This noninferiority trial involved children aged 2 months to 10 years diagnosed with symptomatic UTI that exhibited clinical improvement after the first 5 days of antimicrobials. From there, they received either placebo (short-course group) or more antimicrobials (standard-course group). The standard-course group was associated with lower rates of treatment failure, asymptomatic bacteriuria, and positive urine culture after days 11-14. However, treatment failure rate was still low in the short-course group, and rates of UTI after day 11 to 14 were similar between groups, suggesting that differences in bacteriuria or positive urine culture did not contribute to subsequent UTI development. Children with fever at the time of diagnosis did not show a significant difference in treatment failure between study arms. Furthermore, most children whose therapy failed were afebrile and not at risk for kidney scarring. Given that approximately 67 children need to be treated with standard-course therapy to prevent 1 febrile UTI and that scarring occurs in approximately 1 in 7 children with febrile UTI, approximately 469 children would need to be treated to prevent 1 child from developing kidney scarring.

This trial has several strengths: a large, diverse population of children; enrollment of a sizeable proportion of children with fever at presentation (38%); use of stringent diagnostic criteria for UTI; enrollment of children treated with various antimicrobials;monitoring for targeted antimicrobial resistance in stool commensals; andmodest attrition. Limitations stem from slight imbalance between treatment groups in number of children excluded from the primary analysis, reduced power for subgroup analyses, assessment of emergence of antimicrobial resistance only for E coli and K pneumoniae strains, lack of detailed data on the societal costs and benefits of each treatment strategy, absence of data on adherence to the originally prescribed antimicrobials on days 1 to 5, lack of strain-level data on recovered uropathogens, and lack of data on outcomes, such as kidney scarring.

My site visit with Professor Maida was an enriching group experience that deepened my understanding of pediatric care. One notable case was presented by my classmate Ian, involving a child with an inflammatory reaction to a new ear piercing. We discussed the protocol to remove the foreign body, but also discussed maintaining empathy to the potential for the child to be disappointed about removing the piercing, emphasizing a holistic approach to patient care. We also reviewed the management of asthma exacerbations, differentiating treatment steps based on severity. I enjoyed analyzing and presenting the journal article I chose about UTI treatment duration in kids. In summary, the group dynamic and detailed discussions significantly enhanced my clinical decision-making skills in pediatrics.

My five-week pediatrics rotation revealed the specialty to be a bit less varied in case-type than I had anticipated. Working in an outpatient office, I primarily saw routine well-child visits and mild acute illnesses such as allergic respiratory and gastrointestinal issues. I found that many of the topics I had learned about in the classroom were not apparent in this setting, but I’m not surprised by that given the office was not equipped to handle more acute cases. Comparing experiences with my classmates, it was interesting to realize as well how seasonally affected an office such as the one I worked in can be. For example, while I saw so many patients with allergy symptoms during the spring, my classmates who worked in the winter saw primarily respiratory infections. Perhaps the variety exists more within the seasonal changes that shift trends in chief complaint. Regardless, the repetition certainly enhanced my understanding of the pediatric primary care PA and allowed me to build confidence in my pediatric patient assessment.

Identifying Data:

Patient Initials: JL

Age: 9Y 11M

Date & Time of Encounter: 4/30/24 at 2:14pm

Location of Encounter: Jamaica, Queens

Source of Information: Mother/Self

Reliability: Reliable

Chief Complaint: “Rash on nose” x 2 weeks

History of Present Illness:

9YOM bib mom concerned for rash on Pt’s nose x 1 week. She notes an erythematous, bumpy area on Pt’s external R nostril that began soon after he sustained a small laceration to the area from a branch at the park.  Pt says the area is warm and tender to touch, but denies unprovoked pain or itchiness. Mom reports that the Pt has continued to pick at the newer lesions on his face, and they have become more prominent since onset. They have not spread beyond his nose, they deny known rash or skin lesions elsewhere on the body. Denies fever, congestion, cough, eye pain/swelling/discharge, visual changes. Denies h/o similar symptoms. Denies known sick contacts. Mom says she has tried topical aloe vera to the area without relief or improvement.

Past Medical History:

Present illnesses – Denies

Past medical illnesses – Denies

Immunizations – Per CIR, Pt is UTD on all eligible vaccinations.

Screening tests and results – Last annual physical with CMP and CBC on 6/6/23 without abnormal findings. Vision 20/20 OU uncorrected. Last dental appointment 1/2024.

