These scenarios are fictitious, but are similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. They are designed to highlight management approaches, and show some pitfalls to avoid.
The following case studies, written by Dr David M W Capehorn, relate to his article Identify and treat urinary tract infection promptly in under 16s, as well as NG224, Urinary tract infection in under 16s: diagnosis and management, and NG143, Fever in under 5s: assessment and initial management.
Case 1: Emily
Emily is 10 months old, and has been brought to see you by her mother. She is generally a well child, and was born at term by normal vaginal delivery. She has no significant past medical history, and has never previously had any illness significant enough to warrant a prescription for antibiotics or admission to hospital. There is no significant family history. However, according to her mother, Emily has been unsettled for 48 hours, with slightly reduced feeding, and has been playing a little less than normal.
You examine Emily. She is alert and tries to resist your attempts to examine her by fighting you off. She has a tympanic temperature of 38.3ºC. Her pulse is 136 BPM, and her respiratory rate is 28 breaths per minute. There are no rashes on her skin, which looks a good colour with no mottling, and she has a capillary refill of <2 seconds. General examination of her ears, nose, throat, chest, and abdomen reveals nothing of any significance.
Questions for Reflection
- How do you manage this situation initially?
- What investigations should be arranged?
- How would you arrange and organise any investigations in primary care?
How to Manage This Patient at the Initial Stage
- Emily has a fever-related illness, so initial assessment should be undertaken using general criteria for the assessment of a sick child. It may be helpful to use the NICE guideline on Fever in under 5s: assessment and initial management. In this instance, although Emily seems miserable, she is not showing marked tachycardia or tachypnoea, and her general presentation is not concerning (that is, not at this stage showing clinical signs of being at high or intermediate risk of serious illness). She may feel more comfortable with antipyretic and/or analgesic medication, such as paracetamol, which is recommended by NICE for children with fever who appear distressed. Assessment of her response to medication will be helpful when considering further management as well
- It is important to consider UTI as a diagnostic possibility for Emily. The presenting symptoms can be nonspecific at this age, and can include a fever without other cause. The NICE guidance on UTIs in children suggests collecting and testing a urine sample where there is a fever without cause. This would ideally be done within 24 hours of initial assessment, via dipstick testing
- The main practical difficulty for investigation in primary care is in obtaining the sample for testing. In this instance, it may be possible to ask Emily’s mother to return home to obtain a clean-catch sample and then return to the surgery later for testing of the urine, especially if urine cannot be collected during the consultation. This would also allow time to assess Emily’s response to antipyretic/analgesic medication. If you are comfortable that Emily isn’t showing signs of severe illness, it may be acceptable to ask the parents to return to the surgery with the sample the next morning. A morning consultation would be preferable, as, if a consultation is undertaken later in the day, there may be further difficulty concerning storage of the urine sample. Ideally, the sample could be collected in a cleaned-out potty and transferred to an appropriate urine collection pot, with dipstick testing undertaken within 4 hours of collection.
ContextEmily returns to the surgery the same afternoon and looks much brighter after having paracetamol. Her pulse is now 124 BPM, and her temperature is now 37.2ºC. She has been drinking well. Emily’s mother collected a urine sample in the preceding couple of hours, and it looks cloudy. You test Emily’s urine sample using urine dipstick testing and find it to be positive for both leukocytes and nitrites.
Questions for Reflection
- How do you proceed, and what further treatment do you offer?
- Does the urine sample need to be sent to a laboratory for testing?
- If prescribing antibiotics, which would be most suitable and how long a course should be given?
How to Manage This Patient at the Intermediate Stage
- Emily’s response to antipyretics is reassuring. According to NG224, Emily’s clinical presentation and urine dipstick results are highly suggestive of UTI, and it is reasonable to give her antibiotics immediately
- In Emily’s case, prior to starting her on antibiotics, a urine sample should be sent for MC&S. If it is not possible to send immediately, the sample can be kept in a refrigerator or preserved using boric acid for longer (but the manufacturer’s instructions must be followed to avoid any issues relating to volume or contamination)
- Regarding antibiotics, trimethoprim would be the usual choice, although nitrofurantoin, amoxicillin, and cefalexin may be considered. In a child with no features of severe systemic illness or pyelonephritis, a 3–5-day course of antibiotics would be standard, but the choice can be reviewed in light of culture results after 3 days.
