Case Management

I. Case Presentation
This is a case of a 1-year-old female who was brought to the Emergency Room with a
complaint of fever. Five days prior to admission, the patient was noted to have 5 episodes of
loose, watery, non-bloody stools that amount to 50-100 mL per bout. Oral rehydrating solution
(ORS) was given by the mother, with resolution of symptoms 2 days after. Two days prior to
admission, the patient was noted to have fever with a maximum temperature of 39°C.
Paracetamol at 12 mg/kg/dose was administered by her mother, with temporary resolution of
fever which recurred after 4-6 hours. Two episodes of loose stools with approximately 30-50 mL
per bout were also noted. On the day of admission, there was persistence of fever and loose
stools, with note of irritability and decreased suck. An episode of vomiting of approximately 30
mL of previous ingested milk prompted the consult. The patient had an unremarkable past
medical history and was fully immunized. She had no problems with regards to feeding and
development.
The physical examination at the Emergency Room revealed that the patient was irritable
with normal blood pressure, heart rate, and respiratory rate for age, and febrile at 39.7°C. Her
anthropometric measurements were appropriate for age. Significant findings from the regional
examination include slightly sunken eyeballs and dry lips and buccal mucosa.
Laboratories like urinalysis, fecalysis, complete blood count, urine CS, and blood CS
were done. The CBC revealed leukocytosis with neutrophilia. Urinalysis revealed RBC 5-10/hpf,
WBC 100-150/hpf, protein +1, and many bacteria. Upon urine culture, E. coli 100,000
colonies/hpf was found. The fecalysis showed pus cells 4-5 with no parasites, ova, nor yeast.
With these salient points from the patient’s history, physical examination, and
laboratories, a working impression of Mild to Moderate Dehydration secondary to Acute
Gastroenteritis; Urinary Tract Infection can be made.

II. Case Discussion

a. Epidemiology
Acute gastroenteritis (AGE) is a common pediatric disease that causes diarrhea and
vomiting with associated fever and abdominal pain in children. In 2015, diarrheal diseases
caused an estimated 8.6% of childhood mortality worldwide, making it the 4 th most common
cause of childhood deaths. In developing countries, the main factors that lead to the heavy
burden of AGE includes insufficient access to adequate hygiene, sanitation, and clean drinking
water.1 In the Philippines, diarrhea was the 5th leading cause of deaths in the general population
in 2010, with Food and Water-Borne Diseases constituting most causes.2
Urinary Tract Infections (UTIs) are also commonly seen in the pediatric population,
affecting children of all ages. It is most common in children under 1 year of age. During the first
year of life, males are commonly affected with a male:female ratio of 2.8:5.4, which is attributed
to the most common risk of factor of being uncircumcised. Beyond 1-2 years, there is a shift to
female preponderance, with a male:female ratio of 1:10, usually occurring by the age of 5 years,
which peaks during infancy, toilet training, and onset of sexual activity.1

b. Etiology and Pathogenesis

Acute gastroenteritis can be caused by viral, bacterial, or parasitic pathogens. Rotavirus
is the most common cause of viral AGE among children worldwide. Among bacterial pathogens,
the most common causes of AGE include Nontyphoidal Salmonella (NTS), Shigella,
Campylobacter, Yersinia, and five pathogens of Escherichia coli: Shiga toxin-producing (STEC),
enteropathogenic (EPEC), enteroaggregative (EAEC), and enteroinvasive (EIEC). Foodborne
illness can be caused by Bacillus cereus, Clostridium perfringens, and Staphylococcus aureus.
Parasites like Giardia intestinalis, Cryptosoridium spp., Cyclospora cayetanensis, and
Entamoeba histolytica are the most common parasitic causes of diarrhea. In order to cause
disease, enteropathogens that are infectious in small amounts require transmission with person-
to-person contact via the fecal-oral route. Those that are infectious in larger doses require food
or water vehicles for transmission. 1 Depending on the type of pathogen, there 2 general
mechanisms responsible for acute gastroenteritis: (1) damage to the villous brush border of the
intestine, causing malabsorption and leading to osmotic diarrhea, and (2) release of toxins that
bind to specific receptors causing the release of chloride ions into the intestinal lumen, leading
to secretory diarrhea.3
Urinary tract infections are mostly caused by ascending infections, wherein bacteria from
the fecal flora colonize the perineum, entering the bladder through the urethra, causing
infection. Furthermore, bacteria causing cystitis or bladder infection may further ascend to the
kidney causing pyelonephritis. The most common bacteria involved in urinary tract infections are
the colonic bacteria, which includes Escherichia coli (54-67% of cases), Klebsiella spp., Proteus
spp., Enterococcus, and Pseudomonas.1

