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CASE REPORT

URINARY TRACT INFECTION

Prepared by:

Yosephine Simanjuntak (140100223)


Yulia Sianturi (140100097)

Supervisor:

dr. Hj. Tiangsa br. Sembiring, M. Ked (Ped), Sp.A (K)

PROGRAM PENDIDIKAN PROFESI KEDOKTERAN


DEPARTEMEN ILMU KESEHATAN ANAK
FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA
`MEDAN
2018
Case Report KepLily
Irsa, Sp.A(K)
Urinary Tract Infection

Presentator : Yosephine Simanjuntak (140100223)


Yulia Sianturi (140100097)
Day/Date : Thursday/November 22nd 2018
Academic Advisor : dr. Hj. Tiangsa Sembiring, M. Ked(Ped), Sp.A(K)

INTRODUCTION

Urinary tract infection (UTI) is defined as colonization of a pathogen


occurring anywhere along the urinary tract (kidney, ureter, bladder, and urethra).1
The prevalence of UTI in neonates ranged from 0.1% to 1%, and increased to
14% in neonates with fever, and 5.3% in infants. In asymptomatic infants, bacteriuria
is found 0.3 to 0.4%. The risk of UTI in children before puberty is 3-5% in girls and
1-2% in boys. In children with fever aged less than 2 years, the prevalence of UTI is
3-5%.2
Clinical signs and symptoms of a UTI depend on the age of the child.
Newborns with UTI may present with jaundice, sepsis, failure to thrive, vomiting, or
fever. In infants and young children, typical signs and symptoms include fever,
strong-smelling urine, hematuria, abdominal or flank pain, and new-onset urinary
incontinence. School-aged children may have symptoms similar to adults, including
dysuria, frequency, or urgency. Boys are at increased risk of UTI if younger than six
months, or if younger than 12 months and uncircumcised. Girls are generally at an
increased risk of UTI, particularly if younger than one year. Physical examination
findings can be nonspecific but may include suprapubic tenderness or costovertebral
angle tenderness.3
The definitive diagnosis of UTI in young children requires semi-quantitative
culture of urine obtained by SPA or catheterisation.4 Rapid urine tests (also known as
dipsticks or macroscopic urinalysis) remain useful for diagnosis of UTI. The nitrite
test measures the conversion of dietary nitrate to nitrite by Gram-negative bacteria.5
Various laboratory tests can be carried out to help establish the diagnosis and
differentiate upper and lower UTIs, but most of these examinations are not specific.
Leukocytosis, an increase in absolute neutrophil values, a positive increase in blood
sedimentation rate (LED), C-reactive protein (CRP), is a non-specific indicator of a
UTI.2
Imaging procedures with the highest ratings from the American College of
Radiology Appropriateness Criteria for further evaluation of select children with UTIs
are renal and bladder ultrasonography, radionuclide cystography or voiding
cystourethrography, and renal cortical scan.3
Properly managed children rarely progress to renal failure unless they have
uncorrectable urinary tract abnormalities. However, repeated infection, particularly in
the presence of vesicoureteral reflux, is thought (but not proved) to cause renal
scarring, which may lead to hypertension and end-stage renal disease. In children with
high-grade vesicoureteral reflux, long-term scarring is detected at a 4- to 6-fold
greater rate than in children with low-grade vesicoureteral reflux and at an 8- to 10-
fold greater rate than in children without vesicoureteral reflux.6
The aim of this case is to report a 6 months old girl with diagnose of recurrent
urinary tract infection.

