Enhanced Urinalysis dengan urin Mid-Stream sebagai uji diagnostik infeksi saluran kemih pada anak

MUSIM, Prof.Dr.dr. M.P. Damanik, Sp.AK

2007 | Tesis | S2 Ilmu Kedokteran Klinik (Ilmu Kesehatan Anak)

Infeksi saluran kemih (ISK) merupakan infeksi paling sering pada anak sesudah otitis media dan pharyngitis, dengan prevalensi 4,1-7,5%. Diagnosis ISK sering mengalami kendala karena gejala yang tidak spesifik pada anak. Hasil kultur urin (gold standard) baru bisa diperoleh paling cepat sesudah 48 jam. Selain itu, pemeriksaan dipstick (leukosit esterase, nitrit) dan mikroskopik tidak dapat diandalkan karena akurasinya relatif rendah. Metode enhanced urinalysis (kombinasi penghitungan leukosit urin dengan hemocytometer dan pengecatan Gram untuk bakteriuria) dengan urin tanpa sentrifus mulai populer dan akurasinya perlu dievaluasi. Semua penelitian tersebut dilakukan pada anak <2 tahun dengan urin kateter. Penelitian ini bertujuan untuk menilai sensitivitas, spesifisitas, positive predictive value, negative predictive value, akurasi dan likelihood ratio dari enhanced urinalysis dengan sampel urin mid-stream untuk diagnosis ISK anak, dengan pemeriksaan kultur urin sebagai gold standard. Subyek penelitian adalah anak berumur 3-12 tahun di Poliklinik/Bangsal Anak RS Dr. Sardjito dengan diagnosis klinis ISK dan kooperatif untuk pengambilan sampel urin mid-stream. Subyek diperoleh dengan consecutive sampling. Uji reliabilitas pada 15 sampel dengan desain inter-rater reliability dengan two-way random effects model. Uji diagnostik pada 220 sampel dengan desain cross-sectional, dengan kultur urin sebagai gold standard. Pada setiap subyek dilakukan pengumpulan sampel urin mid-stream dan pemeriksaan dilakukan dalam waktu 1 jam. Untuk uji reliabilitas, dua orang petugas dipilih secara acak untuk memeriksa jumlah leukosit urin (dengan hemocytometer), kemudian dilakukan penghitungan intraclass correlation coefficient sesuai tipe ICC(2,1) beserta 95% confidence interval-nya. Untuk uji diagnostik, satu sampel urin dibawa ke bagian Mikrobiologi laboratorium Patologi Klinik RS Dr. Sardjito untuk pemeriksaan bakteri urin (pengecatan Gram) dan pemeriksaan angka kuman (kultur urin). Sampel lainnya dibawa ke bagian Hematologi untuk pemeriksaan jumlah leukosit urin (dengan hemocytometer). Dilakukan blinding pada semua petugas laboratorium. Analisis statistik menggunakan statistik deskriptif (beserta confidence interval) untuk menunjukkan sensitivitas, spesifisitas, positive predictive value, negative predictive value, akurasi dan likelihood ratio dari enhanced urinalysis untuk diagnosis ISK.

Urinary tract infection (UTI) is amongst the most common infections in children after otitis media and pharyngitis, with a prevalence ranged from 4.1– 7.5%. UTI diagnosis is always problematic due to its unspecific symptoms in children. The result of urine culture, which is the gold standard, can only be obtained as fast as 48 hours, thus treatment will be delayed. In addition to that, the dipstick (leukocyte esterase and nitrite) and microscopic examination are not reliable due to their relatively low accuracy. Enhanced urinalysis method, a combination of urine leukocyte count with hemocytometer and Gram staining to evaluate bacteriuria for unspun urine, is now popular and it’s accuracy need to be evaluated. Research on enhanced urinalysis have been done in children under 2 years old with urine sample from catheter. This study aims to evaluate the sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood ratio of enhanced urinalysis with mid-stream urine sample to diagnose UTI in children, compared with bacterial count from urine culture as the gold standard. The study subject is children aged 3-12 years old who visit Dr. Sardjito Hospital’s Pediatrics Outpatient and Inpatient Ward with UTI. The children should be cooperative in order to get the mid-stream urine sample. Subject will be selected using consecutive sampling. Reliability study will be done in 15 subjects with inter-rater reliability design and two-way random effects model. Diagnostic study with cross-sectional design will be done in 220 subjects, using urine culture as the gold standard. Mid-stream urine sample will be collected from each subject and the test will be done in 1 hour after sampling. For reliability study, two randomly selected laboratory technicians will perform urine leukocyte count (with hemocytometer) and intraclass correlation coefficient with its 95% confidence interval will be computed using ICC(2,1) model. For diagnostic study, one of the urine sample will be sent to Microbiology Department in the Clinical Pathology Laboratory of Dr. Sardjito Hospital for urinary bacterial examination (using Gram staining) and culture. The other sample wil be sent to Hematology Department for urine leukocyte count examination using hemocytometer. All laboratory technicians will be blinded. Statistical analysis using descriptive analysis (with confidence interval) will be done in order to describe the sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood ratio of enhanced urinalysis for UTI diagnosis in children.

Kata Kunci : Diagnosis Infeksi Saluran Kemih,Urin,Mid Stream dan Enhanced Urinalysis, reliability study, diagnostic test, urinary tract infection, mid-stream urine, enhanced urinalysis