What is the recommended treatment for a suspected urinary tract infection (UTI) in a 1-year-old male patient?

OSCE Examination: UTI in a 1-Year-Old Male

Station Overview

Clinical Scenario: A 1-year-old uncircumcised male presents to the emergency department with fever (39.2°C) for 24 hours. No obvious source of infection identified. Parents report decreased oral intake but child appears well-hydrated and interactive.

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CANDIDATE INSTRUCTIONS (10 minutes)

Task 1: History Taking (3 minutes)

Obtain a focused history from the parent regarding:

• Fever characteristics: Duration, maximum temperature, response to antipyretics, associated symptoms 1
• Urinary symptoms: Foul-smelling urine, crying with urination, change in urine color or frequency 2
• Systemic symptoms: Vomiting, diarrhea, irritability, feeding difficulties, lethargy 1
• Risk factors: Circumcision status (uncircumcised males have 36% bacteriuria rate vs 1.6% in circumcised), previous UTIs, known anatomical abnormalities 1
• Respiratory symptoms: Cough, rhinorrhea, difficulty breathing (to exclude viral respiratory infection as fever source) 1

Task 2: Physical Examination (2 minutes)

Demonstrate and describe findings you would assess:

• General appearance: Well-appearing vs ill-appearing (critical for management decisions) 1
• Vital signs: Temperature, heart rate, respiratory rate, blood pressure 3
• Hydration status: Mucous membranes, capillary refill, skin turgor 4
• Abdominal examination: Suprapubic tenderness, costovertebral angle tenderness 2
• Genitourinary examination: Inspect for phimosis, balanitis, labial adhesions 2
• Other systems: Ear examination for otitis media, throat for pharyngitis, chest for pneumonia 1

Task 3: Diagnostic Workup (2 minutes)

Outline your diagnostic approach:

• Urine collection method: Urethral catheterization or suprapubic aspiration—bag specimens must NEVER be used for culture 3, 4
• Urinalysis interpretation: Positive if leukocyte esterase OR nitrites on dipstick, OR white blood cells/bacteria on microscopy 1, 3
• Urine culture: Must obtain BEFORE starting antibiotics; diagnosis requires ≥50,000 CFU/mL of single uropathogen 3
• Additional testing: Consider complete blood count, C-reactive protein, blood culture if toxic-appearing 4

Task 4: Management Plan (3 minutes)

Develop and explain your treatment strategy:

Immediate Antibiotic Selection

• First-line oral options: Amoxicillin-clavulanate, cephalosporins (cephalexin), or trimethoprim-sulfamethoxazole based on local resistance patterns 3, 2
• Parenteral therapy indications: Age <3 months, toxic appearance, unable to retain oral intake, uncertain compliance 3, 4
• Parenteral options: Ceftriaxone (third-generation cephalosporin) or gentamicin 3, 4
• Avoid: Nitrofurantoin (does not achieve adequate serum/parenchymal concentrations for pyelonephritis in febrile infants) 3

Treatment Duration

• Febrile UTI/pyelonephritis: 7-14 days total 3, 2
• Adjust antibiotics: Based on culture and sensitivity results when available 3

Follow-Up and Imaging

• Short-term follow-up: Clinical reassessment in 1-2 days to confirm fever resolution and treatment response 3
• Renal and bladder ultrasound (RBUS): Recommended for all febrile infants <2 years with first UTI to detect anatomic abnormalities 3
• Voiding cystourethrography (VCUG): NOT routinely recommended after first UTI; perform only if RBUS shows hydronephrosis/scarring or after second febrile UTI 1, 3

Prophylaxis Decision

• NOT recommended: Routine antibiotic prophylaxis after first UTI 3
• Consider prophylaxis: Only for children with bowel and bladder dysfunction (BBD) and VUR, or recurrent febrile UTIs 1

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EXAMINER MARKING SHEET

History Taking (25 points)

• Fever duration and characteristics (5 points)
• Urinary symptoms assessment (5 points)
• Circumcision status documented (5 points)
• Previous UTI history (5 points)
• Excluded other infection sources (5 points)

Physical Examination (20 points)

• Assessed general appearance/toxicity (5 points)
• Complete vital signs (5 points)
• Abdominal/CVA examination (5 points)
• Genitourinary examination (5 points)

Diagnostic Approach (25 points)

• Specified catheterization/SPA for urine collection (10 points)
• Correctly interpreted urinalysis criteria (5 points)
• Emphasized culture before antibiotics (10 points)

Management Plan (30 points)

• Appropriate antibiotic selection (10 points)
• Correct treatment duration (7-14 days) (5 points)
• Avoided nitrofurantoin for febrile UTI (5 points)
• Planned 1-2 day follow-up (5 points)
• Ordered RBUS, avoided routine VCUG (5 points)

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COMMON PITFALLS TO AVOID

• Using bag specimens for culture: This leads to false positives and inappropriate antibiotic use 3
• Prescribing nitrofurantoin for febrile UTI: Inadequate tissue penetration for pyelonephritis 3
• Treatment duration <7 days: Shorter courses are inferior for febrile UTIs 3
• Routine VCUG after first UTI: Increases radiation exposure without proven benefit 3
• Delaying antibiotic initiation: Early treatment (within 48 hours) may reduce renal scarring risk 3
• Failing to adjust therapy: Must modify antibiotics based on culture results and local resistance patterns 3
• Missing follow-up window: The 1-2 day reassessment is critical for detecting treatment failure 3