URINARY TRACT INFECTION Current Diagnosis &® Management eae Rochmanadji Widajat Dept.of Pediatrics, Medical Faculty UNDIP / Dr.Kariadi Hospital, SemarangPresentation Goals Se ORM eV h ni MOU dail lite-lt0 lee | 0l0) Lg Urinary Tract Infection (UTI) in children. = To formulate recommendations for Healthcare professionals about the “Strategic Management of UTI” (diagnosis, treatment and evaluation) in the pediatric communities, esp. in children at risk of UTIBackgrounds (1) #UTI is the most frequent disease in Pediat. Nephrology. Therefore the true incidence is still uncertain due to many asymptomatic & other “under & over-diagnosed” cases « Management of UTI are quite strategic because they cause acute morbidity and may result in long-term medical problems Oot IL eof EL em OM noe Ig eh ae/Va-em ro erupere smite eae pass adult period)Backgrounds (2) x wt Le diagnosis is very important : (1) to permit rapid identification, therapy and evaluation of children at risk of UTI; (2) to avoid unnecessary procedures (> costly and harmful) of children who are ine) a= ata cL = The younger the child suffering from UTI the more at risk for renal damage is the symptoms and signs > pay a special attention to the children between age 2 months — 2 years.Current Literature Review about UTI = Definition & classification of UTI = Pathogenesis = Patho-physiology = Clinical Manifestation a Diagnosis a Treatment & strategic management COMB Mami (e)at-ielmeraig ere] = PrognosisBackgrounds (2) x wt Le diagnosis is very important : (1) to permit rapid identification, therapy and evaluation of children at risk of UTI; (2) to avoid unnecessary procedures (> costly and harmful) of children who are ine) a= ata cL = The younger the child suffering from UTI the more at risk for renal damage is the symptoms and signs > pay a special attention to the children between age 2 months — 2 years.Current Literature Review about UTI = Definition & classification of UTI = Pathogenesis = Patho-physiology = Clinical Manifestation a Diagnosis a Treatment & strategic management COMB Mami (e)at-ielmeraig ere] = PrognosisDefinition of UTI re UTI is an invasive and growth of micro- organism in the urinary tracts (> kidney to urethra). = Diagnosis of UTI is still based on finding of a “significant bacteriuria” (Kass criteria, 1956 > >100,000 cfu/ml of a single micro-organism in a clean-catch specimen or urinary catheter ee = Classification of UTI : consists of simple and complicated UTI (or “simplex & complex” UTI)Pathogenesis of UTI rl he route of infection may be Aematogenous, lymphogenous, per-continuitatum, ascendent = The 3 main factors concerning pathogenesis of UTI : Aost — defend mechanism — virulence el Mere emee) ger CATA 4. Host ; girls > boys, toilet training, voiding dysfunction, low hygienic, renal scarring, reflux, adherent uro-epithelial cell 2. Defend mechanism : disability to eliminate micro-org. (lack of immunity), infant < older 3. Virulence of micro-organism ; esp. E.coli uropathogenic > attached fimbriae to specific receptor of uro-epithelial cell > ascendent UTIPatho-physiology of UTI Acute “simplex” (simple infection) > may have a good prognosis (esp. boys) > CURE “Complex” UTI (complicated infection) > recurrent infection & long-term progressive medical problems, as follow : . Renal scarring : in most cases of complex UTI . Obstruction : 1% — 5‘ VUR (up to 30% of UTI, or 90% of UTI with renal scarring) . Renal Hypertension (10% of VUR) . Reduced renal function up to CRF (5-10% of VUR)Dynamics of Bacteriuria Covert infection Symptomatic infection ‘SPONTANEOUS Re-infection Coincidental treatment Persisting of a Fail Relapsing infection a Te Septicaemia Treatment ge Reel (ele Ma oa de Loy a Pca Edelmann CM (ed), 1992es ve 3. = rs ane UE ep AOR ac a ae Clinical Manifestations ee mee ee ee & specific are the symptoms and signs”. Mire eels] s\-caH acon ALE Cystitis (sil) and Asymptomatic bacter PXaU CoM AV telat) +) gett Me ead ced a inflammatory of kidney - high fever, C-reactive protein, leukocytosis, general symptoms Acute Cystitis, Urethritis> Mild Veg ace lower tract : dysuria, pain, felts =.e tomatic (covert) bacteriu ®) Non-specific : UTI in leisy : AFomee Litera eu n ears |eL* eM) pain, to thriveAccurate Diagnosis of UTI = Diagnosis is still based on the culture of an ppropriately collected specimen of urine > significant bacteriuria (spec. up to 95%) a Urinalysis (WBC & nitrite) can only suggest the diagnosis (senst. 