Krisni S Handoko,dr.,Sp.

A(K)
Lab/SMF Ilmu Kesehatan Anak FK.Unibraw RSU Dr.Saiful Anwar Malang

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 -

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

Pathogenesis
Colonization with ascending spread Hematogenous spread Periurogenital spread of infection

PATHOGENESIS

Gut flora Uropathogens Colonization

Barrier normal mucosa

Cystitis BACTERIA VIRULENCE
1. 2. 3. 4. 5. 6. P-fimbrie O & K serotype Haemolicine Colistine V Aerobactin Bactericidal action resistant HOSTS IMMUNE DEFENCE

1. VUR 2. Intrarenal Reflux 3. Urinary tract obstruction 4. Foreign bodies (cateter )

Acute Pyelonephritis

scarring

Urosepsis

Ascending

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 in males Lack the bacteriostatic properties of prostatic secretions.

Risk Factors
Sexual activity
Related to the frequency of sex

Urinary catheters Genetics Others Diabetics Sickle-cell disease Anatomical malformations : Prostate enlargement

CLINICAL
History Acute urethritis Acute dysuria & urinary hesitancy Urethral discharge Fever Acute cystitis Dysuria, urgency, hesitancy, polyuria, and incomplete voids Fever, nausea, and anorexia

CLINICAL
History Acute pyelonephritis Fever, costovertebral angle pain, and nausea and/or vomiting Hematuria Fever and vomiting

CLINICAL
Physical

Acute cystitis
Suprapubic tenderness to palpation Acute pyelonephritis Fever A pelvic examination may reveal findings suggestive of PID, such as cervical motion tenderness or vaginal discharge.

DIFFERENTIAL DIAGNOSIS
Appendicitis Bladder Cancer Bladder Stones Bladder Trauma Cystitis Sepsis, Bacterial Ureteropelvic Junction Obstruction Urethritis Pyelonephritis, Acute Pyelonephritis, Chronic

DIAGNOSIS
Urinalysis Bacteriuria : bacteria identified on culture Significant bacteriuria : bacteria > 100.000 colony /ml fresh urine Gold standard diagnostic UTI Urine collection

Diagnosis of UTI
Determination of the number and type of bacteria important diagnostic procedure. Symptomatic 105 CFU bacteria/ml Asymptomatic 105 CFU bacteria/ml on 2 consecutive specimens Catheterized patients 102 CFU bacteria/ml antibiotic, high urea concentration, high osmolarity, low pH inhibits bacterial multiplication low bacterial colony counts

Urinalysis
Offers a number of valuable clues for an accurate diagnosis: - Color and cloudiness of urine - Acidity - White blood cells (leukocytes). Treatment can be started without the need for further tests if the following urinalysis results are present in patients with symptoms and signs of UTIs: - A high white cell count - Cloudy urine

Diagnosis
Parameter Normal values UTI

Appearance
pH Protein Nitrite test RBC WBC Cast Bacteria

Yellow
4.5-8.5 Negative Negative Negative 0-5 / hpf Negative Absent

Cloudy
Alkaline Positive Positive Positive > 5 / hpf Positive Many present

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

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

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

Antimicrobial 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

Antimicrobial Therapy
Acute Uncomplicated cystitis
Trimethoprim/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

Antimicrobial Therapy
Acute pyelonephritis
Duration 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

Adults

The prognosis for most women with cystitis and pyelonephritis is good; about 25% of women with cystitis will experience a recurrence. The prognosis for emphysematous pyelonephritis is not as good and is discussed in Special Concerns. Infected cysts in polycystic kidney disease respond to treatment slowly.

Children In industrialized countries, kidney damage with long-term complications as a consequence of urinary tract infection per se is currently less common than in the early 20th century, when pyelonephritis was

a frequent cause of hypertension and ESRD in young women

This change is probably a result of improved overall healthcare and close follow-up of children after an episode of pyelonephritis.

In countries with high-quality healthcare, hypertension, impaired renal function, and ESRD are now most commonly encountered in infants with intrauterine renal damage Clinically significant urinary tract abnormalities are frequently identified using intrauterine ultrasonography. After birth, these children may incur additional kidney damage as a result of postnatal infection, but urinary tract infection is not the major cause of the kidney impairment. The major causes of impaired kidney function are developmental abnormalities.