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Peds ID Abx QOTW #16 Answer

a) Admit for IV antibiotics as she failed outpatient therapy

d) Order STI screening labs

UTI or Something Else?

  • The first clue in this case is the growth of an atypical organism
  • Common urinary pathogens include
    • Gram negative rods (E.coli, Klebseilla spp. other enteric organisms)
    • Staphylococcus saprophyticus
    • Group B streptococcus
  • Uncommon pathogens
    • Staphylococcus aureus – if found in urine should consider bacteremia if not recent urogenital procedures (Cystoscopy with stent, nephrostomy tubes, etc.)
    • Enterococcus spp. – usually this is just a colonizer unless obstruction and can be ignored
  • Nearly never a pathogen and if found may suggest contaminated sample
    • Diptheroids, Candida spp. (although if symptomatic may be vaginitis, not UTI), other bowel flora including viridians streptococcus group
  • The clue here is the low WBC count in the urine and atypical organism
  • For such significant symptoms, consider obstruction with stone or other anatomic abnormality
  • If ultrasound does not show hydronephrosis, alternative diagnosis should be sought
  • CT should be secondary to ultrasound in young patients as an imaging modality

Treatment of UTI/Pyelonephritis  

  • Ciprofloxacin was used for treatment of this patient
    • Not unreasonable given working diagnosis
    • Common side effects of ciprofloxacin include nausea and vomiting
  • Drug choice in UTI/Pyelonephritis
    • Macrobid or TMP-SMX is recommend for simple UTIs
    • Resistance maybe over estimated because urinary concentrations are well above MICs
    • Ciprofloxacin x 7 days is recommended for pyelonephritis
    • Bactrim x 14 days is recommended for pyelonephritis
    • Recent article suggested 7 days may have similar clinical outcomes
    • Keflex x 10-14 days (3rd line) is recommended for pyelonephritis
    • A first dose of ceftriaxone is recommended if symptoms are more severe given resistance
      • It should be noted that ~20% of E.coli are now resistant to ciprofloxacin
      • For our institution the exact urinary E.coli resistance rates are not known

STI Evaluation 

  • Given patient’s age and symptoms, and unusual organism growing, antibiotic stewardship service recommend evaluation for STI
  • Patient had a history of Chlamydia infection as well, so STI should be suspected as part of this patient’s constellation of symptoms
  • Patient was found to have Trichomonas vaginalis and was treated with resolution of symptoms
    • Metronidazole 2gm x 1 was given
    • After 1 day of IV therapy, her other antibiotics were discontinued
    • Ceftriaxone was given
  • Other STI workup was done as well
  • HIV testing should be done routinely for patients like this, as well as if seen recurrently for such complaints, either with PMD or in ED
    • Remember the ED maybe the only place such patients are seen