Past Surgical History:

None

Medications: 

None

Allergies:

NKDA, denies known food or environmental allergies

Family History:

Father: alive 37 yrs, healthy

Mother: alive 31 yrs, healthy

Family medical history unknown.

Pt has no siblings.

Social History:

JL is a 9YOM who lives at home w/ his mother and father. There are no other members of the home.

Habits – N/A

Travel – None

Diet – Mom says PT eats an omnivorous diet rich in most fruits and vegetables.

Exercise – Mom says PT plays sports seasonally, but is otherwise sedentary.

Sleep – 9-10 hours a night uninterrupted 

Safety measures – Pt travels primarily by bus

Review of Systems:

General: Denies fever, chills, fatigue, loss of appetite.

Skin, hair, nails: Reports an area of rough, erythematous skin with multiple raised lesions on external R nostril. Denies pruritus, swelling, erythema, or rash elsewhere on body. 

Head: Denies headache, head trauma, dizziness.

Eyes: Denies swelling, pruritus, warmth, and erythema. 

Ears: Denies pruritus, pain, discharge, or hearing loss.

Nose/Sinuses: Describes rash on R nostril as described above. Denies discharge, congestion, epistaxis, anosmia.

Mouth and throat: Denies sore throat, voice changes, dental pain.

Neck: Denies localized swelling, pain, or decreased range of motion.

Respiratory: Denies cough, shortness of breath, difficulty breathing, wheezing.

Cardiovascular system: Denies chest pain, palpitations.

Gastrointestinal system: Denies loss of appetite, nausea and vomiting, dysphagia, abdominal pain, diarrhea.

Genitourinary: Denies urinary frequency, urgency, dysuria.

Musculoskeletal System: Denies deformity, swelling, pain.

Peripheral Vascular System: Denies peripheral edema, color change. 

Nervous System: Denies sensory disturbances, weakness, 

Psychiatric: Mom reports Pt is generally in good spirits. Denies h/o psychiatric care.

Physical

General:  9YOM who appears his stated age, appears well-groomed and dressed appropriately for the weather. Pt maintains eye contact and answers questions appropriately without signs of acute distress.

Vital Signs:

Temperature: 97.9F

O2 Sat: 100% RA

Height: 51”

Weight: 76 lbs.

BMI: 20.54

Respiratory Rate: 18

Heart Rate: 84bpm

Hair, Head, and Face:

Head is normocephalic, atraumatic. Facial features are symmetrical with no signs of drooping or swelling.

Skin, and Nails: 

The skin is warm and moist. Non-icteric with no swelling or signs of ecchymosis. No rash or lesions on torso, back, or extremities.

Eyes:

Symmetrical OU. PERRLA,  EOMs intact with no nystagmus or lid lag. Visual fields full OU. 

No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink. No discharge.

Ear:

Ears are symmetrical and appropriate in size. No lesions, masses, trauma, or FBs on external ears. TMs pearly white with intact light reflex AU. No foreign bodies, discharge, effusions, perforations, or erythema AU. 

Nose and Sinus: 

Singular erythematous 1.5×1.5 cm area containing multiple honey-colored vesicles and pustules on lateral aspect of external R nostril. The nose is otherwise symmetrical without masses, deformities, trauma. Nasal mucosa is pink and moist. 

Mouth and Pharynx: 

The lips are pink with no blisters, fissures, or cyanosis. Tongue and buccal mucosa are pink and moist without swelling. Oropharynx without swelling, erythema, cobblestoning. Tonsils present without swelling, erythema, or exudates. 

Neck, Thyroid, and Lymph Nodes:

The trachea is midline without masses or scars. No anterior cervical lymphadenopathy on palpation.  

Cardiac:

Regular rate and rhythm, S1 and S2 present on auscultation. No murmurs, gallops, rubs, S3, or S4.

Thorax and Lung: 

Lung sounds CTA in all lobes B/L. No adventitious sounds.

Assessment: 

9YOM presents with yellow-crusted erythematous plaques localized to the external right nostril. 

DDx: 

1. Impetigo
2. Erysipelas
3. Molluscum
4. Tinea
5. Verrucae Vulgaris

Plan:

1. Skin Pustules of R nare
   1. Mupirocin Ointment to R nostril 2x a day for 5 days
   2. Wash hands before and after application and otherwise avoid contact with the affected area