A 4-year-old girl is brought to the office by her father due to a day of dysuria and lower abdominal pain. The girl has been toilet-trained for a year but had an episode of urinary incontinence last night. The patient was hospitalized at age 2 for fatigue secondary to hemolytic anemia. Workup ultimately revealed a low glucose-6-phosphate dehydrogenase level at baseline. She has had no hematologic complications since then. Physical examination shows mild suprapubic tenderness but no costovertebral angle tenderness. The remainder of the physical examination is unremarkable. Laboratory results are as follows: Which of the following antibiotics should be avoided in this patient?

Question

A 4-year-old girl is brought to the office by her father due to a day of dysuria and lower abdominal pain.  The girl has been toilet-trained for a year but had an episode of urinary incontinence last night.  The patient was hospitalized at age 2 for fatigue secondary to hemolytic anemia.  Workup ultimately revealed a low glucose-6-phosphate dehydrogenase level at baseline.  She has had no hematologic complications since then.  Physical examination shows mild suprapubic tenderness but no costovertebral angle tenderness.  The remainder of the physical examination is unremarkable.  Laboratory results are as follows:  Which of the following antibiotics should be avoided in this patient?

Quizplus · Accepted Answer

11ec25c8_d69b_46f9_bc81_37cadddf966c_MD0003_00 This patient's dysuria, lower abdominal pain, urinary incontinence, and urinalysis findings suggest a urinary tract infection, for which antibiotic therapy is indicated. However, she likely has glucose-6-phosphate dehydrogenase (G6PD) deficiency given her prior hospitalization for hemolytic anemia with low baseline G6PD levels. G6PD deficiency is an inherited disorder associated with episodes of hemolysis during oxidative stress. In these patients, oxidative medications such as nitrofurantoin are particularly likely to trigger hemolysis and must be avoided. Other common oxidative triggers include infections (leukocytes release highly oxidative reactive oxygen metabolites) and fava beans (metabolized into highly oxidative compounds). G6PD deficiency is X-linked and primarily affects male patients. However, female patients who have homozygous mutations or skewed lyonization of heterozygous mutations (overexpression of erythrocytes with the mutated X-chromosome) can also express the disorder. (Choices A, B, C, and D) Penicillin-class medications (eg, amoxicillin) and cephalosporins (eg, cefixime, cefpodoxime, cephalexin) are generally safe to use in patients with G6PD deficiency. Educational objective: Glucose-6-phosphate dehydrogenase deficiency is an X-linked disorder associated with episodes of hemolytic anemia during oxidative stress. In order to prevent hemolysis, oxidative medications such as nitrofurantoin should be avoided. References: Caring for glucose-6-phosphate dehydrogenase (G6PD)-deficient patients: implications for pharmacy. (http://www.ncbi.nlm.nih.gov/pubmed/26417175)

A 4-Year-Old Girl Is Brought to the Office by Her