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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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