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. The patient is admitted to the hospital, and intravenous antibiotics are started. Urine culture is positive for pansensitive Escherichia coli. Blood culture is negative. After 48 hours, the patient is tolerating oral fluids and is afebrile. The patient is discharged from the hospital on oral antibiotics. Which of the following should be recommended to prevent recurrence of this patient's infection?

Question

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. The patient is admitted to the hospital, and intravenous antibiotics are started.  Urine culture is positive for pansensitive Escherichia coli.  Blood culture is negative.  After 48 hours, the patient is tolerating oral fluids and is afebrile.  The patient is discharged from the hospital on oral antibiotics.  Which of the following should be recommended to prevent recurrence of this patient's infection?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfcc_996d_8f63_a7fe4ba22e1d_MD0005_00 Dysfunction of the bowel and bladder is an important risk factor for urinary tract infection (UTI) in toddlers who are toilet training. Children may develop abnormal elimination habits, such as stool withholding and incomplete defecation, which lead to functional constipation. Fecal retention causes rectal distension, which can obstruct bladder emptying. Incomplete, dysfunctional voiding results in stagnant urine, which promotes microbial growth, increasing the risk for UTI. rectal distension obstruct bladder emptying A thorough history should include assessment of dietary intake, precipitating factors (eg, toilet training), and stool consistency and frequency. Management includes increasing dietary fiber and water intake as well as titrating laxative use (eg, polyethylene glycol) to produce soft, regular bowel movements. (Choice A) Primary nocturnal enuresis is defined by the inability to achieve nighttime dryness in children age >5, and a common first step in management is enuresis alarm therapy. However, this patient is only age 3, and the first step in improving her continence is to treat her constipation. (Choice C) Evaluation and treatment of constipation is necessary to prevent dysfunctional voiding and recurrent UTIs. (Choice D) Prophylactic antibiotics are often indicated in patients with vesicoureteral reflux, which is diagnosed by voiding cystourethrogram in patients with recurrent, febrile UTIs. Prophylactic antibiotics are not indicated for a patient with a single, uncomplicated UTI. (Choice E) Repeat urine culture may be indicated in patients with continued symptoms while on antibiotic therapy to ensure adequate treatment of infection. However, it is not indicated in patients with clinical resolution of a treated UTI and does not change management. Educational objective: Chronic constipation can prevent complete bladder emptying and promote urinary stasis, a risk factor for development of urinary tract infections. References: The association of constipation with childhood urinary tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/18947551) Bladder and bowel dysfunction in children: an update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. (http://www.ncbi.nlm.nih.gov/pubmed/28265323)

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