Diagnosis

Infeksi Saluran
Kemih (ISK)
MASALAH ISK PADA ANAK

ISK sering ditemukan pada anak

Angka kejadian : 2-8 %, < 6
tahun
Di Indonesia : ISK 25,4%
penyakit ginjal anak yang
dirawat
Gejala tidak selalu jelas
Pielonefritis anak < 2 tahun

8-40 % parut ginjal
DEFINISI ISK
Adalah keadaan adanya
infeksi (adanya
pertumbuhan dan
perkembang biakan
mikroorganisme) dalam
saluran kemih, meliputi
infeksi di parenkim ginjal
sampai infeksi di kandung
kemih dengan jumlah
bakteriuria yang
bermakna.
Bensman A, Dunand O, Ulinski T.Urinary tract infection.Dalam: Avner ED, Harmon WE, Niaudet P, Yashikawa N,
penyunting. Pediatric Nephrology .Edisi ke 6. Berlin Heidelberg : Springer Verlag ; 2009: 1299-30.
TERMINOLOGY
SIGNIFICANT BACTERIURIA
The presence of > 100.000 CFU/ml fresh voided clean catch
or
catheterized urine specimen

SYMPTOMATIC UTI
Clinical symptoms: dysuria, frequency, urgency
with or without fever and flank pain
1. Acute cystitis (lower UTI)
2. Acute pyelonephritis

ASYMPTOMATIC BACTERIURIA (ABU)RECURRENT UTI

- Repeated symptomatic episode of UTI with symptom-free
intervals
- Caused by reinfection

RELAPSE UTI:
persistence of the same bacterial species
 Manifestasi Klinis

Demam tinggi (39

Gejala klasik
410C)
Pielonefritis
Gejala-gejala sistemik
akut
Nyeri tekan pinggang

Demam
Muntah
Neonatus Jaundice
Tearful, restlessness
Failure to thrive
 Manifestasi Klinis

Demam tinggi (39

Gejala klasik
410C)
Pielonefritis
Gejala-gejala sistemik
akut
Nyeri tekan pinggang

Demam
Muntah
Neonatus Jaundice
Tearful, restlessness
Failure to thrive
Infant / Toddler
Fever of unknown origin (FUO)
Diarrhea
Restlessness
Diaper rash
Failure to thrive

School Age Periods

Local symptomas / signs
Dysuria, polakisuria, urgency
Loin pain, enuresis
 Clinical signs and symptoms of UTI
Newborns Infants and Preschoolers School Age Children
Jaundice
Sepsis Diarrhea
Failure to thrive Failure to thrive
Vomiting Vomiting Vomiting
Fever Fever Fever
Strong-smelling urine Strong-smelling urine
Abdominal or flank pain Abdominal of flank pain
New onset urinary New onset urinary
incontinence incontinence
Dysuria (preschoolers) Dysuria
Urgency (preschoolers) Urgency
Frequency

Adapted from Todd, 1995 (S)

THE CLINICAL DECISION RULE TO IDENTIFY
THE RISK FOR UTI FOR GIRLS
2 YEARS OF AGE

1. Temperature of 39 C or more
2. Fever for 2 days or more
3. White race
4. Age less than one year
5. Absence of another potential source of fever

2 variables Predicted UTI:

- Sensitivity: 0.95 (95% CI: 0.85; 0.99)
- Specificity: 0.31 (95% CI: 0.28; 0.34)

Gorelic and Shaw, 2000

 Jaundice: Early diagnostic sign
of UTI in infancy

Maybe the first sign of a UTI

7,5% of asymptomatic jaundice infant < 8 weeks old

RSCM : 24 out of 38 jaundice infant

Garcia FJ, Pediatrics, 2002.

Oswari et al, Sari Pediatr, 2005
 Diagnostic approach
History & Standard check list
1. Voiding pattern - onset, frequency, urgency
- hold the urine
2. Wetting - nighttime, daytime, or
combination
- night wetting/week
- wake with wetting
- deep sleeper?
- family history
3. UTI - dysuria, bad odour, cloudy colour
4. Stream - push or wait to initiate voiding
abnormality - strong or weak stream?
- start and stop?
- stream straight?
5. Bowel function - frequency, hard or soft stool
Physical examination
Full exam is essential!

growth
vital sign
G-I tract
urogenital
neurologic
Skin over the spine: hair tuft, dimple
Urogenital

GIRLS: Synechia vulvae

BOYS: - Phimosis

- Postitis / Balano-postitis
Diagnosis Biakan urin

METHODS OF URINE COLLECTION

Mid-Stream specimen
Bag sample: high false rate
Suprapubic puncture: gold STD
Catheterization: Sensitivity: 95%
Specificity: 99%
 Criteria for the diagnosis of urinary tract infection*
Method of collection Colony count Probability of infection
(pure culture)
Suprapubic aspiration Gram-negative bacilli: > 99%
any number
Gram-positive cocci:
> a few thousand
Transurethral 95%
catheterization > 105
Infection likely
104 to 105 Suspicious; repeat
103 to 104 Infection unlikely
< 103
Clean void Infection likely
Boy: > 10 5
95%
Girl: 3 specimens 105 90%
2 specimens 105 80%
1 specimens 105 Suspicious; repeat
5 x 104 to 105 Asymptomatic: infection
10 to4 5 x 104 unlikely

< 104 Infection unlikely

Ref. Hellerstein, 1982

Dugaan infeksi

Mikroskopik urin : - lekosit> 10 /LPB

- Bakteri (+)
HUICOL et al: Pediatr Infect Dis J, 2002

Sampel urin segar < 1

jam

- Piuria, torak leukosit

- Uji kimia : lekosit esterase test, nitrit
PEMERIKSAAN RADIOLOGI

Indikasi :
1. Semua neonatus dengan ISK pertama kali
2. Semua anak laki-laki dengan ISK pertama kali
3. Semua pasien dengan ISK berulang
4. Semua pasien dengan pielonefritis

Pemeriksaan radiologi yang direkomendasikan :

Ultrasono grafi (USG),
Vesicocystourethrogram (VCUG)
Scaning DMSA ( Dimercapto succinic acid).
Rekomendasi Departemen Anak FKUI

UTI

< 2 yrs 2 5 yrs > 5 yrs

USG USG USG
MCU
normal abnormal normal abnormal
normal abnormal
observe MCU observe IVP/DMSA
observe IVP/DMSA

normal abnormal normal abnormal

observe IVP/DMSA observe MCU

Algorithm for imaging after urinary tract infection in children