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
Gejala klasik
Pielonefritis
akut

Demam tinggi (39

410C)
Gejala-gejala sistemik
Nyeri tekan pinggang

Neonatus

Demam
Muntah
Jaundice
Tearful, restlessness
Failure to thrive

Manifestasi Klinis
Gejala klasik
Pielonefritis
akut

Demam tinggi (39

410C)
Gejala-gejala sistemik
Nyeri tekan pinggang

Neonatus

Demam
Muntah
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
Strong-smelling urine
Abdominal or flank pain
New onset urinary
incontinence
Dysuria (preschoolers)
Urgency (preschoolers)

Fever
Strong-smelling urine
Abdominal of flank pain
New onset urinary
incontinence
Dysuria
Urgency
Frequency

Adapted from Todd, 1995 (S)

THE CLINICAL DECISION RULE TO IDENTIFY

THE RISK FOR UTI FOR GIRLS
2 YEARS OF AGE
1.
2.
3.
4.
5.

Temperature of 39 C or more
Fever for 2 days or more
White race
Age less than one year
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
Suprapubic aspiration

Transurethral
catheterization

Clean void

Ref. Hellerstein, 1982

Colony count
(pure culture)
Gram-negative bacilli:
any number
Gram-positive cocci:
> a few thousand
> 10
104 to 105
103 to 104
< 103
5

Probability of infection
> 99%

95%
Infection likely
Suspicious; repeat
Infection unlikely

Boy: > 10
Girl: 3 specimens 105
2 specimens 105
1 specimens 105
5 x 104 to 105
10 to4 5 x 104

Infection likely
95%
90%
80%
Suspicious; repeat
Asymptomatic: infection
unlikely

< 104

Infection unlikely

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
2. Semua
3. Semua
4. Semua

neonatus dengan ISK pertama kali

anak laki-laki dengan ISK pertama kali
pasien dengan ISK berulang
pasien dengan pielonefritis

Pemeriksaan radiologi yang direkomendasikan :

Ultrasono grafi (USG),
Vesicocystourethrogram (VCUG)
Scaning DMSA ( Dimercapto succinic acid).

Rekomendasi Departemen Anak FKUI

UTI

< 2 yrs

USG
MCU

normal abnormal

observe IVP/DMSA

2 5 yrs

USG

normal

observe

normal

observe

> 5 yrs

USG

abnormal

MCU

normal

observe

abnormal

IVP/DMSA

abnormal

IVP/DMSA

normal

observe

abnormal

MCU

Algorithm for imaging after urinary tract infection in children