URINARY TRACT

INFECTION IN CHILDREN
Nadya Magfira
41151096100033

Counselor :
Dr. Ulynar Marpaung, Sp.A
 IDENTITY
Name : Ch. S
Date of birth : 23-01-2013 (4 years
old)
Sex : Female
Address : North Jakarta
Tribe : Javanese
Religion : Islam
Education : Not yet
PARENTS IDENTITY
FATHER MOTHER
Name: Mr. K Name: Mrs. C
Date of birth : 2-04-1972 Date of birth : 26-04-1972
Sex : Male Sex : Female
Address : North Jakarta Address : North Jakarta
Tribe : Javanese Tribe : Javanese
Religion : Islam Religion : Islam
Education : Senior high Education : Junior High
school School
Occupation : private Occupation : private
employee employee
Income : Rp. 3.000.000 Income : Rp. 2.000.000
HISTORY
taken from patients mother in Anggrek Ward Bhayangkara
Hospital Said Sukanto, North-Jakarta at 4-04-2017
DATE
Admission to ER : 3-04-2017
Admission to Anggrek ward : 4-04-
2017
Day of examination : 4-04-2017
Discharged : 7-04-2017
Chief Complaint

Fever since three

days before
admission
 Additional Complaint
Cough, nausea,
vomiting, no
appetite
Present History
FEVER COUGH AND COLD
Fever since 3 days before cough since 3 days
admission sputum +
immeaditely and high advancing every day
meassured temp: 40 C
through out the day
through out the day
not affected by time
fluctuative tempratures
accompanied with runny
not affected by time
nose and sneezing
down after given
paracetamol --> 39 bodrexin syrup --> no
tempra --> no significant significant improvement
change shortness of breath -
Present History
VOMITING
vomiting since 1 days
2/ days
fluid >> food
projectile vomit -
nausea +
lethargic
eager to drink
Urinating and poop -
complaint
Disease Age
Diarrhea -
Otitis -
Pneumonia -
Tuberculosis -
Seizure -
Renal -
Heart -
Blood -
Diphtheria -
Measles -
Mumps -
Dengue fever -
Typhoid fever 2 years old
Worms infection -
Allergy
Accident
-
- PAST
Operation
Others
-
-
HISTORY
Past History
Allergy History

Food allergy: denied

Drugs allergy: denied
Asthma bronchial:
denied
 Food History
Age Breast/for Fruit/ Milk Steam
(month) mula milk biscuit porridge Rice
0-2 Breast milk
2-4 Breast milk
4-6 Breast/form
ula milk
6-8 Breast/form Fruit/ biscuit Milk
ula milk porridge
8-10 Breast/form Fruit/ biscuit Milk
ula milk porridge
10-12 Breast/form Fruit/ biscuit Milk Steam rice
ula milk porridge
 Food History
age more than one years:
Food Frequency and amount
Rice or 3 times per day, portion
replacement
Vegetables 2-3 times per day, portion
Meats 2 times per week
Egg 4 times per week
Fish 4 times per week
Tofu 2 times per day, 1 slice
Tempe 2 times per day, 1 slice
Milk SGM
Others -
Growth and Development
History
motoric development puberty

Prone : 5 month
Sit : 7 month pubic hair : -
stand up : 10 month breast : -
development
walk : 12 month menarche : -
disorder: - month
speak: 18
mental/emotion:
stable
 Marital history
Antenatal care : midwife
Maternity care : midwife
Mode of delivery : normal, spontaneous, no
complication
Gestational age : 38 weeks
Child status :
Weight of birth : 3000 gr
Length of birth : 49 cm
Head circumference : 34 cm
Congenital anomaly :-
 Immunization History
Vaccine Basic (age) Repetition (age)
BCG 3 month
DPT/ DT 2 month 4 month 6 month
Polio 0 month 2 month 4 month 6 month
Measles -
Hepatiti 0 month 1 month 6 month
sB
MMR -
T1PA -
 Family History
The patient's brother suffered from pulmonary TB
at the age of nine years and had completed anti-
tuberculosis drugs for 18 months.
family status Father Mother
Marriage status 1 1
Year of marriage 25 yo 23 yo
Contraception - -
Health status Healthy Healthy

