What's Your Diagnosis? Pediatric UTIs

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Management of Pediatric Toxic Ingestions in the Emergency Department right.

Case Presentation: Management of Pediatric Urinary Tract Infections in the Emergency Department

A 40-day-old girl presents with fever…

The girl has no past medical history and a normal birth history. Her parents say that she felt warm to the touch earlier today, so they took a rectal temperature, which was 100.8°F (38.2°C). They called their pediatrician’s office and were told to take the child to the ED. The parents tell you the girl has otherwise been asymptomatic, has continued to take her regular feeds, and has normal urine output.
On physical examination, the girl is well-appearing, with no focal signs of infection. You initiate a standard workup for a febrile infant. Her CBC, CRP, and procalcitonin are within normal limits, and a blood culture is sent. You obtain urine for a urinalysis via sterile catheterization of the urethra. The urinalysis shows 3+ leukocyte esterase and many bacteria, with no nitrites. You send the urine for culture as well. The girl continues to be well-appearing.
How do you interpret her urinalysis? What further management should you provide?

Case Conclusion

The girl continued to be well-appearing throughout her stay in the ED. Because her serum inflammatory markers were normal and she was well-appearing, according to the AAP febrile infant guidelines, a lumbar puncture was not performed; however, a blood culture was sent. Based on her urinalysis showing leukocyte esterase and bacteria, she was diagnosed with a UTI, and she was prescribed oral cephalexin. Given her well appearance and ability to follow up with her pediatrician the next day, she was discharged home. At follow-up with her primary care provider 24 hours after initiation of antibiotics, she was doing well and the fevers had resolved. Urine culture grew E coli that was sensitive to cephalexin, so this was continued. Her blood culture was negative.