Urinary Tract Infection (UTI)

Omega Mellyana
Sub Bag. Nefrologi Anak
FK UNDIP-RSUP dr. Kariadi
 TERMINOLOGi

ISK :keadaan adanya pertumbuhan dan

perkembangan bakteri dalam saluran
kemih dengan jumlah bakteriuria yang
bermakna
Bakteriuria bermakna :bila ditemukan pada
kultur urin pertumbuhan bakteri sejumlah
>100.000 koloni kuman tunggal/ml urin segar
yang diperoleh dg cara pengambilan yang
steril atau tanpa kontaminasi(GOLD
STANDARD).
 Incidence:
Neonatal period: Male>>female
Childhood period: Female (8%):male(2%)
Collaborative study 7 teaching hospital
(1984-1989):0,1 1,9 % outpatient

Causes : E. Coli, Proteus species,

Klebsiella, Enterococci Staph.
Saprophyticus, Pseudomonas, Staph.
Aureus or epidermidis,viral,fungus.
 Klasifikasi ISK
I. Clinic
Symptomatic UTI :gejala klinik+bukti laboratorium bakteriuria
bermakna
Asymptomatic(covert) bacteriuria (ABU) :
Repeated bacteriuria in a child without any symptoms.
II. Localisation
Upper UTI :>>Acute pyelonephritis is infection involving the renal
parenchyma
Lower UTI :Acute cystitis is infection limited to the lower urinary
tract.
III. Complication
Uncomplicated UTI(Simpleks UTI):infection without anatomic and
fungsional complication
Complicated UTI(Complex UTI):infection with anatomic and
fungsional lesiona; urethra obstruction,Vesico Ureter
Reflux,urolithiasis,scarring kidney,neurogenic bladder
COMPLICATION UTI
 Bowel flora

Emergence of uropathogenic strains

Perineal and anterior urethral colonization

(Vaginal colonization in females)

Normal Mucosal Defence Barriers

BACTERIAL HOST FACTORS

VIRULENCE 1. Enhanced uroepithelial
Cystitis Adherence
2. VUR
Acute 3. Intrarenal reflux
pyelonephritis 4. Obstructed urinary
tract
5. Foreign body
(urinary catheter)
Renal scarring Urosepsis

Pathogenesis of ascending UTI

 Route of infection
Hematogen: jarang>> bacteremia
neonate - 3 month
Anak besar karakteristik karena
virulensi bakteri tsb,spt
S.aureus,P.aeruginosa,Sersetia sp dan
tuberkulosis
Ascenderen
Limfogen?
 Manifestasi klinik
Tergantung dari umur penderita dan lokalisasi
infeksi di dalam saluran kemih
Neonatus: tidak spesifik:
pertumbuhan lambat,muntah,mudah
terangsang,tidak mau makan,temperatur tidak
stabil,perut gembung,ikterus,sepsis
1 bulan- <1 th:
demam,mudah terangsang,tampak sakit,nafsu
makan berkurang,muntah,diare,perut
kembung,dll
Prasekolah- sekolah:
disuria, polakisuria,urgency
 Long-term Consequence

UTI causes = Significant morbidity & suffering for children

= Inconvinience and anxiety for families
= Considerable consumption of medical resources
Most children with UTIs have an exelent prognosis
The process of scarring after acute pyelonephritis is low
Hypertension has been shown in 10% of children &
young adult
Women who had a tendency to recurrent UTIs as girl have
an increased risk of new infections during pregnancy
Diagnosis
The diagnosis procedure is based on urinalysis, with
culture as the most important investigation
Methods of urine collection
1. Meadstream specimen
2. Bag urine sample
3. Suprapubic aspiration urine
4. Bladder catheterization
Culture of Urine
Urine should be refrigerated at 40 C
Diagnosis of ABU : requires repeated samples
Urine interpretation in diagnosis of UTI
Method of collection Quantitative culture :UTI present
Suprapubic aspiration Growth of urinary pathogens in any
number
Catheterization Febrile infants or children usually have >
50 x103 CFU/ml of a single urinary
pathogen, but infection may be present
with counts from 10 x 103 to 50 x 103
CFU/ml
Midstream clean-void Symptomatic patient usually have > 105
CFU/ml of a single urinary tract pathogen
Midstream clean-void Asymptomatic patiens : at least two
specimens on different days with > 105
CFU/ml of the same organism
 Other urine findings
Pyuria : is the presence of > 10 WBCs per high power
field by light microscopy in a centrifuged
urinary sediment.
Nitrite test : the ability of most uropathogens to reduce
nitrate to nitrite (pink azo)
Microscopic hematuria : is more than 5 red cells per mm3
in urine in a Fuchs-Rosenthal counting
chamber.
Macroscopic hematuria : is found in 2030% of acute
cystitis
Site of infection
Localization of bacteria
Measurement of host reactions to renal inflamation :
Renal imaging
Antibiotic treatment
Symtomatic UTIs should be given antibiotic without delay
The drug is depend on the resistance pattern of
urophatogens
Antibiotic prophylaxis
Is indicated at high risk for developing renal scarring
Monitoring
Acute situation
Previous UTIs, recent episodes of high fever, bladder
and bowel emptying habits
Essential full physical examination
Urinalysis, urine culture, serum creatinine

