Case Report

Urinary Tract Infection

Presented by:
Widya Manja Putri
(110100064)
Tgk. Nurhasannah
(110100272)
Supervisor:
dr. H. Emil Azlin, SpA(K)

PEDIATRIC DEPARTMENT
HAJI ADAM MALIK GENERAL HOSPITAL
FACULTY OF MEDICINE SUMATERA UTARA UNIVERSITY
MEDAN
2015

is defined by the presence of

organisms in the urinary
tract, which is usually sterile.

< 1 year
Boys (2.7%): girls
(0.7%)

>6
years

Incidences

1 - 5 years
Boys (0.1-0.2% ): girls
(0.9-1.4%)

Ascending infection of the

urinary tract is a complex
process that has been
associated with bacterial
adhesion, virulence, and
host anatomic, humoral, and
genetic factors.

>80%

Escherichia coli

Gram
negative:
Kleibsiella,
Proteus, Enterobacter, and
occasionally Pseudomonas.
Gram-positive:
group
B
Streptococcus,
Enterococcus,
and
Staphlococcus saprophyticus.

More specific signs and

symptoms as the child
grows older.

Nonspecific
lethargy,
decreased
feeding,
increased
sleep,
vomiting,
loose stools,
and
abdominal
pain

High grade fever

A third of these
patients have
some symptoms
of urinary tract
eventually

DIFFERENTIAL
DIAGNOSIS
Emergent
Management of
Pediatric Patients with
Fever
Fever in the Neonate
and Young Child
Nephrolithiasis
Pediatric Appendicitis
Pediatric
Gastroenteritis in
Emergency Medicine
Pinworms
Urinary Obstruction

Gold standart
for diagnose
Urine
culture

Antibiotics
Symptomatic

Case Report
Chief complaint : Fever
FPW, a 2 years and 3 months old male, 8 kg, 74 cm, was admitted
with chief complaint of fever since 2 weeks ago. Fever was
decreased by medication but increased 6 hours later.
Pale (+) since a week ago. Bleeding and history of bleeding (-),
history of cough (+), history of rainy nose (+), history of nausea
and vomiting (-), history of diarrhea (-), history of unclear urine (+)
since 4 weeks ago, the urine was like white milk (pyuria) was found
since 4 weeks ago, followed by discomfort and unsatisfied
micturition. Stool was normal.
History of Pregnancy : Patient was second child. The mother was
twenty nine years old when pregnancy.
History of Birth : Aterm (39 weeks), spontaneous birth with help of
midwife. Birth weight was 2500 gr and birth length was
37 cm.
History of Immunization : BCG, Hepatitis B I and II, Polio I, DPT I
and II, Measles.
Feeding History : From birth to 18 months : Breast milk only

Generalized Status
BW/BL
: 8 kg/74 cm
BW/A, BL/A, and BW/BL : ZS < -3
Presence Status
Sensorium: GCS 15 (E4V5M6) Compos Mentis, Temperature: 37,2 C.
Pale (+), Icteric (-), Dyspnea (+), Cyanosis (-), Edema (-)
Localized Status
Head
: Eye: light reflex (+/+), isochoric pupil, There was inferior
conjunctiva palpebra pale. Ear/Mouth/Nose: within normal limit.
Thorax :Symmetrical fusiform, retraction found at epigastric intercostal
(Kussmaull breathing),
HR: 116 bpm, regular, no murmur
RR: 40 x/minute, regular, crackles and wheezing was not found
in both lung fields.
Abdomen: Soepel, liver and spleen was not palpable, peristaltic (+)
normal
Extremities: Pulse 116 bpm, regular, adequate pressure/volume, warm
on plantar and palmar, CRT < 3, Pitting edema (-), SaO2 : 9496%, BP: 90/50mmHg

Test

Resu Unit
Refere
lt
nce
Complete Blood Count (CBC)
Hemoglo 9,2
G%
10,7bin
17,1
Leucocyt 18,47 103/mm 6,03
e
0
17,5
Hematocr 17,3 %
38-52
it
Thromboc 820
103/mm 2173
yte
497
White Blood Cell Count
Neutrophi 53,5 %
37-80
l
Lymphocy 27,9 %
20-40
te
Monocyte 18,1 %
2-8
Eosinophi 0,1
%
1-6
l
Creatinin
: 3,67
Basophil: 11,09
0,4
%
0-1
GFR
Procalcitonin
: 78,72
Anion Gap : 135 ( 109 + 3,6 ) =
22,4

Test

R Unit
Refer
es
ral
ul
t
Arterial Blood Gas Analysis
pH
7,047 7,357,45
pCO2
13,4
mmHg 38-42
pO2
95,5
mmHg 85100
HCO3
3,6
mmHg 22-26
Total CO2
4
mmHg 19-25
BE
-24,9 mmHg (-2)
+2
Sa02
99
%
95100
Carbohydrate Metabolism
Random
122,4 mg/dL
< 200
Blood
Glucose
Electrolyte
Calcium
8,8
mg/Dl
8,4(Ca)
10,8
Natrium
135
mEq/L
135(N)
155
Kalium (K) 4,0
mEq/L
3,6-

Diagnose : dd/ Urinary tract infection, Chronic

pyelonephritis, Chronic glomerulonephritis +
Anaemia ec dd/ Chronic disease, Fe deficiency +
metabolic acidosis
Therapy:
bed rest
Inj. Ampicillin 400 mg / 6 hrs IV
Inj. Ceftriaxone 400 mg/12hrsIV
Paracetamol Syrup 3 x cth
Fluid balance / 6 hours
Follow up Vital sign
Diagnostic Planning:
Complete Blood Count (CBC), Arterial Blood
Gas Analysis (AGDA), electrolyte
Dipstick
Urinary culture
Urinary tract ultra-sonography

