A 5-year-old girl is brought to the clinic for follow-up after being diagnosed with a febrile urinary tract infection 3 days ago. She was prescribed oral antibiotics, which she has been taking for the past 3 days. Despite taking the antibiotics, the patient continues to have a fever and has had 3 episodes of nonbloody, nonbilious emesis. The patient last vomited this morning but has been able to tolerate ice chips. Urine culture grew 100,000 colony-forming units/mL of Escherichia coli, and sensitivities are pending. Temperature is 38.8 C (101.8 F), blood pressure is 110/70 mm Hg, pulse is 144/min, and respirations are 20/min. Bilateral tympanic membranes are clear. The oropharynx is dry but has no exudates or erythema. The lungs are clear to auscultation bilaterally. Bowel sounds are hypoactive. There is tenderness along the left costovertebral angle. In addition to broadening antibiotic coverage, which of the following is the best next step in management of this patient?

Question

A 5-year-old girl is brought to the clinic for follow-up after being diagnosed with a febrile urinary tract infection 3 days ago.  She was prescribed oral antibiotics, which she has been taking for the past 3 days.  Despite taking the antibiotics, the patient continues to have a fever and has had 3 episodes of nonbloody, nonbilious emesis.  The patient last vomited this morning but has been able to tolerate ice chips.  Urine culture grew >100,000 colony-forming units/mL of Escherichia coli, and sensitivities are pending.  Temperature is 38.8 C (101.8 F), blood pressure is 110/70 mm Hg, pulse is 144/min, and respirations are 20/min.  Bilateral tympanic membranes are clear.  The oropharynx is dry but has no exudates or erythema.  The lungs are clear to auscultation bilaterally.  Bowel sounds are hypoactive.  There is tenderness along the left costovertebral angle.  In addition to broadening antibiotic coverage, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d732_cc29_bc81_192afccbc484_MD0003_00 This patient has a urinary tract infection (UTI), which occurs more commonly in young girls due to short urethras and close proximity of the urethral opening to the anus. Escherichia coli is the most common pathogen. Presentation can include fever, dysuria, urgency, or frequency. Urine culture is diagnostic, and empiric antibiotics (eg, third-generation cephalosporin in children) are initiated while awaiting results. Symptoms generally improve by 48 hours of appropriate antibiotic therapy. This patient with a UTI has persistent fever and costovertebral tenderness despite oral antibiotic therapy. These findings are concerning for renal infection, either pyelonephritis or renal abscess. The next steps in management are to broaden antibiotics to cover a resistant organism and to obtain a renal and bladder ultrasound. An ultrasound evaluates kidney involvement as well as anatomic abnormalities that may predispose the patient to UTI (eg, hydronephrosis suggestive of vesicoureteral reflux). (Choice A) Abdominal radiograph can detect constipation, a predisposing factor for UTI. However, x-ray would not detect a renal abscess; therefore, it is not the best imaging modality to evaluate this patient's persistent fever. (Choice B) Although CT of the abdomen and pelvis can also identify a renal abscess, it would expose the patient to unnecessary radiation. (Choice C) Reassurance and follow-up is appropriate for a UTI that is responding to antibiotics. This patient is not improving, and a delay in appropriate treatment could lead to permanent kidney injury. (Choice E) A voiding cystourethrogram is performed after a first febrile UTI if the patient has an abnormal renal ultrasound, high fever with unusual pathogen (ie, not E coli), or signs of chronic kidney injury. Renal ultrasound should first be performed in this patient to rule out renal abscess. Educational objective: Urinary tract infections typically improve within 48 hours of appropriate antibiotic therapy. In children with persistent symptoms (eg, fever), antibiotics should be broadened, and renal and bladder ultrasonography should be obtained to evaluate for anatomic abnormalities or the development of a renal abscess. References: Clinical assessment of children with renal abscesses presenting to the pediatric emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/27876028)

A 5-Year-Old Girl Is Brought to the Clinic for Follow-Up