ContextYou arrange a telephone review of Emily’s progress after 24–48 hours, in which Emily’s mother reports that Emily seems largely back to normal. She no longer has a fever, and is eating and drinking well. You check the urine culture result at 72 hours, and this reveals a pure growth of an Escherichia coli organism.
Questions for Reflection
- How does this information influence further management?
- What imaging investigations are needed for follow up?
- What other discussions would you have with the family?
How to Manage this Patient in the Longer Term
- The UTI is confirmed as being a ‘typical’ organism (E. coli) and Emily has responded quickly to antibiotics within the first 48 hours of commencement. When recovery is rapid, in a first UTI over the age of 6 months with a typical organism and no other atypical features, no specific follow up is needed
- For the same reasons, no imaging will be necessary in this case
- Discussion should be had with the family regarding associated risk factors (for example, fluid intake, constipation) and how to avoid further infections. Advice can also be given about the early collection of urine samples in any future episode of pyrexial illness.
Case 2: Johnny
ContextJohnny is 3 and a half years old, and had one previous confirmed lower-tract E. coli UTI 6 months ago. In that case, he recovered quickly and didn’t need follow up. Johnny is generally a healthy child, with no other significant past medical history or family history.
Johnny presents to your practice with symptoms of increased urinary frequency and pain on passing urine, and his mother suspects another urine infection. Johnny’s mother has attended the surgery with a sample she collected earlier this morning, stored in a spare urine sample pot provided to her by the surgery at the time of Johnny’s previous UTI.
Johnny seems clinically quite well when you examine him, as he is talking and interacting with you. He has a pulse rate of 100 BPM and a tympanic temperature of 37.5ºC, 2 hours after being given paracetamol by his parents. The urine dipstick testing reveals significant leukocytes and nitrites.
Questions for Reflection
- What is the appropriate clinical management?
- What follow up is needed, and why?
How to Manage This Patient in the Initial Stage
- NICE guidance would suggest that it is appropriate to consider this to be a urine infection, in light of the dipstick testing results. Johnny doesn’t seem to be systemically compromised based on clinical appearance and observations, but the sample should be sent for MC&S. Antibiotics should be commenced (first-line antibiotics usually being trimethoprim or nitrofurantoin)
- Follow up, either by telephone or face to face, is needed for two reasons. Firstly, it allows you to assess Johnny’s response to therapy after 48 hours; secondly, it allows you to reassess your diagnosis, antibiotic choice, and management decisions, in light of the urine culture.
ContextJohnny remained well, and his lower tract symptoms resolved quickly within 24–48 hours. The subsequent urine culture revealed a pure growth of Proteus bacteria.
Questions for Reflection
- How does this information influence further management and investigations?
- Does Johnny need referral to secondary care paediatrics?
How to Further Manage This Patient
- NG224 recommends that an uncomplicated UTI in this age group can simply be treated, and that no imaging would be necessary unless the urine infection is recurrent or atypical. In this instance, Johnny wouldn’t meet the definition of having a recurrent UTI (as neither of his two UTIs involved upper-tract symptoms, and three lower-tract UTIs are required to meet the definition of recurrent). However, the organism is not an E. coli, so the UTI meets the definition of atypical. Under the current NICE guidance, therefore, a bladder ultrasound scan should be requested with bladder emptying. If that investigation is normal, no further follow up would be needed, unless further infections occur
- If the ultrasound scan has abnormal results, referral to secondary care would be needed, as assessment by a paediatric specialist would be required, and consideration would be given to a DMSA scintigraphy scan and possibly an MCUG.
NG=NICE Guideline; BPM=beats per minute; UTI=urinary tract infection; MC&S=microscopy, culture, and sensitivity; DMSA=dimercaptosuccinic acid; MCUG=micturating cystourethrogram