CASE
FS, a 6 months old girl, was admitted to Haji Adam Malik Medan General
Hospital on Tuesday, 16 October 2018 at 14.30 WIB with the main complain of
bloody urine. Bloody urine was experienced since 2 day before admission to hospital,
the patient was irritated/cried during urination. The volume of urine couldn’t be
assessed because the patient uses diapers, the color of urine was red-ish. History of
bloody urine was found since a month ago and also reoccurred again a week ago.
Fever has been experienced within the past 5 days with high temperature, the highest
temperature was 38,9°C. The fever went down by taking antipyretic medicine. Fever
was not accompanied by shivering or seizures. Vomiting was not present. Patient was
initially a polyclinic patient, who has experienced bloody urine and has been
diagnosed with urinary tract infection by the pediatrician a month ago, the patient was
given oral antibiotic treatment but the patient’s mother forgot the name of the drug
given. The patient had done microbiology urine test 1 week ago and showed that the
patient is resistant to cephalosporin, cotrimoxazole, ciprofloxacin.
Maternal pregnancy history: Maternal age when pregnant was 25 years old.
Patient’s mother routinely checked herself during pregnancy and had antenatal care
control. History of illness during pregnancy was not found, fever (-), hypertension (-),
diabetes mellitus (-), drugs (-).
Birth history: Patients was born normally and assisted by the midwife. Aterm,
birth weight 3000 grams, cyanosis was absent, cried immediately. The patient got an
injection in her upper left leg before taken home.
Immunization history: BCG, polio, DPT and hepatitis B immunization.
History of illness: Urinary Tract Infection
History of drug use: Paracetamol.
Dietary habit: The patient is still given exclusive breastfeeding.

Physical Examination
Present status:
Awareness: GCS 15 (E4V5M6) Temperature 38,2°C,
BW: 6,1 kg BW / A: -2 < Z < 0 BW / BL: -1 < Z < 0
BL: 63 cm BL / A : -2 < Z < 0
General condition: fair Disease state: moderate Nutritional state: Normal
There was no dyspnea, anemia, jaundice, cyanosis, and edema.

Localized Status:
Head:
 Face : Symmetrical
 Eyes : Light reflexes on both eyes are present, both pupils were
isochoric with diameter of 2 mm, inferior palpebral
conjungtiva no pale, no icteric sclera nor ptosis.
 Nose : The nose was normal without nose flares and there were no
septum deviation nor redness on the mucosa of the nose.
 Mouth : Mouth also appeared normal without cyanosis and pursed lip
breathing, no cyanotic tongue.
Neck : Normal with no lymph node or thyroid enlargement.
Thorax : Symmetrical fusiform, no retraction
HR : 90 x/min, reguler no murmur
RR : 20 x/min, regular no rhonchi
Abdomen : Peristaltic sound was normal. Liver//renal not palpable
Extremities : Pulse 90 x / min, regular, warm acral, CRT < 2". Blood
pressure was 90/60 mmHg
Genital : Female

Laboratory Finding
The result of laboratory check done in Haji Adam Malik Medan General Hospital was
issued on 16/10/2018, and the result was as follow:
Examination Lab Blood Count Result Value (<1 years old)
Hemoglobin : 9.0 (10.5 – 13.1) g/dL
Erythrocyte : 3.45 (3.6 – 5.2) x 106/µL
Leukocyte : 17.890 (6.000 – 17.500) /µL
Hematocrit : 28.00 (35 – 43) %
Thrombocyte : 384.000 (229.000 – 553.000) /µL
MCV : 81 (74 – 102) fl
MCH : 26.10 (23.0 – 31.0) pg
MCHC : 32.10 (28.0 – 32.0) g/dl

Differential Counting
Neutrophil (segmented) : 29.00% (25.00 – 60.00)
Lymphocyte : 52.70% (25.00 – 50.00)
Monocyte : 6.70% (1.00 – 6.00)
Eosinophil : 11.40% (1.00 – 5.00)
Basophil : 0.2% (0.00 – 1.00)
Diabetes :
Glucose ad random : 80 (33 - 111)

Urine Culture (08/10/2018)


Bacteria : Escherichia coli
Drugs Result Drugs Result
Cefoperazone/Sulbactam S Ampicilin R
Tigecycline S Ceftazidime R
Fosfomycin S Cefotaxime R
Piperacillin/Tazobactam S Gentamicin R
Chloramphenicol S Amoxicillin/Clavulanic acid R
Meropenem S Ceftriaxone R
Amikacin S Ofloxacin R
Ciprofloxacin R Cefuroxime R
Norfloxacin R Tetracyclin R
Cotrimoxazole R Azithromycin R

Differential Diagnosis
- Recurrent Urinary Tract Infection
- Acute glomerulonephritis
- Nephritic syndrome

