N550C Case Studies

Due Date: February 2019 (RECORD in TYPHON as 10 Aquifer conference hours, be sure to
also include the 10 hours in your TIME LOG)
CLIPP #10: 6 mth old with a fever – Holly
CLIPP #15: Two siblings with vomiting – Caleb (age 4 years) and Ben (age 8 weeks)
fmCASE #3: 65 yo female with insomnia – Mrs. Gomez
fmCASES #7: 53 yo male with leg swelling – Mr. Smith
fmCASES #9: 50 yo female with palpatations – Ms. Yang
Due Date: March 2019 (RECORD in TYPHON as 10 Aquifer conference hours, be sure to
also include the 10 hours in your TIME LOG)
CLIPP #16: 7 yo with abdominal pain and vomiting – Isabella
CLIPP # 18: 2 week old with poor feeding – Tyler
fmCASES #15: 42 yo male with right upper quadrant pain – Mr. Keenan
fmCASES #22: 70 yo male with new-onset unilateral weakness – Mr. Wright
fmCASES #24: 4 week old female with fussiness – Amelia Arlington
Due Date: April 2019 (RECORD in TYPHON as 10 Aquifer conference hours, be sure to also
include the 10 hours in your TIME LOG)
CLIPP # 19: 16 mth old with first seizure – Ian
CLIPP #21: 6 yo boy with bruising – Alex
CLIPP #23: 15 yo with lethargy and fever – Sarah
fmCASES #26: 55 yo male with fatigue – Mr. Cunha
fmCASES #28: 58 yo male with shortness of breath – Mr. Barley
Due Date: May 2019 (RECORD in TYPHON as 12 Aquifer conference hours, be sure to also
include the 12 hours in your TIME LOG)
CLIPP #24: 2 yo with altered mental status – Madelyn
CLIPP # 25: 2 mth old with apnea – Jeremy
CLIPP #27: 8 yo with abdominal pain – Jenny
fmCASES #29: 72 yo male with dementia – Mr. Marshall
fmCASES #31: 66 yo female with shortness of breath – Mrs. Hernandez
fmCASES #33: 28 yo female with dizziness – Mrs. Saleh

Recommendations for Empiric Antibiotic Treatment of

Pyelonephritis
In a child who has not recently been on antibiotics, the most likely cause of an initial episode of
pyelonephritis is E. coli (85-90% of the time), with the remainder of cases caused by other
enteric gram-negative organisms (Klebsiella or Proteus), or by enterococcus.
Parenteral antibiotics

 Resistance rates of ampicillin to E. coli are rising, so ampicillin

 alone would not provide adequate coverage. (If sensitivity testing sh
alone would be effective.)
Ampicillin/gentamicin
 When combined with gentamicin-which has excellent activity
 against coliforms-it is a good option for the treatment of pyelonephr
 Ampicillin is also a good choice to treat enterococci.

 Provides excellent coverage against most gram-negative bacilli

 (the major exception being Pseudomonas aeruginosa)
 Not effective against enterococci
 Excellent safety profile in children
Ceftriaxone
 Can be given once daily
 Calcium-containing medications cannot be given through the same
 IV line as they may interact with ceftriaxone to form precipitates
 in the lungs and kidneys

 Not first-line for Urinary Tract Infections, but may be indicated in

Meropenem  regions where there is increasing resistance due to
 extended-spectrum beta-lactamases (ESBLs).

 Can be used, but is not the best choice due to cost and potential
 adverse reactions in children
Ciprofloxacin
 Approved for children older than 1 year for complicated UTI
 with resistant organisms

Oral antibiotics

 Provides good coverage for E.Coli and other enteric gram-negative

Cephalexin (Keflex)
 rods
  Inexpensive and well tolerated

 The combination of trimethoprim-sulfamethoxazole is effective at

 treating UTIs, with the exception of Pseudomonas and
Trimethoprim/Sulfamethoxazole
 resistant E.Coli. A rare, but concerning side effect is
 Stevens-Johnson syndrome.

 An acceptable concentration level is reached only in the urine,

Nitrofurantoin  not in the blood; therefore, approved only for the treatment of
 cystitis, not pyelonephritis

Amoxicillin/clavulanate  Would be effective, but-due to potential for skin

(Augmentin)  and gastrointestinal adverse reactions-would not be the first choice.

References

Calculating an anion gap

Anion Gap = Serum Na – (HCO3+Cl)
An elevated anion gap (>12) indicates that a patient’s acidosis is
attributed to unmeasured cations, including those from ingestions,
lactic acidosis, uremia, and DKA.
A commonly used mnemonic for causes of elevated anion gap metabolic acidosis is
MUDPILES: methanol, uremia, DKA, paraldehyde, INH/Iron, lactic acidosis, ethanol/ethylene
glycol, salicylates.