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Krisni S Handoko,dr.,Sp.A(K)Lab/SMF Ilmu Kesehatan Anak

FK.Unibraw

RSU Dr.Saiful Anwar Malang

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UTI :

A UTI is a bacterial infection that affects any part of

the urinary tract

Upper UTI / pyelonephritis : kidney parenchyma

Lower UTI / cystitis : bladder

Asymptomatic bacteriuria : urinary symptom -

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ETIOLOGY

Most common organism: E. coli (80%)

Klebsiella, Proteus,Pseudomonas,

Enterobacter

The most common type of UTI is acute cystitis

often referred to as a bladder infection

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PathogenesisColonization with ascending spread

Hematogenous spread

Periurogenital spread of infection

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PATHOGENESISGut flora

Uropathogens

Colonization

Barrier normal mucosa

Cystitis

BACTERIA VIRULENCE HOSTS IMMUNE DEFENCE

1. VUR

2. Intrarenal Reflux

3. Urinary tract obstruction

4. Foreign bodies (cateter )

Acute Pyelonephritis

scarring Urosepsis

Ascending

1. P-fimbrie2. O & K serotype3. Haemolicine4. Colistine V5. Aerobactin6. Bactericidal action resistant

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Risk Factors

Gender

Women are more prone to UTIs than men

because in females, the urethra is much

shorter and closer to the anus than inmales

Lack the bacteriostatic properties of

prostatic secretions.

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Risk Factors

Sexual activity

Related to the frequency of sex

Urinary catheters

Genetics Others

Diabetics

Sickle-cell diseaseAnatomical malformations :

Prostate enlargement

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CLINICAL

History

Acute urethritis

Acute dysuria & urinary hesitancy

Urethral discharge

Fever

Acute cystitis

Dysuria, urgency, hesitancy, polyuria, andincomplete voids

Fever, nausea, and anorexia

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CLINICAL

History

Acute pyelonephritis

Fever, costovertebral angle pain, and

nausea and/or vomiting

Hematuria

Fever and vomiting

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CLINICAL

Physical

Acute cystitis

Suprapubic tenderness to palpation Acute pyelonephritis

Fever

A pelvic examination may reveal findingssuggestive of PID, such as cervical motion

tenderness or vaginal discharge.

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Appendicitis Sepsis, BacterialBladder Cancer Ureteropelvic

Junction ObstructionBladder Stones UrethritisBladder Trauma Pyelonephritis, AcuteCystitis Pyelonephritis,

Chronic

DIFFERENTIAL DIAGNOSIS

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Urinalysis

Bacteriuria : bacteria identified on culture

Significant bacteriuria :

bacteria > 100.000 colony /ml fresh urine

Gold standarddiagnostic UTI

Urine collection

DIAGNOSIS

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Diagnos is o f UTI

Determination of the number and type of bacteria

important diagnostic procedure.

Symptomatic

10

5

CFU bacteria/ml Asymptomatic

105 CFU bacteria/ml on 2 consecutive specimens

Catheterized patients

10

2

CFU bacteria/ml antibiotic, high urea concentration, high osmolarity, low

pH inhibits bacterial multiplication low bacterial

colony counts

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Urinalysis

Offers a number of valuable clues for an accuratediagnosis:

- Color and cloudiness of urine

- Acidity- White blood cells (leukocytes).

Treatment can be started without the need for furthertests if the following urinalysis results are present in

patients with symptoms and signs of UTIs:

- A high white cell count

- Cloudy urine

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Diagnosis

Parameter Normal values UTI

Appearance Yellow Cloudy

pH 4.5-8.5 Alkaline

Protein Negative Positive

Nitrite test Negative Positive

RBC Negative Positive

WBC 0-5 / hpf > 5 / hpf

Cast Negative Positive

Bacteria Absent Many present

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Treatment

Initiate immediately after culture

Reduces severity of renal scarring

Oral route preferred 7-14 day course is standard

2-4 days appears to be as effective

Not yet recommended

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Goals of Therapy

Prevent or treat systemic consequences

Relieve symptoms

Eradicate invading organism

Eliminate uropathogenic bacterial strains

from fecal & vaginal reservoirs

Prevent reoccurrence of infection

Prevent long-term sequelae

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Antimicrobial Selection

Empiric Therapy- based on most probable pathogens- local rates of resistance

- acute infection vs chronic- reinfection or relapse- indwelling catheter etc

Good urine concentration

Minimal effects on fecal and vaginal flora

Acceptable safety profile

Cost-effective

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Ant im icrobial Therapy

Cystitis - usually responds to 3 days of treatment

- effective concentrations into the urine > serum

uncomplicated pyelonephritis - 2 weeks treatment- effective concentrations into the urine = serum

complicated infections / prostatitis - 6 weeks

IV antibiotics may be required in seriously ill

patients, but oral drugs usually effective

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Ant im icrob ial Therapy

Acute Uncomplicated cystitisTrimethoprim/sulfamethoxazole

(TMP/SMX)

1 DS (160/800 mg) BID x 3 days

Fluoroquinolones:

Ciprofloxacin 250 mg BID x 3 days

Levofloxacin 250mg QD x 3 days

Gatifloxacin 200 mg QD x 3 days

Nitrofurantoin: 100 mg QD x 3 days

Cephalosporins, doxycycline,

amoxicillin/clavulanate

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Acute pyelonephritisDuration on therapy= 7-14 days

TMP/SMX

1 DS (160/800 mg) BID x 14 days

Fluoroquinolone

Ciprofloxacin 500 mg BID x 14 days

Levofloxacin 250mg QD x 14 days

Gatifloxacin 250 mg QDx 14 days Cephalosporins, doxycycline,

amoxicillin/clavulanate

For more seriously ill patients IV

therapy

Ant im icrob ial Therapy

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Adults The prognosis for most women with cystitis

and pyelonephritis is good; about 25% of

women with cystitis will experience arecurrence.

The prognosis for emphysematouspyelonephritis is not as good and isdiscussed in Special Concerns.

Infected cysts in polycystic kidney diseaserespond to treatment slowly.

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Children

In industrialized countries, kidney damagewith long-term complications as aconsequence of urinary tract infection per

se is currently less common than in theearly 20th century, when pyelonephritis wasa frequent cause of hypertension and ESRDin young women

This change is probably a result ofimproved overall healthcare and closefollow-up of children after an episode ofpyelonephritis.

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In countries with high-quality healthcare, hypertension,impaired renal function, and ESRD are now mostcommonly encountered in infants with intrauterinerenal damage

Clinically significant urinary tract abnormalities arefrequently identified using intrauterineultrasonography. After birth, these children may incuradditional kidney damage as a result of postnatal

infection, but urinary tract infection is not the majorcause of the kidney impairment. The major causes ofimpaired kidney function are developmentalabnormalities.

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