Diagnosis
Recurrent Urinary Tract Infection

Therapy
- Bed rest
- Diet High Calorie High Protein 610 kkal
- IVFD NaCl 0,45% D 5% 25gtt/i micro
- Amikacin 90 mg/ 12 hours
- Paracetamol syr 3 x XXX tsp

Planning
- Lab blood count
- Routine urinalysis
- Kidney USG

Follow Up
Follow Up 16/10/2018 :
S: The bloody urine was still present, fever still present. There was no dyspnoea,
anemia, jaundice, cyanosis, and edema.
O: Sensorium: Patient’s awareness was compos mentis with temperature of 38,2˚C,
The head shape appeared normal, the face appeared symmetrical, light reflexes on
both eyes are present, both pupils were isochoric with diameter of 2 mm, no inferior
palpebral conjungtiva paleness and no icteric sclera. The nose was normal without
nose flares. Mouth also appeared normal without cyanosis and pursed lip breathing,
no cyanotic tongue. The neck was normal with no lymph node or thyroid
enlargement. The chest was normal, it was symmetrical fusiform, with heart rate of 90
beats/min, regular without murmur, respiratory rate of 20 breaths/min, regular without
ronchi or stridor. In the abdomen examination, the peristaltic was found normal, liver,
spleen, and kidney were not palpable. Pulse in the extremity was 90 pulses/min,
regular, acral was warm, with capillary refill time of less than 2 seconds. Genitalia
was female.

Laboratory Examination
The result of laboratory check done in Haji Adam Malik Medan General Hospital was
issued on 16/10/2018, and the result was as follow:
Examination Lab Blood Count Result Value (<1 years old)
Hemoglobin : 9.0 g/dL (10.5 – 13.1)
Erythrocyte : 3.45 x 106/µL (3.6 – 5.2)
Leukocyte : 17.890 /µL (6.000 – 17.500)
Hematocrit : 28.00% (35 – 43)
Thrombocyte : 384.000 /µL (229.000 – 553.000)
MCV : 81 fl (74 – 102)
MCH : 26.10 pg (23.0 – 31.0)
MCHC : 32.10 g/dl (28.0 – 32.0)
Differential Counting
Neutrophil (segmented) : 29.00% (25.00 – 60.00)
Lymphocyte : 52.70% (25.00 – 50.00)
Monocyte : 6.70% (1.00 – 6.00)
Eosinophil : 11.40% (1.00 – 5.00)
Basophil : 0.2% (0.00 – 1.00)
Diabetes :
Glucose ad random : 80 (33 - 111)

Urine Microbiology (08/10/2018)


Drugs Result Drugs Result
Cefoperazone/Sulbactam S Ampicilin R
Tigecycline S Ceftazidime R
Fosfomycin S Cefotaxime R
Piperacillin/Tazobactam S Gentamicin R
Chloramphenicol S Amoxicillin/Clavulanic acid R
Meropenem S Ceftriaxone R
Amikacin S Ofloxacin R
Ciprofloxacin R Cefuroxime R
Norfloxacin R Tetracyclin R
Cotrimoxazole R Azithromycin R

A: Recurrent Urinary Tract Infection

P : - Diet High Calorie High Protein 610 kkal


- IVFD NaCl 0,45% D 5% 25gtt/i micro
- Amikacin 90 mg/ 12 hours
- Paracetamol syr 3 x 60 – 90 mg

Follow Up 17/10/2018
S: The bloody urine was still present, fever still present. There was no dyspnea,
anemia, jaundice, cyanosis, and edema.
O: Sensorium: Patient’s awareness was compos mentis with temperature of 37,9˚C,
The head shape appeared normal, the face appeared symmetrical, light reflexes on
both eyes are present, both pupils were isochoric with diameter of 2 mm, no inferior
palpebral conjungtiva paleness and no icteric sclera. The nose was normal without
nose flares. Mouth also appeared normal without cyanosis and pursed lip breathing,
no cyanotic tongue. Dry lips mucosa was not found. The neck was normal with no
lymph node or thyroid enlargement. The chest was normal, it was symmetrical
fusiform, with heart rate of 88 beats/min, regular without murmur, respiratory rate of
24 breaths/min, regular without rhonchi or stridor. In the abdomen examination, the
peristaltic was normal, the skin pinch goes back faster, liver, spleen and kidney were
not palpable. Pulse in the extremity was 88 pulses/min, regular, acral was warm, with
capillary refill time of 2 seconds. Genitalia was female.