Follow up : Within 24 hours, after 4-5 days and 3-4 weeks,

after 6 monts and 1 year
 Asymptomatic Bacteriuria (ABU)

Symptoms in school girls with ABU

History of urgency, urge incontinence, difficult micturation
Relationship between symptomatic and asymptomatic bacteriuria
Untreated symptomatiic UTI may deal spontaneously or the may
turn into ABU
ABU may develop into symptomatic UTI
Treatmen of children with ABU
Screening for bacteriuria in healhty children should be discontinued
Follow up includes bladder and bowel history, physical examination
as in symptomatic UTI
Avoid the of antibiotics in ABU
 MANAGEMENT
General principle:
1. Rapid diagnosis
2. Immediate antibacterial treatment, while
awaiting confirmation of diagnosis
3. Prevention of further infection pending
investigation
4. Adequate investigation of first known UTI
5. Arrangement for appropriate further
treatment
6. Follow-up until symptoms are controlled
 ANTIBACTERIAL TREATMENT

The choice of drugs and route of

administration will depend on:
a. Age, condition of the child: oral/
parenteral route
b. Local community or hospital antibact.
Resistance
c. History of recent antibacterial treatment
d. The possible effect of the chosen drug on the
bowel flora resistance pattern
GENERAL RULES IN MANAGEMENT

Symptomatic medication:
fever, vomiting
Fluid intake
Empty the bladder completely
Proper perineal hygiene
Pyridium 7-10 mg/kg/day
Lowering urine pH to 5 or less
Hospitalisation
Table 3. SOME ANTIMICROBIALS FOR ORAL
TREATMENT OF UTI

ANTIMICROBIAL DOSAGE

AMOXICILLIN 20-40 mg/kg/d in 3 doses

SULFONAMIDE
TMP in combination 6-12 mg TMP, 30-60 mg
with SMX SMX per kg per d in 2 doses
Sulfisoxazole 120-150 mg/kg/d in 4 doses
CEPHALOSPORIN
Cefixime 8 mg/kg/d in 2 doses
Cefpodixime 10 mg/kg/d in 2 doses
Cefprozil 30 mg/kg/d in 2 doses
Cephalexin 50-100 mg/kg/d in 4 doses
Table 2. SOME ANTIMICROBIALS FOR PARENTERAL
TREATMENT OF UTI.

ANTIMICROBIAL DAILY DOSAGE

CEFTRIAXONE 75 mg/kg /d
CEFOTAXIME 150 mg/kg/d
CEFTAZIDIME 150 mg/kg/d
CEFAZOLIN 50 mg/kg/d
GENTAMICIN 7,5 mg/kg/d
TOBRAMYCIN 5 mg/kg/d
TICARCILLIN 300 mg/kg/d
AMPICILLIN 100 mg/kg/d
FOLLOW UP
NORMAL KIDNEYS
1 yr IVU or DMSA
SCARRED KIDNEYS: Monitoring
BP
Renal growth
Plasma creatinine / GFR
Urine culture
Somatic growth
URINE CULTURE
Infants/early childhood:
every 3 months
fever (+) culture antibacterial drugs
Older children:
regular supervision
prophylactic (?)
ALGORITME PENANGGULANGAN & PENCITRAAN ANAK ISK
ISK PERTAMA(Biakan urin)

Neonatus/bayi Anak

Gejala Gejala ISK

Sistemik Bawah

Rawat
Rawat jalan:AB oral
inap,AB i.v*
Biakan urin (48 jam
sesuaikan AB)**

USG+MSU
2 4 mgg sesudah tx
Normal Tidak normal

Tindak lanjut u/ cegah infeksi*** Pertimbangkan PIV atau skan****

 KETERANGAN
*: AB:Ampisillin+Aminoglikosida atau
Ampisillin +Sefotaksim selama 5 hari
**AB sesuai kultur diberikan selama 10
14 hari
***Banyak minum, jangan tahan
kencing,kencing habiskan sebelum tidur
****Untuk melihat apakah ada refluks
Vesikoureter atau nefropati refluks
MANAGEMENT OF RECURRENT INFECTION

Low dose prophylactic antibiotic

Treatment of predisposing factors:

Thread-worms
Avoidance of bubble bath
Vulval irritation
The perineum : kept clean
Relief of constipation
Neurogenic bladder
Poor habit
VUR