A 3 yo female presents with fever, dysuria, and frequency for about 2 days.
A 3 yo female presents with fever, dysuria, and frequency for about 2 days. Mother report she cries when she urinates. The mother reports child does not have any nausea or vomiting. She reports she is allergic to Penicillin.
Labs: UA: ++ leukocytes, + nitrates, + blood
Diagnosis
Urinary Tract Infection
1. Discuss what are the potential treatments for this child’s diagnosis
2. What antibiotic/s should be given for this patient’s diagnosis?
3. How long should you prescribe the chosen antibiotic?
4. What teaching would you give this child’s parents on the prescription
5. Write out a correct prescription for the antibiotic you are going to prescribe for this patient. (Be sure to include all elements needed for a correct prescription)
UTI in children is common, with girls being at higher risk that boys, and often caused by organisms that are from the intestinal flora, with Escherichia coli accounting for about 85 to 90% of cases (Mattoo et al, 2021). According to the CDC, treatment with antibiotics for asymptomatic children is not recommended, but since in the case given, the 3 year old child is symptomatic, she would require antibiotic therapy and symptomatic management. For the fever and dysuria, acetaminophen (Tylenol) may be given. Dosage of up to 15 mg/kg/dose may be given for the management of pain and fever (Lubrano et al, 2016). Acetaminophen is available in 160mg/5ml oral suspension. Patient can be given 5ml every 6 hours as needed for pain or fever. A study done by Yousefichaijan, et al (2016) showed that zinc supplementation has a significant effect in alleviating the symptoms of dysuria, urinary frequency, and urgency in UTI. Zinc is known to increase the response to treatment in many infections (Yousefichaijan, et a, 2016).
Non pharmacological management for the child includes increased fluid intake and meticulous genital hygiene (Leung et al, 2019). Because the child has dysuria and cries when urinating, it is also important to inform the parents to help the child void about every 1.5 to 2hr and not to hold the urine.
The American Academy of Pediatrics recommend that young febrile children be given antibiotics to which only a small portion of organisms are resistant to, due to the high risk of renal involvement. Sulfonamides are usually prescribed for acute UTIs since most of these infections are due to E.coli, which is sensitive to sulfonamide (Rosenthal and Burchum, 2021). Sulfamethoxozale, a sulfonamide, is soluble in urine and reaches effective concentrations within the urinary tract (Rosenthal and Burchum). This is usually marketed together with trimethoprim as TMP/SMZ because their effects are synergistic and when used together, these become bactericidal (Osmosis, n.d.). Febrile UTI (pyelonephritis) does not always require intravenous antibiotics, and the route of administration should be based on the severity of the illness, presence of renal abnormalities, and the child’s age and ability to take oral medications (Veauthier and Miller, 2020). TMP/SMZ is in the list of the antibiotics commonly used to treat urinary tract infections in children as recommended by the American Academy of Family Physicians (Veauthier and Miller, 2020).
The usual pediatric dose for patients 2 months to 18 years is 8/40 (trimethoprim/ sulfamethoxazole) mg/kg/day divided every 12 hours (NIH, 2021). This is considered safe for the child who has penicillin allergy. TMP/SMZ can be administered orally, and both components are well distributed throughout the body ((Rosenthal and Burchum, 2021).
Oral antibiotics when given for 7-10 days are usually adequate for treating uncomplicated febrile UTI (Mattoo et al, 2021). To reduce the risk of renal scarring and morbidity, prompt treatment with antibiotics, ideally within 48 hours of fever onset is recommended (Mattoo et al, 2021).
It is important for the nurse practitioner to educate the parents of the child on how to administer the medication, the timing of the medication, duration of treatment and possible side effects to watch out for. TMP/SMZ is usually given in 2 doses, 12 hours apart. Since the patient in this case study is 31 lbs, (14 kg), she would require 112/560 (trimethoprim/sulfamethoxazole) mg/day based on the recommended 8/40 (trimethoprim/ sulfamethoxazole) mg/kg/day. Oral suspension of TMP/SMZ (Bactrim) is available in (40mg/200mg)/5mL. Based on this, the parents should be instructed to give 5ml of oral liquid every 12 hours or two times a day (BID) for 10 days. It is important to emphasize to the parents to use specially marked measuring medicine cups/spoons or other device to measure each dose accurately. Parents should be educated also that even when the antibiotics relieve the symptoms early in the course of treatment, the medication should still be given to the child as directed. Missing a dose or doses, or not finishing the recommended duration of therapy may result to a decrease in the effectiveness of treatment or increase the risk of bacterial resistance in the future (NIH, 2021).
See attachment for prescription.
References:
Mattoo, T. K., Shaikh, N., & Nelson, C. P. (2021). Contemporary management of Urinary Tract Infection in children. Pediatrics, 147(2). https://doi.org/10.1542/peds.2020-012138
Lubrano, R., Paoli, S., Bonci, M., Di Ruzza, L., Cecchetti, C., Falsaperla, R., Pavone, P., Matin, N., Vitaliti, G., & Gentile, I. (2016). Acetaminophen administration in pediatric age: an observational prospective cross-sectional study. Italian journal of pediatrics, 42, 20. https://doi.org/10.1186/s13052-016-0219-x
National Institutes of Health. (2021, April). BactrimTM sulfamethoxazole and trimethoprim DS (double strength) tablets and tablets USP. U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugX…
Osmosis. (n.d.). Antimetabolites: sulfonamides and trimethoprim. https://www.osmosis.org/learn/Antimetabolites:_Sulfonamides_and_trimethoprim
Veauthier, B., & Miller, M. V. (2020, September 1). Urinary tract infections in young children and infants: Common questions and answers. American Family Physician. https://www.aafp.org/pubs/afp/issues/2020/0901/p27…
Yousefichaijan, P., Naziri, M., Taherahmadi, H., Kahbazi, M., & Tabaei, A. (2016). Zinc Supplementation in Treatment of Children With Urinary Tract Infection. Iranian journal of kidney diseases, 10(4), 213–216.
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