Curriculum Vitae

Nama
Pekerjaan

: Dr. Sudung O. Pardede, Sp.A(K)

: Staf pengajar Divisi Nefrologi,
Departemen Ilmu Kesehatan Anak
FKUI-RSCM, Jakarta
Riwayat pendidikan:
1982
1992
2002

: dokter umum
: dokter spesialis anak
: dokter spesialis anak konsultan

: FK UKI
: FKUI
: FKUI

Riwayat pekerjaan:
1983
1984 1989

: dokter RSUP Pekanbaru, Riau

: Kepala Puskesmas Kec. Langgam,
Kabupaten Kampar, Riau
1993 sekarang : staf pengajar Departemen IKA FKUI RSCM
1997
: fellow nefrologi di Academisch Ziekenhuis Njimegen,
Nederland
1999 2002
: sekretaris III PP IDAI
2002 2008
: sekretaris I PP IDAI
2008 sekarang: sekretaris umum PP IDAI
1999 sekarang: bendahara KAMAS

Sudung O. Pardede
Department of Child Health
Faculty of Medicine University of Indonesia Cipto Mangunkusomo Hospital
Jakarta

A common health problem

Cumulative incidence: 2%-8% by 10 years

UTI: sign of urinary tract abnormalities
Cause ESRD
Uncomfort symptoms
Unexplained fever in neonates

Definition
Condition in which there is growth of bacteria
within the urinary tract in significant number
Renal parenchymal infection
Lower urinary tract infection

Complications
Short term problems
Acute kidney injuri (AKI)
Urosepsis
Scar formation

Long-term sequela of renal scarring

Hypertension
Proteinuria
Progressive-related complications to ESRD
Pregnancy-related complications
Smellie JM. Clinical Paediatric Nephrology, 1994, p.160-74
Lamber H, Coulthard M. Cilical Paediatric Nephrology, 2003,197-226
Wong SN. Practical Paediatric Nephrology, 2005, 160-7.

Clinical manifestations
Vary depends on age, site of infection, severiy of
inflammation
Neonates:

Non specific
Slow weight gain
Temperature instability
Feeding difficulties
Irritability
Vomiting
Diarrhea
Abdominal distention
Jaundice
Sepsis : 30%

< 1 years:
Fever
Irritability
Sickly appearance
Refusal of food
Vomiting
Diarrhea
Abdominal distention
Jaundice

Preschool and school aged

Dysuria
Urgency
Increased frequency
Enuresis
Flank pain
Fever, chills
Costovertebral tenderness
Macroscopic hematuria

American Academic of Pediatrics

2 months - 2 years:
unexplained fever: UTI is considered
All UTI (particularly with high fever)
considered as pyelonephritis until proven

(strength of evidence: strong)

American Academic of Pediatrics, Pediatrics 1999;103:843-1052

Causes of UTI
Common: E. coli: 60-92%
Other common:

Klebsiella sp.
Proteus sp.
Enterococcus
Enterobacter
Acinetobcter

Less common:

Psedomonas sp.
Group B Streptococcus
Staphylococcus aureus and epidermidis
Staphylococcus saprophyticus
Haemophylus influenzae

Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3rd ed., 2003,p.197-226

Saadeh SA, Ma*oo TK. Pediatr Nephrol 2011

Route of infection

Ascending from urethral orifice bladder

Hematogenous route (neonates)

Table : Hosts factors preventing bacterial

adherence to uroepithelium
Mechanical action of voiding
Tamm Horsfall protein
Bacterial interference by endogenous
periurethral flora
Urinary oligosaccharides
Spontaneous exfoliation of uroepithelial cells
Urinary immunoglobulins
Mucopolysaccharide lining of the bladder wall

Table : Hosts factors predisposing to UTI

in children
Maternal UTI
Lack of breast feeding
Receptors for uropathogen
Defective bladder mucosal factor
Presence of the prepuce
Antibacterial eradication of vaginal flora
Urinary secretory IgA

