Clinical scenario 2: Sarah

Sarah, an 18 month old, presents with a two day history of fever to 39°C. She has no history of cough; rhinorrhoea; vomiting; diarrhoea or rash. She attends day care. She has a 5 year old sibling who is at school and is well at the moment. She is eating less than normal but drinking well and passing urine as normal.

On examination she appears slightly flushed with a fever of 38.5°C. Her HR is 110 and RR 28. Her peripheries are warm and her capillary refill time is 1-2 seconds.

She has no rash, no conjunctivitis, her ENT examination is unremarkable. Her heart sounds are dual with no murmur and her chest is clear. Her abdomen is soft and non-tender. Her immunisations are up to date.

The following seven questions refer to Sarah’s clinical scenario.

Question 04

Which ONE of the following signs of toxicity would increase your Menu of suspicion that there is a significant medical illness in this child?
Alertness, arousal or activity decreased
Breathing difficulties (tachypnoea, increased work of breathing)
Colour (pale or mottled; circulation (cool peripheries), or cry (weak, high pitched)
Decreased fluid intake or decreased urine output
All of the above
Check answer

Explanation

The correct answer is: All of the above.

Question 05

In the absence of the above signs of toxicity, which ONE of the following investigations would you perform?
Urinalysis +/- M/C/S
Full blood count
CRP
Blood culture
Chest X-ray
Check answer

Explanation

Urinalysis +/- M/C/S. Since the introduction of vaccines for HiB and Pneumococcus, the risk of occult bacteraemia in a well, immunised child with fever without a focus has reduced to <1%. The risk remains approximately 5% in an unimmunised child.

The risk of a urinary tract infection remains significant (approximately 5%). In any child who appears toxic, the Menu of suspicion should be raised for a significant bacterial infection. In addition to urinalysis, consideration should be given to performing FBC (+/- acute phase reactants) and blood culture. Lumbar puncture should be considered on an individual basis and Chest X-ray is more likely to yield positive results if there are respiratory symptoms. If in doubt, seek senior medical advice.

Question 06

Which ONE of the following is the gold standard for urine collection in this child?
Clean catch
Mid-stream urine
Catheter urine
Suprapubic aspirate
Bag urine
Check answer

Explanation

Clean catch urine is an appropriate method of collection in the toilet trained child, however, timely collection is often difficult and rates of contamination may still be high. Bag urine samples are inappropriate because of high contamination ratios. When it is urgent to get a urine specimen and in any child prior to toilet training, a catheter urine sample is the recommended invasive technique. Urine culture is essential prior to the commencement of antibiotics for suspected urinary tract infection.

Question 07

If the urinalysis is negative, which ONE of the following is the most likely cause for Sarah’s fever?
Viral illness
Meningitis
Bacteraemia
Urinary tract infection
Pneumonia
Check answer

Explanation

In a well looking child with no obvious focus of infection, the most likely cause is a viral infection.

Question 08

If the results of the urinalysis were negative and Sarah remained well, which ONE of the following would be your next course of action?
Discharge
Discharge with GP follow up next 24-48 hours
Admit for observation
Proceed to FBC and blood cultures
Perform a full septic screen
Check answer

Explanation

Discharge with GP follow up next 24-48 hours. It is safe for Sarah to be discharged, but it is important that parents are advised regarding signs of toxicity, as well as to recommend review to ensure that Sarah’s status has not deteriorated.

Question 09

The Urinalysis is positive for nitrites and leukocytes. The specimen is sent for M/C/S. Which ONE of the following would you include in your plan of action?
Admit for IV ampicillin and gentamicin
Urgent renal ultrasound
Oral antibiotics
Renal ultrasound in next six weeks
Outpatient MCUG
Check answer

Explanation

A relatively well child who is tolerating oral intake can be discharged with oral antibiotics with advice to follow up with the GP in 48 hours to chase formal urine culture results. Acceptable oral antibiotics pending culture results include cephalexin, Augmentin Duo and Bactrim.

Question 10

In which circumstances would you amend your management plan?
Children aged less than three months
Shock
Toxic/vomiting
Atypical/complicated UTIs
Recurrent UTI
All of the above
Check answer

Explanation

All of the above. Infants less than 3 months generally require IV antibiotics. A shocked child needs to be stabilised and will be admitted for IV fluids and IV antibiotics. A child not tolerating oral intake will need IV fluids and IV antibiotics.


Children younger than six months with a first UTI who respond well to treatment (i.e. within 48 hours) require a renal ultrasound within 6 weeks of presentation and no other investigations. Children older than six months with a first UTI who respond well to treatment (i.e. within 48 hours) do not require renal ultrasound or more extensive imaging of the renal tract. A DMSA and MCUG should be performed in the child under six months with recurrent UTI. A DMSA should be considered in children older than six months with recurrent UTI (NICE guidelines)

For more information, please see:

NSW Health guidelines: Children and Infants with Fever - Acute Management

The Children’s Hospital Westmead: Urinary tract infection identification and management practice guideline

The Children’s Hospital Westmead: UTI GP fact sheet
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