83% and spec. 78%). ee ige eit eh Cpa lol a eel performed as soon as possible (> to see predisposing factors) Ce ee ema memel-wolace gem tala em Wit after the first episode (> to prevent the possible complications) a DMSA study (Tc-99 radiation) > good at detecting scarsPay attention of over & under-diagnosis ! Sarl Over-diagnosis of UTI : among girls with vulvitis, local irritants and children with fever, anorexia who complain with dysuria (due to highly concentrated urine). = Under-diagnosis of UTI : among infants & young children with non-specific symptoms = UNFORTUNATELY : for many children to receive “blind” antibiotics for suggested UTI without urine sampling > diagnosis of UTI is still uncertain !!Strategic Management of UTI according with Age etc. (1) aan UTI in infants 2 mo’ — 2 yrs old with unexplained fever (evidence > 5%) 1,1, Above cases assessed as being so ill; > immediate-rational antibiotics is given > immediate urine specimen by SPA or trans- urethral catheterization > consider hospitalization ! 41.2. Above cases as being not so ill : > no immediate antibiotics is given Seamer] Mm Elg (atl foci masa M18] (eT 18) (SPA / catheterization) if suggested to UTI 2. Cases at the age < 2 mo’ > consider SEPSIS !Strategic Management of UTI according with Age etc. (2) 3, Cases at the age > 2 years + toilet trained > put cleaned-catch mid-stream urine sample 4. Cases at the age > 2 years + untrained > train parents to collect mid-stream urine > choice cleaned-catch urine or trans-urethral catheterization 5. Recurrent Infection >consider “renal scarring, reflux”> penis circumsition & treat constipation > long-term antibiotics for prophylaxis until imaging studies are completedFrequent re-infection > nsider Surgery Consider prophylaxis (ureteric reinplantation) (circumsition & antibiotic)Some antibiotics for acute par-enteral treatment of UTI ao = ANTIBIOTICS DAILY DOSAGE (Ota b cola Piss} Xe Pa ae a Cefotaxime 150mq/kg/d, every 6h Ceftazidine 150mg/kg/d, every 8h Cefazolin 50mg/kg/d, every 8h (er=nle-Ten cela) 7,5mg/kg/d, every 8h Ticarcilllin 300mg/kg/d, every 6h Amoxicillin 100mg/kg/d, every 8h = Time of administration : 48 h, if subsided can be change to oral to 7 — 14 daysSome antibiotics for oral treatment of UTI a ANTIBIOTICS DAILY DOSAGE Amoxicillin 20 — 40mg/kg/d in 3 doses ai ache 6-12mg TMP+ 30-60mg/ka/d in 2 doses (eta 8mqg/kg/d, in 2 doses Cefpodixime 10mg/ka/d, in 2 doses Cefprozil 30mg/kg/d, in 2 doses Cephalexin 40-100mg/kg/d, in 4 doses PMN in Mo) m= Teli N IC ieaLMO MMMM Ts) sc BC ae aE em el Late)Some antibiotics for Prophylaxis of UTI +P ANTIBIOTICS DAILY DOSAGE TMP + SMX 2mg TMP + 10mg SMX/kg as single bedtime dose, or 5mg TMP + 25mg SMX/kg twice per week Nitrofurantoin 1-2mg/kg/d as single dose Sulfisoxazole 10-20mq/kg/d in 2 doses Nalidixic acid 30 mg/kg/d, in 2 doses = Recommended for : children 2 mo’-2 yrs & Recurrent UTI, until imaging studies has been completedWELT reCli Ci eel AO. Pee Management Ba Surgical Management Controversial of Medical vs Surgical : 1. No clear advantage has been shown in many studies 2. Prophylaxis, early detection and treatment of infection are still essential 3. Consideration of Surgical treatment include : Saree ice - deterioration of DMSA appearance 4. But, it is not known how long Antibiotics prophylaxis Ete lf Reo niall)UTI in Neonatal period te Incidence : 0.7% in full-term & almost 3% in preterm babies > / susceptibility continues during the 1* year of life. = Micro-organism : Eschericia Coli, Klebsiella Pneumonia, Protheus Mirabilis, Pseudomonas Aeruginosa, E/S-coccies, and Candida albicans (esp. in preterm infant) = Clinical Symptoms : atypical, + hypothermia, irritable, poor feeding, vomiting. Unexplained jaundice should raise suspicion of Urosepsis a Treatment ~ sepsis > immediate-rational ABPROGNOSIS = Acute simplex UTI > may have good prognosis a always good !!) Ci Coe hace M alee min em ene Rene aoe clear ay] 81k (ep es |e a lites at Oe unm iu renal scarring (> will need long cohort. acme 40 — 50 years !) a Itis likely that the a eT] eal roarll damage lies in the increased Beacon aesets[Eys teri cece tells tc Peeters ait a of younger children with UTI ' : = Neonatal UTI > Prognosis is Tel meeele Gd EoRecommendations 1, The presence of UTI should be considered in ab Infants & young children of 2 mo’ — 2 yrs with unexplained fever 2. The Strategic Management of UTI should be performed related to the children’s age and the severity of illness > follow the Algorithm. 3. The more severe illness of children the sooner antibiotics are immediately given ER DUM n =a) ol tell tia mela olen Men Celeia mci arele)(e} be obtained either by SPA or Trans-urethral bladder catheterization (not by a culture of urine sample collected in a bag) 5. Early detection & prophylaxis of UTI should be well informed to the HC and the communitiesMANY THANKS TO PROF. LYDIA KOSNADI Ceara ato] Pmt os & COLLEAGUES ALWAYS REMEMBER TO THE KINDNESS OF YOU m WE DO HOPE MAY GOD BLESS YOU FOREVER