No Age Sex Alive Stillbir Aborti Death Healt

th on (caus h
e) status
1 22 yo Female V - - - Health
y
2 12 yo Male V - - - Health
y
 Housing Data
Home ownership:
private
Home condition :
clean, good
ventilation, good
lightning, good
water condition
Environment:
densely populated
PHYSICAL EXAMINATION
Physical examination was held on april 4th
2017 at anggrek 2 ward Bhayangkara
Hospital, Said Sukanto Jakarta
 General Examination
General condition : looked
moderate ill
Vital sign :
Heart rate : 110 bpm
Respiratory rate : 22 times
Temperature : 39,4
Anthropometry :
Body weight : 15 kg
Body height : 100 cm
 Nutritional Status
WFA: 15/ 16 x100 = 93,7%
HFA: 100/104 x 100 = 96,1 %
WFH: 15/15 x 100 = 100 %

normal nutritional status

 systematical examination
systematically results
examination
Head
- measurement normocephal
- hair and scalp black, normal distribution, strong
Eyes pale conjunctiva -, icteric sclera, sunken -
ENT
- Ears normotia, secret -/-, cement -/-, hyperaemic -/-
- Nose deviation -, nostril breathing -, secret -, oedema
- Throat conca -/-
T2/T2, detritus -, wide crypt - , Pharynx :
hyperaemic +
Mouth
- mouth wet mucosa, stomatitis -, cyanosis -, coplicks spot
- tongue
wet mucosa, clean, tremor
Neck no enlargement of lymph node
 systematical examination
systematically results
examination
chest wall epigastric retraction
Intercostal retraction
pulmo Inspection : symmetric when static and dynamic
Palpation : vocal fremitus +/+
Percussion : sonor +/+
Auscultation : vesicular +/+, rhonchi -/- ,
wheezing -/-
cor Inspection : ictus cordis cant saw
Palpation : ictus cordis felt in ICS V MCS
Percussion :
Margin of right heart : ICS IV PSD
Margin of left heart : ICS V MCS
Margin of waist heart : ICS III PSS
Auscultation : S1S2 regular, murmur -, gallop
 systematical examination
systematically results
examination
abdomen Inspection : even
Auscultation : bowel sound + normal
Palpation : epigastric tenderness +, hepar and
lien not palpable
Percussion : tympani
Other : ballotement pain +/+ palpabel -/-,
CVA pain +/+
Anal and rectum anal exist, diaper rash -, no abnormalities
genital Pubic hair : -
Mons pubis: tanners stage 1
extremity warm, oedema -/-/-/-, CRT < 2s, normal ROM
vertebrae deformity -, kyphosis -, scoliosis -, lordosis -, gibbus

skin cyanosis -, icteric -, petechi
 neurological examination
Physiologic reflex:
Brachioradialis : +2/+2
Biceps : +2/+2
Triceps : +2/+2
Patella : +2/+2
Achilles : +2/+2
Pathologic reflex : -
Motoric :
5555 5 555
5555 5 555
Meningeal sign :-
LABORATORIUM
EXAMINATION
3-04-2017 Until 4-04-2017
 Routine Blood Count
3-04-2017
Results Normal range
Haemoglobin 11,0 12-14 g/dL
Leucocyte 11.500 5.000-10.000 u/dL

Haematocrite 32 37-43 %
Thrombocyte 195.000 150.000-400.000
/uL
Erythrocyte 4,20 4,5-5,5 Thousand
 Results Normal

