What is the best course of action for a 7-year-old female patient with a recent history of urinary tract infection (UTI) due to Escherichia coli (E. coli), currently on Ceftin (cefuroxime), who presents with fever, vomiting, and sore throat?

Management of 7-Year-Old with Fever, Vomiting, and Sore Throat on Ceftin for E. coli UTI

Evaluate this child immediately for possible pyelonephritis or treatment failure of her UTI, perform a thorough throat examination to assess for streptococcal pharyngitis, and obtain appropriate cultures before making treatment decisions.

Initial Assessment and Diagnostic Approach

This clinical scenario requires distinguishing between three possibilities: treatment failure/progression of the UTI to pyelonephritis, a new concurrent infection (streptococcal pharyngitis), or an adverse drug reaction.

Key Clinical Considerations

The tachycardia (pulse 144) is concerning in a 7-year-old with only low-grade fever (100.6°F). This suggests either:

• Dehydration from vomiting
• Systemic infection (possible pyelonephritis)
• Sepsis (though less likely with this fever)

1

Immediate Evaluation Required

Perform a focused physical examination looking for:

• Costovertebral angle tenderness or flank pain - suggests pyelonephritis 1
• Pharyngeal examination - assess for tonsillar exudate, erythema, or petechiae suggesting Group A Streptococcus 1
• Hydration status - assess mucous membranes, capillary refill, skin turgor
• Abdominal examination - assess for suprapubic tenderness or other sources of infection

Diagnostic Testing

Obtain the following tests:

• Repeat urinalysis and urine culture (via catheterization if needed for reliability) - to assess treatment response and rule out treatment failure 1

  • The presence of persistent pyuria and/or bacteriuria would indicate treatment failure 1
  • E. coli causing 75-95% of pediatric UTIs should be susceptible to cefuroxime, but resistance patterns vary 1

• Rapid strep test and/or throat culture - given the sore throat presentation 1

• Consider blood culture if the child appears toxic or if pyelonephritis is suspected 1

Treatment Decision Algorithm

If UTI Treatment Failure or Pyelonephritis is Suspected:

The child should be evaluated for atypical or complicated UTI given poor response to antibiotics within 48 hours. 1

Immediate management:

• If the child appears toxic, unable to retain oral intake, or has signs of pyelonephritis, initiate parenteral antibiotics immediately 1

  • Recommended: Ceftriaxone 75 mg/kg IV/IM once daily or cefotaxime 150 mg/kg/day divided every 6-8 hours 1
  • These provide broader coverage and better tissue penetration than oral cefuroxime 1

• Renal and bladder ultrasound should be performed given this represents an atypical presentation (poor response to appropriate antibiotics) 1

  • This is rated as "usually appropriate" (rating 9) for atypical or recurrent febrile UTI 1

If Streptococcal Pharyngitis is Confirmed:

Cefuroxime (Ceftin) provides adequate coverage for Group A Streptococcus 2, 3

• The current antibiotic regimen can be continued if strep throat is confirmed and the child is improving
• However, if the child is not improving or appears more ill, consider switching to a more targeted therapy

Regarding Current Cefuroxime Therapy:

Cefuroxime is FDA-approved for UTIs caused by E. coli and should be effective 2

• Standard pediatric dosing: 20-30 mg/kg/day divided twice daily 2
• However, only 2 days of therapy may be insufficient to assess response - typical improvement should occur within 24-48 hours of appropriate therapy 1

Critical Decision Points

The child requires urgent care evaluation today because:

1. Tachycardia out of proportion to fever suggests possible dehydration, systemic infection, or early sepsis 1

2. New symptoms (fever, vomiting, sore throat) while on antibiotics for UTI could represent:

   • Treatment failure requiring imaging and antibiotic adjustment 1
   • Progression to pyelonephritis requiring parenteral therapy 1
   • Concurrent new infection requiring additional evaluation 1

3. Vomiting may prevent adequate oral antibiotic absorption and could necessitate parenteral therapy 1

Disposition and Follow-Up

If the child can be managed as outpatient:

• Ensure adequate hydration
• Close follow-up within 24-48 hours to reassess clinical response 1
• Parents should be instructed to return immediately if fever persists >48 hours, vomiting continues, or the child develops flank pain, increased lethargy, or appears more ill 1

Consider hospitalization if:

• Unable to retain oral fluids/medications
• Signs of pyelonephritis or sepsis
• Age <3 months (though this patient is 7 years old)
• Toxic appearance
• Inadequate follow-up available 1

After acute management, this child will require:

• Renal and bladder ultrasound given the atypical presentation 1
• Possible voiding cystourethrogram (VCUG) if ultrasound shows abnormalities or if she develops recurrent febrile UTI 1
• Evaluation for bladder/bowel dysfunction if recurrent infections occur 1