A : Recurrent Urinary Tract Infection

P : - Diet High Calorie High Protein 610 kkal


- IVFD NaCl 0,45% D 5% 25gtt/i micro
- Amikacin 90 mg/ 12 hours
- Paracetamol syr 3 x 60 – 90 mg

Planning

- Kidney ultrasonography

Follow Up 19/10/2018
S : Bloody urine was still present but decreased, fever was found.
O: Sensorium: Patient’s awareness was compos mentis with temperature of 37,7˚C,
The head shape appeared normal, the face appeared symmetrical, light reflexes on
both eyes are present, both pupils were isochoric with diameter of 2 mm, no inferior
palpebral conjungtiva paleness and no icteric sclera. The nose was normal without
nose flares. Mouth also appeared normal without cyanosis and pursed lip breathing,
no cyanotic tongue. Dry lips mucosa was not found. The neck was normal with no
lymph node or thyroid enlargement. The chest was normal, it was symmetrical
fusiform, with heart rate of 96 beats/min, regular without murmur, respiratory rate of
20 breaths/min, regular without rhonchi or stridor. In the abdomen examination, the
peristaltic was normal, liver, spleen, and kidney were not palpable. Pulse in the
extremity was 96 pulses/min, regular, acral was warm, with capillary refill time less
than 2 seconds. Genitalia was female.

Laboratory Examination
The result of laboratory check done in Haji Adam Malik Medan General Hospital was
issued on 19/10/2018, and the result was as follow:
Urinalysis Result Value (<1 years old)
Density : 1.005 (1.005 – 1.030)
pH : 6.0 (5 – 8)
Nitrit : Positive Negative
Leucocyte : Positive
Leucocyte : 8 – 10 <6
Epitel :0–1
Casts : Negative Negative
Crystal : Negative
Complete Urine
Color : cloudy yellow Yellow
Glucose : Negative Negative
Bilirubin : Negative Negative
Keton : Negative Negative
Protein : Negative Negative
Urobilinogen : Negative
Blood : Negative Negative
FCM :
Erythrocyte :4–6 <3

Kidney/Urinary Tract USG :


there are no abnormalities in the kidneys and bladder

A : Recurrent Urinary Tract Infection

P : - Diet High Calorie High Protein 610 kkal


- IVFD NaCl 0,45% D 5% 25gtt/i micro
- Amikacin 90 mg/ 12 hours
- Paracetamol syr 3 x 60 – 90 mg

Follow Up 22/10/2018
S : Bloody urine and fever was not present.
O: Sensorium: Patient’s awareness was compos mentis with temperature of 36,7˚C,
The head shape appeared normal, the face appeared symmetrical, light reflexes on
both eyes are present, both pupils were isochoric with diameter of 2 mm, no inferior
palpebral conjungtiva paleness and no icteric sclera. The nose was normal without
nose flares. Mouth also appeared normal without cyanosis and pursed lip breathing,
no cyanotic tongue. Dry lips mucosa was not found. The neck was normal with no
lymph node or thyroid enlargement. The chest was normal, it was symmetrical
fusiform, with heart rate of 92 beats/min, regular without murmur, respiratory rate of
20 breaths/min, regular without rhonchi or stridor. In the abdomen examination, the
peristaltic was normal, liver, spleen, and kidney were not palpable. Pulse in the
extremity was 92 pulses/min, regular, acral was warm, with capillary refill time less
than 2 seconds. Genitalia was female.