Urine Color
Clarity
Yelowish
Rather
range


4-04-2017 cloudy
Reaction/ 5,0 5-8,5
pH
Density 1.030 1.000-1.030
Protein - Negative
Bilirubin - Negative
Glucose - Negative
Keton + Negative
Blood/ Hb - Negative
Nitrit - Negative
Urobilinoge 0,1 0,1-1,0 IU
n
Leucocyte + Negative
Sediment:
Leucocyte 7-8 0-5
Eritrocyte - 1-3
Epithel +
Cilinder -
Crystal -
Other Bacteria: +
 Summary
A 4 yo girl came to ER with her parents because
of fever since three days before admission.
Complaints are associated with cough, cold,
nausea, vomiting and no appetite. in physical
examination theres looked moderate ill,
temprature: 39C, pharynx: hyperaemic, tonsil:
T2/T2, abdoment: epigastric tenderness, CVA pain
+/+, ballotment +/+. from additional examination
theres: Leucocyte: 11.500, urine: cloudy,
leucocyte: +, leucocyte: 7-8, bacteria +.
 working diagnosis
Suspect UTI
Acute Tonsilofaringitis
 treatment
IVFD RL 1250 cc/24 jam
Cefotaxime 2 x 750 mg IV
Paracetamol 4 x 150 mg PO
Bicnat 3 x 100 mg PO
Ambroxol 3 x 1 cth PO
 Prognosis
Quo ad vitam : bonam
Quo ad functionam: bonam
Quo ad sanactionam: dubia ad
bonam
follow-up day -2
subject fever <, cough +,
rhinorhea +, nausea <.
Vomit + once daily
objective T: 38 C
ENT: hyperaemic pharynx,
T2-T2
Abdomen:
Inspection: even,
Auscultation: Normal bowel
sound. Palpation:
tenderness , hepar and Palpation:
lien not palpable,
Percussion: tympani. CVA +/
+, Ballotment +/+
lab: CBC:
11.5/6.300/33/185.000/4,28
Diff count: 1/0/0/69/25/5
ESR: 55
assessme suspect UTI, Acute tonsilofaringitis
nt
plan IVFD RL 1250 cc/24 jam
Cefotaxime 2 x 750 mg
IV
Paracetamol 4 x 150 mg
day-3 day-4
fever -, cough + fever -, cough +,
<<, rhinorhea +, rhinorhea -,
nausea -. Vomit -, nausea -. Vomit ,
appetite >> appetite +
T: 36,8 C T: 36,2 C
ENT: hyperaemic ENT: hyperaemic
pharynx - , T2-T2 pharynx - , T2-T2
Abdomen: Abdomen:
Inspection: even, Inspection: even,
Auscultation: Normal Auscultation: Normal
bowel sound. bowel sound.
Palpation:
tenderness , hepar tenderness , hepar
and lien not and lien not
palpable, Percussion: palpable, Percussion:
tympani. CVA -/-, tympani. CVA -/-,
Ballotment -/- Ballotment -/-
IVFD RL 500 cc/24 Cefixime 2 x 50
jam mg PO
Cefotaxime 2 x Paracetamol 4 x
750 mg IV 150 mg PO
URINARY TRACT
INFECTION IN
CHILDREN
LITERATURE REVIEW
URINARY TRACT INFECTION
Grow and breed of germs or microbes in
the urinary tract in significant amounts.
Bacteriuria
Is the presence of bacteria in the urine.
The bacteriuria is meaningful if:
mid-stream, urine catheterization, and
urine collector : 100.000 cfu (colony
forming units)/mL
supra pubic means: in any quantity.
Classification
Clinical manifestation:
Symptomatic : bacteriuria with clinical maifestation
Asymptomatic : bacteriuria wo clinical manifestation
Location of infection:
Upper UTI
Lower UTI
Urinary tract abnormalities:
Simplex UTI/ complicated: with anatomic or functional abnormalities:
VUR
Stone
Anomaly obstruction
Neurogenic bladder
Corpus alienum
Non-simplex UTI/ non-complicated
 Bacteriuria

