What are the admitting orders for a 15-year-old patient with Urinary Tract Infection (UTI), rule out pyelonephritis, Community Acquired Pneumonia (CAP), moderate dehydration, and Gastroesophageal Reflux Disease (GERD)?

Admitting Orders for 15-Year-Old with UTI r/o Pyelonephritis, CAP, Moderate Dehydration, and GERD

This patient requires hospital admission with IV antibiotics for both CAP and presumed pyelonephritis, IV fluid resuscitation for moderate dehydration, and continuous monitoring given the dual serious infections.

Admission Status and Monitoring

• Admit to: General pediatric ward with continuous pulse oximetry monitoring 1
• Level of care: Standard inpatient care unless SpO2 <92% on FiO2 ≥0.50, respiratory distress, or hemodynamic instability develops, which would require ICU transfer 1
• Vital signs: Every 4 hours including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation 1
• Strict intake and output monitoring for dehydration assessment 2

Diagnostic Workup

Immediate Labs

• Blood cultures x2 sites before antibiotics (mandatory for moderate-to-severe CAP requiring hospitalization) 1
• Urine culture with antimicrobial susceptibility testing (required for all suspected pyelonephritis cases) 2, 3
• Urinalysis with microscopy for WBCs, RBCs, nitrites 2, 3
• Complete blood count with differential 1
• Basic metabolic panel including electrolytes, BUN, creatinine to assess dehydration and renal function 2
• C-reactive protein or procalcitonin if available for severity assessment 1

Imaging

• Chest X-ray (PA and lateral) to confirm CAP diagnosis and assess severity 1, 4
• Renal ultrasound to rule out urinary tract obstruction, stones, or structural abnormalities in the setting of pyelonephritis 2, 3

IV Fluid Management

• IV fluid resuscitation: Normal saline (0.9% NaCl) bolus 20 mL/kg over 1 hour, then reassess hydration status 4
• Maintenance fluids: After initial resuscitation, continue D5 0.45% NaCl at maintenance rate (approximately 60-80 mL/hr for a 15-year-old, adjusted for weight) 4
• Goal: Restore adequate hydration, maintain urine output >1 mL/kg/hr, and support renal perfusion during pyelonephritis treatment 2, 5

Antibiotic Therapy

For Community-Acquired Pneumonia

• Ceftriaxone 1-2 grams IV once daily (preferred first-line agent for hospitalized pediatric CAP) 4, 6
• Alternative if atypical pathogen suspected: Add azithromycin 500 mg IV/PO once daily (for coverage of Mycoplasma pneumoniae or Chlamydophila pneumoniae) 4, 7

For UTI/Pyelonephritis

• Ceftriaxone 1-2 grams IV once daily provides dual coverage for both CAP and pyelonephritis 2, 3, 6
• This single agent covers both conditions effectively, avoiding polypharmacy 2, 6
• Duration: Plan for 7-14 days total antibiotic course for pyelonephritis, with transition to oral antibiotics once afebrile for 24-48 hours and clinically improved 2, 3

Antibiotic Adjustment Strategy

• Narrow antibiotics based on urine culture and blood culture susceptibility results within 48-72 hours 2, 3
• If persistent fever after 72 hours: Obtain repeat imaging (CT scan if ultrasound non-diagnostic) to evaluate for complications such as renal abscess or obstruction 2

Respiratory Support

• Supplemental oxygen: Titrate to maintain SpO2 >92% 1, 4
• Start with nasal cannula 2-4 L/min if hypoxemic 1, 4
• Escalate to high-flow nasal cannula or non-invasive ventilation if requiring FiO2 >0.50 to maintain SpO2 >92%, and transfer to ICU 1

GERD Management

• NPO initially until tolerating oral intake without vomiting 4
• Proton pump inhibitor: Omeprazole 20 mg IV/PO once daily 4
• Head of bed elevation to 30-45 degrees 4
• Advance diet as tolerated, starting with clear liquids, then regular diet avoiding acidic/spicy foods 4

Symptomatic Management

• Antipyretics: Acetaminophen 650 mg PO/IV every 6 hours PRN fever >38.5°C or pain 4
• Alternative: Ibuprofen 400-600 mg PO every 6-8 hours PRN (avoid if significant dehydration until fluid status improved) 4
• Antiemetics: Ondansetron 4 mg IV/PO every 8 hours PRN nausea/vomiting 4

Activity and Diet

• Activity: Bedrest with bathroom privileges initially, advance as tolerated 4
• Diet: NPO until nausea/vomiting resolves, then advance to regular diet as tolerated 4
• Encourage oral fluid intake once tolerating PO to maintain hydration and promote urinary flow 2, 5

Reassessment and Follow-up Planning

• Clinical reassessment at 48-72 hours: Evaluate for expected improvement in fever, respiratory symptoms, and urinary symptoms 4, 2
• If no improvement by 72 hours: Consider alternative diagnoses, complications (empyema, parapneumonic effusion, renal abscess), or resistant organisms 4, 2
• Transition to oral antibiotics when afebrile for 24-48 hours, tolerating PO, and clinically improved 4, 2
• Discharge planning: Complete 7-14 day total antibiotic course (IV + oral), outpatient follow-up in 1-2 weeks, repeat imaging only if clinically indicated 4, 2

Common Pitfalls to Avoid

• Delaying imaging in persistent fever: If fever persists beyond 72 hours of appropriate antibiotics, obtain CT scan to rule out complications like renal abscess or complicated pneumonia 2
• Inadequate fluid resuscitation: Moderate dehydration requires aggressive initial fluid bolus before maintenance fluids 4
• Missing atypical pneumonia coverage: Consider adding azithromycin if clinical presentation suggests atypical pathogen (gradual onset, prominent cough, minimal fever) 4, 7
• Premature discontinuation of antibiotics: Ensure full 7-14 day course for pyelonephritis to prevent relapse and renal scarring 2, 3