trimethoprim (Bactrim DS [double
strength]): Pills twice a day for 10-14 days
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