A 3-year-old girl is brought to the emergency department due to pain and fever. Two days ago, she developed mild abdominal and back pain. Her fever began yesterday morning and reached a maximum of 40.1 C (104.2 F) last night. Over the last 8 hours, she had 6 episodes of emesis but has since tolerated a few sips of water. The girl has a history of constipation since the start of toilet training at age 2 and has "pellet-like" stools once a week. She has frequent urinary accidents during the day and night. She takes no medications and has no other medical problems. Immunizations are up to date. Temperature is 40 C (104 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 20/min. Physical examination shows a tired-appearing girl with dry mucous membranes. She has right costovertebral tenderness. The abdomen is soft, nontender, and nondistended. The remainder of the examination is unremarkable. Laboratory results are as follows: A 20-mL/kg normal saline bolus is administered. The patient has another episode of emesis and an additional void in the emergency department. Item 1 of 2 Which of the following best describes the appropriate management plan for this patient?

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Explanation: 11ec2b69_bfcc_243a_8f63_0355a6a677e5_MD0005_00 Pyelonephritis is a kidney infection that typically presents with fever, nausea/vomiting, and flank/suprapubic pain. Additional findings include costovertebral angle tenderness, pyuria (eg, leukocyte esterase on dipstick analysis or >5 WBC/hpf on microscopy), and bacteriuria. Risk factors include female sex and a history of bladder and bowel dysfunction, as in this girl with chronic constipation. Initial management of suspected urinary tract infections (UTIs), including pyelonephritis, includes empiric systemic antibiotic therapy (eg, 3rd-generation cephalosporins). Intravenous antibiotics are indicated for patients with hemodynamic instability, the inability to tolerate oral medications (ie, persistent vomiting), or failure of improvement on oral antibiotics. Infants age <2 months are at increased risk of sepsis and should also be initially treated intravenously (Choice B). (Choice A) Renal ultrasound is indicated in children with febrile or recurrent UTIs. Imaging should be performed after completion of treatment as renal inflammation during acute illness can lead to false-positive results. (Choice C) The height of the fever does not influence the decision to treat with oral versus intravenous antibiotics if the patient is otherwise hemodynamically stable. Persistent fevers in a patient on oral therapy could warrant intravenous therapy. (Choice E) Oral antibiotics are first-line therapy for a UTI in a hemodynamically stable child with the ability to tolerate oral medications. This patient requires intravenous therapy to ensure adequate delivery of medication and can be transitioned to oral therapy if oral intake improves. Educational objective: Pyelonephritis is a kidney infection that presents with fever, nausea/vomiting, and flank pain. Intravenous antibiotics are indicated for patients who are unable to tolerate oral medication, have failed oral antibiotics, or are hemodynamically unstable. References: Antibiotics for acute pyelonephritis in children. (http://www.ncbi.nlm.nih.gov/pubmed/25066627) Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis. (http://www.ncbi.nlm.nih.gov/pubmed/18074149)

A 3-Year-Old Girl Is Brought to the Emergency Department Due