c. Clinical Manifestations
The clinical manifestations of acute gastroenteritis may overlap with those of the urinary
tract infections, especially pyelonephritis. For AGE, one of the most notable manifestation is
diarrhea, defined as the passage of 3 or more abnormally loose or liquid stools per day.
Accompanying fever, fecal blood, abdominal pain, no vomiting before onset of diarrhea, with a
high stool frequency of more than 10 per day are more common with bacterial diarrhea. 1
Furthermore, because of increased gastrointestinal losses, AGE may manifest with signs and
symptoms of dehydration.
There are 2 basic forms of UTIs: pyelonephritis and cystitis. Pyelonephritis is infection
involving the renal parenchyma and is characterized by abdominal, back, or flank pain, fever,
malaise, nausea, vomiting, and diarrhea. These findings are also noted in AGE. notably, fever
may be the only manifestation, especially if with temperature of >39°C without another source
lasting for >24 hours for males and >48 hours for females. For infants younger than 24 months
who have fever, pyelonephritis is the most common serious bacterial infection. Cystitis, on the
other hand, only involves the bladder and presents with dysuria, urgency, frequency, suprapubic
pain, incontinence, and malodorous urine. It does not cause fever and there is no renal
involvement.1

d. Diagnostics
Acute gastroenteritis usually does not require diagnostic laboratory testing. According to
the Clinical Practice Guidelines, acute infectious diarrhea can be suspected if a patient presents
with diarrhea that may be accompanied by nausea, vomiting, abdominal pain, or fever.
Extensive clinical history and complete physical examination should be done to assess the
disease severity, degree of dehydration, and presence of complications and comorbidities.
Routine stool examination can be done to examine for mucus, blood, or leukocytes. A finding of
>5 leukocytes per hpf may suggest an infection with a classical bacterial enteropathogen in an
infant not breastfeeding. Stool cultures are not routinely done because it is costly. It is only
indicated for severe cases, high risk of transmission of enteric pathogen, high risk of
complications, and for epidemiological purposes.2 In the presence of severe dehydration,
electrolyte measurements will be useful. If there is suspicion of systemic bacterial infection,
blood culture should be obtained.1
The suspicion of UTIs may be based on symptoms or findings on urinalysis, or both.
However, confirmation must be made through urine culture. For children 2-24 months who are
not toilet-trained, the appropriate collection of urine should be done through catheterization or
suprapubic aspiration, whereas, for toilet-trained children, a midstream urine sample is
satisfactory.1 According to the American Academy of Pediatrics Clinical Practice Guidelines for
UTI, the establishment of UTI should be made using both urinalysis result that suggest infection
(pyuria and/or bacteriuria) and the presence of at least 50,000 colony-forming units (CFUs) per
mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA. 4
In addition, nitrite and leukocyte esterase test can be done and may show positive results in
infected urine.1 Imaging studies are not needed to make a clinical diagnosis of UTI or
pyelonephritis. It may be considered, however, if there are concerns about acute lobar
nephronia or renal abscess, with ultrasound being the first-line type of imaging. The AAP also
recommends initial renal and bladder ultrasound for children 2-24 months with a first episode of
UTI.4