Laboratory Examination:
The result of laboratory check done in Haji Adam Malik Medan General Hospital was
issued on 22/10/2018, and the result was as follow:
Urinalysis Result Value (<1 years old)
Complete Urine
Color : clear yellow Yellow
Glucose : Negative Negative
Bilirubin : Negative Negative
Keton : Negative Negative
Density : 1.010 (1.005 – 1.030)
pH : 6.0 (5 – 8)
Protein : Negative Negative
Urobilinogen : Negative
Nitrit : Negative Negative
Leucocyte : Negative
Blood : Negative Negative

FCM :
Erythrocyte :0–1 <3
Leucocyte :0–1 <6
Epitel :0–1
Casts : Negative Negative
Crystal : Negative

A : Recurrent Urinary Tract Infection

P : - Diet High Calorie High Protein 610 kkal


- IVFD NaCl 0,45% D 5% 25gtt/i micro
- Amikacin 90 mg/ 12 hours
- Paracetamol syr 3 x 60 – 90 mg

Planning

- Outpatient care

Patient was discharged Tuesday, 23rd October 2018 around 14:45 PM after the
instruction from supervisor and would be outpatient.

DISCUSSION
UTIs are relatively common in children. By seven years of age, 8 percent of
girls and 2 percent of boys will have at least one episode. Common uropathogens
include Escherichia coli (accounting for approximately 85 percent of UTIs in
children), Klebsiella, Proteus, Enterobacter, Citrobacter, Staphylococcus
saprophyticus, and Enterococcus.3 The specific pathogen that was found in this
patient’s urine culture was Gram-negative bacteria, Escherichia coli, the most
common pathogens that can cause UTI.
Anatomical factors and alterations also play an important role in the
pathogenesis of UTI in women. The shortness of the urethra, with its close
relationship to the anus, makes it easy for bacteria to ascend in the urinary tract. In
women, fecal-perineal-urethral contamination is the most probable explanation for
infections caused by enteric bacteria, as demonstrated by experiments evaluating the
genotype of Escherichia coli strains causing UTI in women. 7
Table 1. Presenting Symptoms and Signs of Childhood UTI by Age Groups5
Presenting symptoms and signs
Age groups Diagnosis
Common Less Common
Vomiting, poor
Neonates, infants UTI Fever feeding

Hematuria
Young children (Non- Offensive, cloudy
UTI Irritability
toilet trained) urine

High fever Abdominal pain


Pyelonephritis Malaise
Vomiting, Loin pain
Older children (Toilet
Hematuria
trained) Dysuria
Cystitis Offensive, cloudy
Voiding dysfunction urine

Similar to the reference, the patient in this report has also been diagnosed with
UTI with clinical manifestation of fever, irritability, and hematuria. Fever and
irritability are the common presenting symptoms and signs, while hematuria is the
less common one.5 From physical examination can be found abdominal pain,
abdominal distention, or flank pain.3 Based on the physical examination carried out
on this patient was found no specific abnormality.
From laboratory examination, urinalysis and dipstick tests for UTI were
examined to find the increasing of leukocyte esterase, nitrite, blood, and protein.3 The
nitrite test measures the conversion of dietary nitrate to nitrite by Gram-negative
bacteria. A positive nitrite test makes UTI very likely, but the test may be falsely
negative if the bladder is emptied frequently or if an organism that does not
metabolize nitrate (including all Gram-positive organisms) is the cause of infection.
The leukocyte esterase test is an indirect measure of pyuria and, therefore, may be
falsely negative when leukocytes are present in low concentration. A microscopic
urinalysis is useful to determine whether there are white blood cells in the urine,
which is a sensitive indicator of inflammation associated with infection.5 From this
case, the nitrite, leukocyte, eritrocyte were positive. No specific blood test result to
identify UTI. From blood test can be found leukocytosis, an increase in absolute
neutrophil values, a positive increase in blood sedimentation rate (LED), C-reactive
protein (CRP), is a non-specific indicator of a UTI.2 Similar to the reference, the
patient has increased leukocyte. From the sensitivity test based on urine culture, the
patient was resistant to quinolone, cotrimoxazole, ampicillin, cephalosporin,
amoxicillin/clavulanate, however still sensitive to amikacin, tigecycline, fosfomycin,
chloramphenicol, tazobactam.
Imaging procedures for further evaluation of select children with UTIs are
renal and bladder ultrasonography, they are effective for evaluating anatomy.3 Based
on the renal ultrasonography carried out on this patient was found no specific
abnormality.
Table 2. Some Empiric Antimicrobial Agents for Treatment of UTI2