Symptomati Asymptomati
c c
the presence of bacteria in
the urinary tract without
causing clinical
manifestations
Pyelonephrit
Cystitis
is
Chief complaint: fever Chief complaint:
urinary disturbance;
urgency, frequency,
dysuria
Location of infection

Upper UTI Lower UTI

Clinical manifestation:

Fever, back pain

Laboratorium:

Leucocyte cillinder,
Clinical manifestation:
urinary microglobulin-
2 increased, and Dysuria,
found ACB polakisuria,
Laboratorium urgency
parameter (ESR, CRP,
Neutrofil, PCT etc)
Renal Skintigraphy
Urinary Tract Infection

Uncomplicat
Complicated
ed/ simple
anatomical and / or without any structural
urinary functional nor functional
abnormalities stasis abnormality which can
or reverse flow (reflux) cause statis of the
of urine urine

urinary tract stones

obstruction
urinary tract anomalies
renal cysts
neurogenic bulbs
foreign bodies
etc
Aetiology
 PREDIPOSITION FACTOR
Urine obstruction
Structure abnormalities
Urolithiasis
Corpus alienum
Reflux/ VUR
Etc

Children or baby with UTI their own faces

ascending infection
Pathogenesis of UTI
 Pathogenesis of UTI
E. Coli type globo positive (e.coli who can
attached globo from glycolipids) often
found in pielonephritis inflammation:
High fever
ESR >>
Leukosituria
Ureter dilatation (only - child with
pielonephritis dont show reflux)
Pielonephritis : renal parencyma focal
infection, odema, PMN infiltration
Diagnose
History
Physical examination
Laboratory examination
URINE CULTURE
History
Impaired ability to control the bladder
urination pattern
urine flow
Fever is a symptom and a frequent
clinical sign and is sometimes the only
symptom of UTI in children
Physical examination
vital signs including blood pressure
Anthropometric
mass examination in the abdomen,
bladder, urethra
neurological examination of the lower
extremities, the spine spina bifida
Genitalia Externa: phimosis, hypospadias,
epispadia on male or female vaginal
sinekia in women
AAP recomendations:
Age History Diagnosis
< 2 month Fever Urine culture
2 months Fever of unknown Urine culture
2years origin Treatment as pyelonephritis

Girl 2 months Fever 39 C If 2 or more of these risk

2 years Fever 2 days factors are identified, the
White sensitivity for UTI may be
< 1 years 95% with a specificity of 31%
Fever of
unknown origin
Clinical manifestation
Neonate Infant 1 year 4years
Apathy Fever Seizures
Anorexic weight loss acoarding to high
Ictheric or failure to thrive fever
cholestatis decreased Vomiting
Vomit appetite Diarrhea
Diarrhoea Whiny Dehydration
Fever (sometimes Colic
undetectable) Vomiting > 4 years
Hypothermi Diarrhea
Do not want to Jaundice Local clinical
drink abdominal symptoms:
Oliguria distension dysuria, urgency,
Irritable Pain on kidney frequency,
abdominal palpation bedwetting
distension High fever may be Rare: abdominal
accompanied by pain, lumbago, or
Sometimes just seizures pyrexia
Clinical manifestation

Cystitis Pyelonephritis
Fever rarely exceeds 38 C
Pain in the lower abdomen
High fever accompanied by chills
Urinary disorders:
Symptoms gastrointestinal tract:
Frequency
Nausea
Painful urinating
Suprapubic discomfort Vomiting
Urgency Diarrhea
Difficulty in urination low back pain
Neurologic symptoms can be Irritability and
Urinary retention seizures

