What is the management for a 5-year-old girl presenting with fever and dysuria (painful urination)?

Management of Febrile UTI in a 5-Year-Old Girl

Oral amoxicillin (or amoxicillin-clavulanate) is the recommended first-line treatment for this well-appearing 5-year-old girl with fever and dysuria, as oral therapy is equally effective as parenteral treatment for uncomplicated febrile UTI in children who can tolerate oral intake. 1, 2

Initial Diagnostic Approach

Before initiating antibiotics, obtain a urine specimen by catheterization (not bag collection) for both culture and urinalysis to confirm the diagnosis. 1, 2 Bag specimens have false-positive rates of 12-83% and should never be used for culture. 1

• A positive urinalysis shows leukocyte esterase or nitrites on dipstick, or white blood cells/bacteria on microscopy 1
• Definitive diagnosis requires ≥50,000 CFU/mL of a single uropathogen plus pyuria 2

Antibiotic Selection and Route

Oral therapy is the appropriate choice for this patient because:

• Well-appearing children who can tolerate oral intake should receive oral antibiotics rather than parenteral therapy 2
• Only 1% of febrile infants with UTIs are too ill for oral therapy 2
• Oral versus IV therapy shows no difference in duration of fever or renal scarring rates at 6-12 months 1

Specific Antibiotic Recommendations:

Option A (Oral Amoxicillin/Amoxicillin-Clavulanate) is CORRECT:

• Amoxicillin-clavulanate 20-40 mg/kg/day divided into 3 doses is first-line therapy 2
• Treatment duration: 7-14 days (recent evidence supports 5 days may be noninferior) 1, 2, 3
• Adjust based on culture sensitivities when available 2

Option B (IV Ciprofloxacin) is INCORRECT:

• Ciprofloxacin is NOT a first-choice drug in pediatric populations due to increased incidence of joint/musculoskeletal adverse events 4
• IV therapy is reserved only for toxic-appearing children or those unable to retain oral intake 2

Option C (IM Ceftriaxone) is INCORRECT for initial management:

• IM ceftriaxone (75 mg/kg every 24 hours) is reserved for toxic-appearing children or those unable to retain oral medications 2
• This patient's presentation does not indicate severe illness requiring parenteral therapy

Option D (Sodium Bicarbonate) is INCORRECT:

• No role in treating bacterial UTI 2

Critical Management Points

Timing is crucial: Initiate treatment within 48 hours of fever onset to prevent renal scarring, as delays beyond 48 hours increase scarring risk by >50%. 1, 2

Alternative oral options if amoxicillin-clavulanate is unavailable or patient is allergic:

• Cephalosporins (cefixime, cephalexin) 1, 2
• Trimethoprim-sulfamethoxazole (based on local resistance patterns) 2

Follow-Up Requirements

• Perform renal and bladder ultrasound after initiating treatment to detect anatomic abnormalities 2
• Instruct parents to seek prompt evaluation for future febrile illnesses 1, 2
• Clinical response should occur within 48 hours; if fever persists, reevaluate and consider imaging for complications 1

Common Pitfalls to Avoid

• Do not use bag specimens for culture - they have unacceptably high false-positive rates and lead to overtreatment 1, 2
• Do not delay treatment waiting for culture results in a febrile child with positive urinalysis 2
• Do not use fluoroquinolones as first-line in children due to musculoskeletal toxicity concerns 4
• Do not assume mucopurulent urine indicates bacterial superinfection - this can occur with viral infections 5