Antibiotics Dose
Aminoglycosides
- Gentamicin (IV) 7,5 mg/kgBW/days (divided per 6 hours)
- Amikacin (IV) 15 mg/kgBW/days (divided per 12 hours)
Cephalosporins
- Cefixime (Oral) 8 mg/kgBW/days (divided into 2 doses)
- Cefprodixime (Oral) 10 mg/kgBW/days (divided into 2 doses)
- Cefprozil (Oral) 30 mg/kgBW/days (divided into 2 doses)
- Cephalexin (Oral) 50-100 mg/kgBW/days (divided into 4 doses)
- Ceftriaxone (IV) 75 mg/kgBW/days
- Cephotaxime (IV) 150 mg/kgBW/days (divided per 6 hours)
- Cephtadizime (IV) 150 mg/kgBW/days (divided per 6 hours)
- Lorakarbef (Oral) 15-30 mg/kgBW/days (divided into 2 doses)
Penicillins
- Amoxicillin (Oral) 20-40 mg/kgbW/days (divided into 3 doses)
Sulfonamid
- Trimetroprim (TMP) – 6-12 mg TMP and 30-60 mg SMX
/kgBW/days (divided into 2 doses)
sulfametoksazol (SMX) (Oral)

The therapeutic purpose of UTI is to eradicate the specific bacteria and prevent
further complications such as renal scarring, which may lead to hypertension and end-
stage renal disease.6 In addition to causal therapy for infection, supportive and
symptomatic therapy must also be considered, for example treatment of fever and
vomiting. Fluid therapy must be adequate to ensure good diuresis. 2
In this case, the patient was given the following treatment during the admission:
 Hydration with D5% NaCl 0,45% fluid with 15 drips/minutes (micro) to
maintain fluid balance.
 Amikacin 15 mg/kgBW/days (divided per 12 hours). Patient was given
Amikacin because she is already resistant to quinolone, cotrimoxazole,
ampicillin, cephalosporin, amoxicillin/clavulanate, however still sensitive to
amikacin, tigecycline, fosfomycin, chloramphenicol, tazobactam.
 Paracetamol as antipyretic 10-15 mg/kgBW/times.

This shows that the treatment has been corresponding between the reference and
field application.
The following evaluation should be monitored tightly:
 Urinalysis
 Dipstick test
Properly managed children rarely progress to renal failure unless they have
uncorrectable urinary tract abnormalities. However, repeated infection, particularly in
the presence of vesicoureteral reflux, is thought (but not proved) to cause renal
scarring, which may lead to hypertension and end-stage renal disease as
complications. In children with high-grade vesicoureteral reflux, long-term scarring is
detected at a 4- to 6-fold greater rate than in children with low-grade vesicoureteral
reflux and at an 8- to 10-fold greater rate than in children without vesicoureteral
reflux.6

CONCLUSION
There have been reported case of a 6 months old girl with diagnose of recurrent
urinary tract infection. Diagnosis is made based on the history taking, physical and
laboratory examination. In general, the prognosis in this children is good as so long as
it is treated well and immediately.
REFERENCES

1. Chang SL, Shortliffe L. Pediatric Urinary Tract Infections. Pediatr Clin N Am.
2006; 53: 379-400.
2. Pardede S, Tambunan T, Alatas H, et al. Konsensus Infeksi Saluran Kemih Pada
Anak. 2011.
3. White B. Diagnosis and Treatment of Urinary Tract Infections in Children.
American Family Physician. 2011 Feb; 83(4);409-415.
4. World Health Organization Department of Child and Adolescent Health and
Development. Urinary Tract Infections in Infants and Children in Developing
Countries in the Context of IMCI. 2005.
5. Robinson J, Finlay J, Lang ME, et al. Urinary tract infection in infants and
children: Diagnosis and management. Paediatr Child Health. 2014;19(6):315-19.
6. Weinberg G. Urinary Tract Infection (UTI) in Children. Available from:
https://www.msdmanuals.com/professional/pediatrics/miscellaneous-bacterial-
infections-in-infants-and-children/urinary-tract-infection-uti-in-
children#v1092698t (Accessed: 27 October 2018).
7. Minardi L, D’Anzeo G, Cantoro D, et al. Urinary tract infections in women:
etiology and treatment options. Int J Gen Med. 2011;4:333-43.