e. Management
The management of AGE focuses mainly on rehydration and replacement of continued
losses in diarrheal stools and vomitus. The approach to its management involves the rapid
evaluation of dehydration status and correction of fluid losses within 4-6 hours. The World
Health Organization recommends the use of low-osmolality oral rehydrating solution (ORS)
containing 75 mEq of sodium, 64 mEq of chloride, 20 mEq of potassium, and 75 mmol/L of
glucose, with total osmolality of 245 mOsm/L. Small volumes of ORS can be given initially,
beginning with as little as 5 mL at a time. 1 For children who are unable to tolerate oral fluids,
initial intravenous rehydration may be required but oral rehydration is still the preferred mode.
The supplementation of zinc may help to reduce the duration and severity of diarrhea. Routine
empiric antibiotic therapy is not recommended as treatment for AGE. According to the CPG, it
may be administered if there is suspected cholera, bloody diarrhea, and diarrhea associated
with other acute infections. Breastfeeding should still be continued for breastfed infants and fluid
replacement with carbonated, sweetened, caffeinated and sports drinks should be avoided
because these could further worsen diarrhea.2 Figure 1 and 2 shows the algorithm for the
management of no signs of dehydration and mild to moderate dehydration, and severe
dehydration, respectively.
The choice of the treatment’s route of administration for UTIs should base on practical
considerations. Nonetheless, both oral and parenteral administration are equally efficacious.
Treatment of acute cystitis should be prompt to avoid progression to pyelonephritis. A 3 to 5-day
course with trimethoprim-sulfamethoxazole (TMP-SMX) (6-12 mg TMP/kg/day in 2 divided
doses) is effective for E.coli. For Klebsiella and Enterobacter, Nitrofurantoin (5-7 mg/kg/24hr in
3-4 divided doses) is also effective. 1 A duration of 7-14 days of antibiotic treatment is capable
for reaching significant tissue levels for pyelonephritis. 4 Dehydrated patients with acute febrile
UTIs, who are unable to tolerate fluids should be admitted for IV rehydration and IV antibiotic
therapy. For hospitalized children, empiric treatment with ceftriaxone (50 mg/kg/24hr, not to
exceed 2g) or cefepime (100 mg/kg/24hr q12h) or cefotaxime (100-150 mg/kg/24hr in 3-4
divided doses) can be used until urine culture results are back. For febrile UTI, nitrofurantoin
should not routinely be used.1
Figure 1. Protocol for no signs of dehydration and mild to moderate dehydration (CPG)2
Figure 2. Protocol for severe dehydration (CPG)2
III. Case Management

Figure 3. Concept map of the disease pathogenesis and the patient’s clinical manifestations

For a patient presenting with fever, diarrhea, and vomiting, AGE and UTI are the most
common differential diagnosis. Laboratory findings of leukocytosis, hematuria, pyuria, and
bacteriuria, with pus cells on fecalysis further support these diagnoses. In addition, one of the
most common complication of diarrhea and vomiting is dehydration, which manifests as
irritability, decreased suck, sunken eyeballs, and dry lips and buccal mucosa. The initial
approach to the management of this patient is to first assess the degree of dehydration since
the principal management for AGE is hydration and fluid replacement. As seen on Table 1, the
patient’s dehydration status is mild to moderate based on the Department of Health CPG on
AID. The WHO also have dehydration classification with severity of minimal or no dehydration,
some dehydration, and severe dehydration. If the severity is based on the WHO classification,
the patient’s status is Some Dehydration. The decision for admission for this patient lies on her
dehydration status and an underlying urinary tract infection as demonstrated by the urinalysis
result.
Table 1. Clinical Manifestation of Dehydration in Children According to Severity (DOH CPG)2

Upon admission, the following additional laboratory tests can be requested: urine culture
for confirmation of UTI, serum electrolytes like sodium, chloride, and potassium to determine
any electrolyte imbalances, and renal and bladder ultrasonography especially since this is the
patient’s first febrile UTI episode.
Oral rehydration with reduced osmolarity ORS can be initiated for the patient. Following
the CPG, with the patient weighing 10 kg, 750 mL of ORS can be given in 4 hours. This can be
administered gradually, starting at as little as 5 mL at a time, then gradually increasing. If the
patient is unable to tolerate oral rehydration, ORS can be administered via nasogastric tube. In
addition, 50-100 mL ORS can be given after each stool to replace the losses. The degree of
dehydration should then be reassessed. If the patient responds well to the management, the
present regimen of hydration should be continued and the patient’s status should be reassessed
frequently. Breastfeeding should still be continued, and the folks should be advised not to give
carbonated, sweetened, and caffeinated drinks, as these may worsen the diarrhea and cause
electrolyte imbalance. Zinc supplementation can be given at 20 mg/day for 10-14 days to
shorten the duration of diarrhea and reduce the frequency of loose stools. Probiotics can also
be given as an adjunct therapy throughout the duration of the diarrhea. To address the patient’s
UTI, since the patient presents with fever, she may be treated as pyelonephritis for 7-14 days.
Empiric treatment with IV Ceftriaxone (50 mg/kg/24hr) may be started while awaiting urine
culture results.
 References
1. Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM. Nelson Textbook of
Pediatrics. 21st ed. Elsevier. 2020.
2. Department of Health. The CPG on the Management of Acute Infectious Diarrhea in Children
and Adults. Department of Health. 2017.
3. King CK, Glass R, Bresee JS, Duggan C. Managing Acute Gastroenteritis Among Children.
CDC MMWR. Accessed October 3, 2021.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
4. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and
Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and
Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics.
2011;128(3):595-610. DOI: https://doi.org/10.1542/peds.2011-1330