What are the discharge instructions for a patient with pyelonephritis and thrombocytopenia?

Discharge Instructions for a 17-Year-Old with Pyelonephritis and Platelet Count of 109,000/μL

Antibiotic Therapy

This patient should be discharged on oral ciprofloxacin 500 mg twice daily for 7 days, or alternatively levofloxacin 750 mg once daily for 5 days, if local fluoroquinolone resistance rates are ≤10%. 1, 2

• If fluoroquinolone resistance exceeds 10% in your community, the patient should receive an initial intravenous dose of ceftriaxone 1 gram before discharge, followed by oral fluoroquinolone therapy 1
• Alternatively, if the uropathogen is known to be susceptible, trimethoprim-sulfamethoxazole 160/800 mg (one double-strength tablet) twice daily for 14 days is appropriate 1
• Oral beta-lactam agents are less effective and should be avoided unless other options are contraindicated 1
• The FDA-approved pediatric dosing for ciprofloxacin in patients aged 1-17 years with pyelonephritis is 10-20 mg/kg orally every 12 hours (maximum 750 mg per dose) for 10-21 days 2

Thrombocytopenia Management

With a platelet count of 109,000/μL, this patient does not require admission for thrombocytopenia alone and can be safely managed as an outpatient with close hematology follow-up. 3

• The American Society of Hematology recommends observation over treatment for platelet counts ≥30,000/μL in asymptomatic patients 1, 3
• Schedule hematology follow-up within 24-72 hours of discharge to evaluate for immune thrombocytopenia (ITP) or other causes of thrombocytopenia 1, 4, 5
• No specific treatment for thrombocytopenia is indicated at this platelet level unless the patient develops mucosal bleeding or has additional risk factors 1, 3

Warning Signs Requiring Emergency Return

Instruct the patient to return immediately for any of the following:

• Fever >38.5°C (101.3°F) persisting beyond 48-72 hours of antibiotic therapy 1
• Worsening flank pain or development of severe abdominal pain 6
• Inability to tolerate oral medications or fluids 6
• Signs of significant bleeding including: petechiae, purpura, nosebleeds that don't stop with pressure, blood in urine or stool, or any mucosal bleeding 1, 3
• Severe headache, visual changes, or altered mental status 1
• Rapid fall in platelet count if rechecked 3

Follow-Up Requirements

Two separate follow-up appointments must be scheduled before discharge:

1. Hematology appointment within 24-72 hours to evaluate thrombocytopenia and determine if further workup or treatment is needed 1, 4, 5
2. Primary care or urology follow-up within 7-14 days to ensure clinical resolution of pyelonephritis and review final urine culture results 1, 6

Activity and Bleeding Precautions

With a platelet count of 109,000/μL, implement the following precautions:

• Avoid contact sports, high-impact activities, and activities with high risk of trauma until platelet count is reassessed 1, 3
• Use soft toothbrush and avoid flossing aggressively 1
• Avoid aspirin, NSAIDs (ibuprofen, naproxen), and other antiplatelet medications unless specifically prescribed 3, 4
• Avoid intramuscular injections 1
• Use electric razor instead of blade razor 1

Hydration and Symptom Management

• Maintain adequate oral hydration with at least 2-3 liters of fluid daily 6
• Acetaminophen (not NSAIDs) may be used for fever or pain control 6
• Complete the entire antibiotic course even if symptoms improve 1, 6

Common Pitfalls to Avoid

The most critical error is failing to ensure the 24-72 hour hematology follow-up appointment is scheduled before discharge. 4, 5 This can lead to loss to follow-up and missed diagnosis of potentially serious hematologic conditions.

Do not prescribe NSAIDs for pain control in this patient given the thrombocytopenia and increased bleeding risk 3, 4

Ensure the patient understands that clinical improvement should occur within 48-72 hours of starting antibiotics; lack of improvement warrants imaging with CT scan to evaluate for complications such as renal abscess or obstruction 1, 6