Follow up (25th Mei 2015)

S Fever (-) T: 37,0oC

O Presence Status
Sens.: GCS 15, CM, T: 37,0 C. Pale (+), Icteric (-), Dyspnea (-),
Cyanosis (-), Edema (-)
Localized Status
Head
: There was inferior conjunctiva palpebra pale.
Thorax: Symmetrical fusiform, retraction (-)
HR: 116 bpm, reg, murmur (-), RR: 40 x/minute, reg, crackles
and wheezing (-)
Abdomen: within normal limit
Extremities: Pulse 116 bpm, reg, adequate pressure/volume, warm on
plantar and palmar, CRT < 3, Pitting edema (-), SaO2 : 9496%, BP: 90/50mmHg
Urogenital : Male: scrotum, penis, anus were found.
A dd/ Urinary tract infection, Chronic pyelonephritis, Chronic
glomerulonephritis + Anaemia ec dd/ Chronic disease, Fe deficiency +
metabolic acidosis
P

bed rest
Inj. Ampicillin 400 mg / 6 hrs IV
Inj. Ceftriaxone 400 mg/12hrsIV
Paracetamol Syrup 3 x cth

Follow up (26th Mei 2015)

S Fever (-) T: 37,2oC
O Presence Status
Sens.: GCS 15, CM, T: 37,2 C. Pale (-), Icteric (-), Dyspnea (-),
Cyanosis (-), Edema (-)
Localized Status
Head
: There was inferior conjunctiva palpebra pale.
Thorax: Symmetrical fusiform, retraction (-)
HR: 116 bpm, reg, murmur (-), RR: 24 x/minute, reg, crackles
and wheezing (-)
Abdomen: within normal limit
Extremities: Pulse 116 bpm, reg, adequate pressure/volume, warm on
plantar and palmar, CRT < 3, Pitting edema (-), BP:
110/80mmHg
Urogenital : Male: scrotum, penis, anus were found.
A dd/ Urinary tract infection, Chronic pyelonephritis, Chronic
glomerulonephritis + Anaemia ec dd/ Chronic disease, Fe deficiency
P bed rest
Inj. Ampicillin 400 mg / 6 hrs IV
Inj. Ceftriaxone 400 mg/12hrsIV
Paracetamol Syrup 3 x cth
Labs result: Urinary culture: aerobic bacteria Staphylococcus aureus,

Follow up (28th Mei 2015)

S Fever (-) T: 37,2oC
O Presence Status
Sens.: GCS 15, CM, T: 37,2 C. Pale (-), Icteric (-), Dyspnea (-),
Cyanosis (-), Edema (-)
Localized Status
Head
: There was inferior conjunctiva palpebra pale.
Thorax: Symmetrical fusiform, retraction (-)
HR: 112 bpm, reg, murmur (-), RR: 24 x/minute, reg, crackles
and wheezing (-)
Abdomen: within normal limit
Extremities: Pulse 112 bpm, reg, adequate pressure/volume, warm on
plantar and palmar, CRT < 3, Pitting edema (-), BP:
110/80mmHg
Urogenital : Male: scrotum, penis, anus were found.
A dd/ Urinary tract infection ec Staphylococcus aureus + Anaemia ec dd/
Chronic disease, Fe deficiency
P

bed rest
Inj. Ampicillin 400 mg / 6 hrs IV
Inj. Ceftriaxone 400 mg/12hrsIV
Paracetamol Syrup 3 x cth

Discussion
Case

Theory

Male, 2 years and 3 months old

In children aged 1-5 years, the annual

incidence of UTI is 0,9-1,4% for girls
and 0,1-0,2% for boys

Chief complaint of fever since 2

weeks ago.
Pale (+) since a week ago.
History of unclear urine (+) since
4 weeks ago, the urine was like
white milk (pyuria) was found
since 4 weeks ago, followed by
discomfort
and
unsatisfied
micturition.

Fever remains a more common

presentation in the neonates, infants,
and younger children whereas older
children present with other symptoms.
80% of the fever > 38oC.
Dysuria, frequency,, new onset
incontinence, flank pain can also be
the main symptom of UTI in younger
children.

Hb decrease: 9,2
Leucocyte increase: 18.470
Ht decrease: 7,3
Platelet increase: 820.000
Creatinin: 3,67
Procalcitonin: 78,72
AGDA: metabolic acidosis

When the child appears sick, a CBC,

CRP, blood culture, and procalcitonin
should be obtained to evaluate for
sepsis. Blood culture is usually done
for sick-looking children.
Elevation of serum procalcitonin is
reported to correlate with pyelonefritis

Discussion
Case

Theory

Therapy:
bed rest
Inj. Ampicillin 400 mg / 6
hrs IV
Inj. Ceftriaxone 400
mg/12hrsIV
Paracetamol Syrup 3 x
cth
Fluid balance / 6 hours
Follow up Vital sign

First-line agents include amoxicillin,

TMP-SMX, nitrofurantoin, and
cephalosporin. Total duration of
therapy should be 7-14 days

Urinary culture:
Aerobic bacteria Staphylococcus
aureus, cefoxitin resistant,
screening test (+) MRSA,
sensitive: nitrofurantoin,
tigecycline, tetracycline
Dipstick: leu/nit: +++/-

Common pathogens causing UTI

include Pseudomonas and
Staphylococcus aureus.
Nitrite are generated form the
breakdown of dietary nitrate by
bacteria and leucocyte esterase is the
breakdown product of white cells.

THANK YOU