Enuresis
Laboratory Examination
Urinalysis
Blood examination
Urine Culture
Urinalysis
Leukosituria (80-90%) Symptomatic, Bacteriuria
may occur in the absence of leukosituria.
Nitrite: describes bacteria in urine, bacteria: nitrate
becomes nitrite
Leukocyte esterase: dipstick test, describes its
many leukocytes
Protein
Blood

Hematuria and uria proteins are sometimes present

in UTI but can not be used as diagnostic indicators.
Urinalysis
UNGAL and uNGAL / Cr (iron carrier
protein) markers of bacterial infection.
UNGAL / Cr> 30 ISK
Bacteria with contrast phase
microscopes:
Uncentrifuged: 107 cfu / LPB
Centrifuged: 105 cfu / LPB
ACB (anti coated bacteri) using
fluorescents labeled immunoglobulin:
unable to function in children
(adolescents and adults)
Blood examination
Leukocytosis
an increase in value of absolute
neutrophils,
increased rate of sedimentation of blood
(ESR)
C-reactive protein (CRP) positive
Procalcitonin cytokine of acute
inflammation pyelonephritis and renal
scar
Urine culture
Spesiment achivement :
Suprapubic aspiration GOLD STANDAR
urine catheter reliable in girls but
traumatic
midstream
urine collector baby and infant
Interpretation:
Supra pubic aspiration: any amount of germs.
Catheterization technique: > 50,000 cfu / mL
Midstream: > 100,000 cfu / mL
Urine collector: > 100.000 cfu / mL
Imaging algorithm
Imaging algorithm
Imaging algorithm
Admission criteria
Acute pyelonephritis
UTI with complications of renal failure
and hypertension
UTI with sepsis or shock
UTI with general toxic conditions
oral difficulties
vomiting and dehydration
Antibiotic
For lower UTI or cystitis: 5 - 7 days, orally
For upper UTI or acute pyelonephritis: 7-
10 days, parenteral.
If after 3-4 days of parenteral antibiotics
appears clinical improvement, treatment may
be continued with oral antibiotics until either
antibiotics are complete or duration of
parenteral and oral administration: 7-10 days
(switch therapy).
Neonate : 10-14 days parenteral
Antibiotics
In developing countries there is high
uropathogenic resistance to:
Ampicillin
Cotrimoxazole
and chloramphenicol
the sensitivity of most pathogenic
pathogens in urine is approximately 96%
against gentamicin and ceftriaxone
Oral antibiotics
Parenteral antibiotics
Antibiotics
Parenteral antibiotics should be
considered in:
toxic
Vomiting
Dehydrated
other urinary tract abnormalities.
If the patient's condition does not
improve within 48 hours, urine culture
should be repeated and consider doing
an imaging check immediately to
determine the urological abnormality.
Referal criteria
UTI is accompanied by complications such as
decreased renal function, hypertension,
urosepsis.
UTIs that do not show improvement with
antibiotics in accordance with the resistance test.
Complex UTI (UTI with obstructive uropathy, RVU,
neurogenic bladder, hydronephrosis, posterior
urethral valve, etc.)
UTI in neonates.
Recurrent UTIs.
When advance imaging examination needed
THANK YOU
Sensitivity and specificity
of components of
urinalysis
BICNAT IN UTI
BICNAT IN UTI
UPPER UTI
 Treatment longevity

1. Sistitis 5-7 hari

2. Pielonefritis 10-14 hari
 Education
ISK reinfeksi 40-50% dalam 2
tahun pengamatan
Parasite infection (cacing benang)
Bubble bath
Pakaian dalam terlalu sempit
Pemakaian deodoran iritatif
Perbaiki status gizi
terhadap mukosa perineum dan
vulva Edukasi pola hidup sehat
Pemakaian toilet paper yang salah Menghilangkan/ mengatasi faktor resiko
Konstipasi Asupan cairan tinggi dan miksi teratur
Tidak mampu mengosongkan VU
secara sempurna
Neurogenic bladder
RVU
Belum sirkumsisi
Profilaksis antibiotik