Table : Hosts factors predisposing to UTI in

children
Anatomic factors:
VUR and intrarenal reflux
Urinary tract obstruction
Foreign body in urinary tract
Duplicated collecting system
Ureterocele

uroepitelial cell adherence

Nonsecretors with blood group antigens

Table. Bacterial factors associated with

uropathogenics virulence of E. coli
P-fimbriae
Capsul
Adhere to uroepithelium
Belongs O and K serotype
Produce hemolysin
Produce colistin V
Produce aerobactin
Resistant to antibacterial action
Ability to grow
Rapid doubling time
Ability to colonize the gut

Bowel ora
Emergence of uropathogenic strains
Perineal & anterior urethral colonizaFon
(vaginal colonizaFon in females)
Normal mucosal defence barries
BACTERIAL
VIRULENCE

CysFFs
Acute pyelonephriFs

Renal scarring

HOST FACTORS
1. Enhanced uroepithelial
adherence
2. VUR
3. Intrarenal reux
4. Obstructed urinary tract
5. Foreign body
(urinary catheter)

Urosepsis

Fig. Pathogenesis of ascending UTI

Laboratory investigation
Urinalysis:
Leucocyturia:
Leucocyte esterase test
Nitrite stick tests
Most bacteria that cause UTI produce nitrite
Specificity : 90-100%, sensitivity 53% (15-82%)
Bacteria take time to produce nitrite
UTI: tends to void more frequent

Hematuria and proteinuria: sensitivity and specificity: low

Phase-contrast microscopy: bacteria

Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3rd ed., 2003,p.197-226

Table : Sensitivity and specificity or components of the

urinalysis alone and combination
Test
Leukocyte esterase
Nitrite
Leukocyte esterase or
nitrite positive
Microscopy: WBCs
Microscopy: bacteria
Leukocyte esterase or
nitrite or microscopy
positive

Sensitivity %
(Range)

Specificity %
(Range)

83 (67-94)
53 (15-82)
93 (90-100)

78 (64-92)
98 (90-100)
72 (58-91)

73 (32-100)
81 (16-99)
99.8 (99-100)

81 (45-98)
83 (11-100)
70 (60-92)

1. Methods of urine collection

a. Suprapubic aspiration: gold standard

b. Catheterization: Sensitivity: 95%; Specificity: 99%
c. Mid-stream specimen
d. Urine collector/bag sample: high false positive

2. Interpretation of culture
Depends of method of urine collections and clinical
manifestations
Kass criteria:
Urine catheterization and mid stream: 100.000 cfu/mL urine
Supra-pubic aspiration: any bacteria

Others: urine catheterization: > 50.000 cfu/mL

Practically: if bacteria:

> 100.000 cfu/mL

: siginificant
10.000 100.000 cfu/mL : doubtfull, must be repeated
1.000 10.000 cfu/mL
: contamination
< 1.000 cfu/mL
: negative.
Usually: one strain bacteria.
If bacteria > 1 strain: contamination

Complex UTI
UTI with anatomical and functional urinary
tract abnormalities which cause stasis of
urine:
Vesico-uretero reflux (VUR)
Hydronephrosis
Urolithiasis
Neurogenic bladder, etc)

Acute pyelonephritis
UTI in neonate

Definition of atypical UTI and recurrent UTI

Atypical UTI
Seriously ill
Poor urine flow
Abdominal or bladder
mass
creatinine
Septicaemia
Failure to respond to treat
with suitable AB within 48
hours
Infection with non E. coli
organisms

Recurrent UTI
2 or more episode of UTI
with acute pyelonephritis
or
1 episode of UTI with
acute pyelonephritis plus
1 or more episode of
cystitis or
3 or more episode of UTI
with cystitis

National Institute for Health and Clinical Excellence. (2007):

Management

1. Eradication of acute
infection
Depends on:
infection location (cystitis vs pyelonephritis)
patients age
severity of presentation
antimicrobial resistance pattern

