A 4-year-old boy is brought to the clinic for evaluation of fever and pain with urination. The fever began yesterday morning, and in the evening the patient would cry while urinating. Ibuprofen improved his fever and pain, but he began to vomit this morning. Medical history includes a febrile urinary tract infection at age 13 months that resolved after a course of antibiotics. At that time, a renal and bladder ultrasound was normal. Temperature is 39.1 C (102.4 F). Palpation elicits suprapubic and right-sided costovertebral angle tenderness. Urinalysis reveals positive nitrites and leukocyte esterase. A urine culture shows 100,000 colony-forming units/mL of Escherichia coli. The patient is given antibiotics, and his symptoms resolve in 24 hours. A repeat renal and bladder ultrasound is normal. Which of the following is the best next step in management of this patient?

Question

A 4-year-old boy is brought to the clinic for evaluation of fever and pain with urination.  The fever began yesterday morning, and in the evening the patient would cry while urinating.  Ibuprofen improved his fever and pain, but he began to vomit this morning.  Medical history includes a febrile urinary tract infection at age 13 months that resolved after a course of antibiotics.  At that time, a renal and bladder ultrasound was normal.  Temperature is 39.1 C (102.4 F).  Palpation elicits suprapubic and right-sided costovertebral angle tenderness.  Urinalysis reveals positive nitrites and leukocyte esterase.  A urine culture shows >100,000 colony-forming units/mL of Escherichia coli.  The patient is given antibiotics, and his symptoms resolve in 24 hours.  A repeat renal and bladder ultrasound is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d733_415a_bc81_a39573cdda87_MD0003_00 This child with a history of a febrile urinary tract infection (UTI) now has a second episode of febrile UTI (fever, dysuria, costoverterbal angle tenderness, abnormal urinalysis with positive urine culture). UTIs occur when bacteria (most commonly Escherichia coli) are introduced into the bladder and/or kidneys. Infants often have fever alone, whereas older children may also experience urinary symptoms (eg, dysuria, urgency, frequency, bedwetting) and suprapubic pain. Vomiting and costovertebral tenderness, as seen in this patient, can be signs of renal involvement (eg, pyelonephritis). Recurrent UTIs raise suspicion for a predisposing urologic abnormality, the most common of which is vesicoureteral reflux (VUR). VUR refers to retrograde flow of urine from the bladder to the ureter and renal pelvis. Repeated kidney infections caused by refluxed urine can lead to renal scarring, kidney injury, and hypertension vesicoureteral reflux A renal ultrasound should be obtained following an initial UTI in any child and can be repeated in case of recurrent febrile UTI; it may detect hydronephrosis suggestive of VUR but is not sensitive for the diagnosis. Therefore, a voiding cystourethrogram (VCUG) is often obtained in children with UTI in whom VUR should be excluded. Indications for VCUG include: ≥2 febrile UTIs (as in this patient); abnormal renal ultrasound; fever ≥39 C (102.2 F) with bacteria other than E coli; signs of chronic kidney disease (ie, poor growth, hypertension). If high-grade VUR (eg, grade IV or V) is detected on VCUG, daily antibiotic prophylaxis is considered to prevent further UTIs and renal damage (Choice B). high-grade VUR (Choice A) CT of the abdomen and pelvis can identify renal anomalies but exposes the patient to unnecessary radiation and is not the best modality to detect retrograde urine flow. (Choice C) No additional management is required after a first febrile UTI with normal renal ultrasound. However, because this patient has had a second febrile UTI, VCUG is indicated to assess for VUR. (Choice D) Repeat urine culture in 48 hours may be necessary if there is no response to antibiotics but is not beneficial in 4 weeks to document urine sterility. This patient's symptoms resolved within 24 hours. Educational objective: A voiding cystourethrogram is indicated to assess for predisposing urologic abnormalities (eg, vesicoureteral reflux) in a child with ≥2 febrile urinary tract infections, abnormal renal ultrasound, high fever with an unusual pathogen, or signs of chronic kidney disease. References: Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data. (http://www.ncbi.nlm.nih.gov/pubmed/25089634)

A 4-Year-Old Boy Is Brought to the Clinic for Evaluation