A 4-year-old girl is brought to the emergency department for evaluation of bloody diarrhea. Five days ago, she developed vomiting and diarrhea. The vomiting resolved, but she continued to have 4-5 episodes of diarrhea per day. The patient then developed bloody stools last night. She has had minimal fluid intake in the last 24 hours and has been sleeping most of the day today. Her younger brother had similar symptoms this week and required hospitalization 2 days ago for dehydration; his stool culture was positive for Escherichia coli O157:H7. The patient has no chronic medical conditions and has not traveled outside of the country. Temperature is 37.1 C (98.8 F), blood pressure is 120/70 mm Hg, pulse is 150/min, respirations are 30/min. She appears tired and anxious on physical examination. The oral mucosa appears dry, and capillary refill is 4 seconds. The remainder of the physical examination is unremarkable. The patient is admitted to the hospital for further management. Which of the following is the most appropriate therapy for this patient's condition?

Question

A 4-year-old girl is brought to the emergency department for evaluation of bloody diarrhea.  Five days ago, she developed vomiting and diarrhea.  The vomiting resolved, but she continued to have 4-5 episodes of diarrhea per day.  The patient then developed bloody stools last night.  She has had minimal fluid intake in the last 24 hours and has been sleeping most of the day today.  Her younger brother had similar symptoms this week and required hospitalization 2 days ago for dehydration; his stool culture was positive for Escherichia coli O157:H7.  The patient has no chronic medical conditions and has not traveled outside of the country.  Temperature is 37.1 C (98.8 F), blood pressure is 120/70 mm Hg, pulse is 150/min, respirations are 30/min.  She appears tired and anxious on physical examination.  The oral mucosa appears dry, and capillary refill is 4 seconds.  The remainder of the physical examination is unremarkable.  The patient is admitted to the hospital for further management.  Which of the following is the most appropriate therapy for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d691_f814_bc81_a11b03860294_MD0003_00 Shiga toxin-producing Escherichia coli O157:H7 (STEC) is an enterohemorrhagic strain of bacteria that is most commonly transmitted via ingestion of undercooked beef. Shiga toxin invades the colonic epithelial wall and produces abdominal pain, vomiting, and bloody diarrhea about 3-4 days after exposure. Diagnosis is confirmed by stool culture. Hemolytic uremic syndrome (HUS) is a complication that occurs in <10% of patients with STEC and is characterized by the classic triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. It is most common in children age <5. The risk of HUS is increased in patients who have received antibiotics or antimotility agents (eg, loperamide) to treat the diarrhea. Therefore, treatment of E coli O157:H7 infection is supportive care only (eg, rehydration). (Choices A, B, and C) Azithromycin, ceftriaxone, and ciprofloxacin are treatment options for bloody diarrhea due to a Shigella infection, which is less commonly implicated in the development of HUS. In contrast to STEC infection, antibiotics decrease the length of illness in Shigella infections and do not increase the risk of HUS. (Choice E) Antibiotic therapy with trimethoprim-sulfamethoxazole is indicated for severe (eg, hospitalized) or high-risk (eg, infants) cases of Salmonella gastroenteritis in children. Diarrhea in Salmonella infection is bloody in a minority of cases and often resolves on its own. (Choice F) Vancomycin or metronidazole is the treatment for Clostridium difficile infection, which causes profuse watery diarrhea and abdominal cramping following antibiotic (eg, clindamycin) use. Bloody diarrhea is rare. Educational objective: Treatment of infections due to Shiga toxin-producing Escherichia coli O157:H7 is supportive care only. Antibiotics increase the risk of developing hemolytic uremic syndrome. References: Shiga toxin producing Escherichia coli. (http://www.ncbi.nlm.nih.gov/pubmed/26004641) Enterohemorrhagic Escherichia coli (EHEC). (http://www.ncbi.nlm.nih.gov/pubmed/30137794)

A 4-Year-Old Girl Is Brought to the Emergency Department for Evaluation