Empiric therapy should be initiated after urine

specimen for culture has been obtained
Elimination of acute infection and prevent
urosepsis
Reduce/prevent renal parenchyme damage
Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3rd ed., 2003,p.197-226
Saadeh SA, Ma*oo TK. Pediatr Nephrol 2011

Acute pyelonephritis
Hospitalization
10 14 days
Parenteral AB maybe replaced by oral AB after 5
days:

Patient has improved symptomatically

Systemic signs of toxicity have disappeared
Patient: afebrile for 48 hours
Organisme is sensitive to an orally administered AB

Low dose AB prophylaxis for prolonged period

Cystitis
Oral antibiotics
Severe cystitis (pain, vomiting, dehydration):
hospitalization
7-10 days (3-5 days)
Trimetoprim-sulfametokszol, nitrofurantoin,
amoxicillin, amoxicillin-clavulanic, cefixime

UTI in neonate
Commonly associated with sepsis
IV antibiotics
AB: 10 14 days

Table : Some antimicrobials for oral treatment of UTI

Antimicrobial

Dosage

Amoxicillin-clav.
Sulfonamide
TMP in combination
with SMX
Sulfisoxazole
Cephalosporin
Cephalexin
Cefixime
Cefpodixime
Cefprozil

20-50 mg/kg/d in 3 doses

6-12 mg TMP, 30-60 mg
SMX per kg per d in 2 doses
120-150 mg/kg/d in 4 doses
50-100 mg/kg/d in 3 doses
8 mg/kg/d in 2 doses
10 mg/kg/d in 2 doses
30 mg/kg/d in 2 doses

Table: Some antimicrobials for parenteral

treatment of UTI
Antimicrobial

Daily dosage

Ceftriaxone
Cefotaxime
Ceftazidime
Cefazolin
Gentamycin
Tobramycin
Ticarcillin
Ampicillin

75 mg/kg/d
150 mg/kg/d
150 mg/kg/d
50 mg/kg/d
7,5 mg/kg/d
5 mg/kg/d
300 mg/kg/d
100 mg/kg/d

2. Detection and treatment (surgery) of

functional/anatomical urinary tract
abnormalities

Physical examinations
Radiological examinations

Ikatan Dokter Anak Indonesia

(IDAI)
UKK Nefrologi

Konsensus ISK pada Anak

2011

Gambar: Algoritme pencitraan pada bayi (< 6 bulan) dengan ISK

Gambar: Algoritme pencitraan pada anak (6 bulan 3 tahun) dengan ISK

Gambar: Algoritme pencitraan pada anak (> 3

tahun) dengan ISK

3. Detection, prevention, and

treatment of recurrent infection
Urine culture
Treat predisposing factors
Prophylaxis
antibiotics
probiotics

Prophylaxis treatment
Indications:

Children with high risk: obstructive uropathy

High grade VUR (The International VUR Study of Children)
Recurrent UTI
Acute pyelonephritis

Not recommended:
first febrile UTI without VUR or with grade I-II VUR
routinely for the first UTI

Complex UTI: prophylaxis for 3 - 4 months

Children in prophylaxis with reinfection:
Treat with other antibiotic, not to increase the dose
National Institute for Health and Clinical Excellence. (2007):
Montini and Hewitt, Pediatr Nephrol 2009;24:1605-9.

Table: Antibacterial prophylaxis for UTI

Trimetoprim
Co-trimoxazole
Trimetoprim
Sulphamethoxazole
Cephalexin
Nitrofurantoin
Nalidixic
Cefaclor
Cefixime

:1-2 mg/kgbw/d
: 1-2 mg/kgbw/d
: 5-10 mg/kgbw/d
: 10-15 mg/kgbw/d
: 1 mg/kgbw/d
: 15-20 mg/kgbw/d
: 15-17 mg/kgbw/d
: 1-2 mg/kgbw/d

Smellie JM. Clinical Paediatric Nephrology, 1994, p.160-74

Lamber H, Coulthard M. Cilical Paediatric Nephrology, 2003,197-226
Wong SN. Practical Paediatric Nephrology, 2005, 160-7.