What are the admitting orders for a 16-year-old male with a 4-day history of fever, epigastric pain, abdominal pain, increased frequency but reduced amount of urine, hematuria, and sore throat, diagnosed with urinary tract infection (UTI) with possible pyelonephritis?

Admitting Orders for 16-Year-Old Male with Suspected Pyelonephritis

Initial Assessment and Monitoring

Admit this patient to the hospital for intravenous antibiotic therapy given his 4-day fever duration, systemic symptoms, and inability to exclude complicated infection in a male adolescent. 1, 2

• Vital signs: Every 4 hours including temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation 1
• Strict intake and output monitoring: Essential given reduced urine output and hematuria 1
• Daily weight: Monitor for fluid status 1

Diagnostic Studies

Immediate Laboratory Tests

• Urinalysis with microscopy: Evaluate for pyuria (≥10 WBCs/high-power field), hematuria, nitrites, and leukocyte esterase 3, 1
• Urine culture and antimicrobial susceptibility testing: Mandatory before initiating antibiotics in all pyelonephritis cases 3, 1
• Complete blood count with differential: Assess for leukocytosis, left shift, and evaluate severity of infection 3
• Comprehensive metabolic panel: Including creatinine, BUN, electrolytes to assess renal function and guide antibiotic dosing 2
• Blood cultures x2 (from separate sites): Given fever and concern for bacteremia/urosepsis 1, 4
• C-reactive protein: Baseline inflammatory marker 1

Imaging

• Renal and bladder ultrasound within 24-48 hours: Rule out urinary obstruction, stones, abscess, or anatomic abnormalities—particularly important in males with pyelonephritis 3, 1

Antibiotic Therapy

Initiate intravenous cefepime 2 grams every 12 hours for severe pyelonephritis. 2 This is the preferred empiric choice given:

• FDA-approved for complicated pyelonephritis including cases with concurrent bacteremia 2
• Appropriate dosing for patient weight (40.9 kg) with normal renal function 2
• Broad coverage for E. coli and other common uropathogens 2, 5, 4

Alternative regimen if cefepime unavailable: Ceftriaxone 1-2 grams IV once daily 3, 1, 5

Duration and Transition

• Continue IV antibiotics until: Patient is afebrile for 24-48 hours, clinically improving, and able to tolerate oral intake 3, 1
• Transition to oral therapy: Ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg once daily based on culture sensitivities 3, 1
• Total antibiotic duration: 7-14 days total (IV + oral combined) 3, 1, 4

Supportive Care

• IV fluids: Normal saline at maintenance rate (approximately 1500-2000 mL/24 hours) given reduced urine output; adjust based on clinical status 1
• Antipyretics: Acetaminophen 650 mg PO/IV every 6 hours as needed for fever >38.5°C 1
• Antiemetics: Ondansetron 4 mg IV every 8 hours as needed for nausea 1
• Pain management: Ketorolac 15 mg IV every 6 hours as needed for flank/abdominal pain (maximum 5 days) 1

Diet and Activity

• Diet: Regular diet as tolerated; advance from clear liquids if nausea present 1
• Activity: Bed rest with bathroom privileges initially; advance as tolerated 1

Monitoring for Treatment Response

If fever persists beyond 72 hours of appropriate antibiotic therapy, obtain contrast-enhanced CT scan of abdomen/pelvis to evaluate for complications (renal abscess, obstruction, emphysematous pyelonephritis). 1 This is a critical pitfall—delayed imaging in persistent fever can miss surgical emergencies.

• Repeat CBC and CRP at 48-72 hours: Assess response to therapy 1
• Follow-up urine culture: 1-2 weeks after completion of antibiotics to document clearance 3, 4

Special Considerations for This Patient

Male Gender

• Pyelonephritis in males is inherently more concerning for anatomic abnormalities or complicated infection 6
• The ultrasound is particularly important to exclude prostatic involvement or urethral abnormalities 1

Pharyngitis Component

• The concurrent sore throat with mild tonsillar inflammation may represent:
  • Viral upper respiratory infection coinciding with UTI
  • Post-streptococcal glomerulonephritis (though hematuria from pyelonephritis more likely)
• Consider rapid strep test and throat culture if pharyngitis symptoms are prominent 1
• Monitor for worsening hematuria or renal function deterioration

Weight-Based Dosing Alert

• At 40.9 kg, this patient is below typical adult weight
• Cefepime 2 grams every 12 hours is appropriate as he is ≥16 years old and the dose does not exceed adult maximum 2
• Ensure adequate hydration to maintain renal perfusion for antibiotic clearance 2

Nursing Orders

• Notify physician if: Temperature >39°C, systolic BP <90 mmHg, heart rate >120 bpm, urine output <0.5 mL/kg/hour, worsening flank pain, altered mental status, or inability to tolerate oral intake 1
• Fall precautions: Given fever and potential orthostatic changes 1