Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urine infection
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

The patient is a male infant. He was referred to the ED for six-day history of fevers, non-productive, cough, and decreased feeding. Work-up in the pediatrician's office was suspicious for urinary tract infection. Viral panel also returned positive for parainfluenza. 

The patient's vital signs included temperature 37.2, heart rate 142, respiratory rate 34, and 97% oxygen saturation in room air. Physical examination was significant for no distress, moist mucous membranes, clear lungs, regular heart rate and rhythm, and benign abdomen. Laboratory evaluation was remarkable for CRP (C-reactive protein) 1, CO2 (carbon dioxide) 19, and normal procalcitonin. Blood and urine cultures were obtained. 

The patient was treated with a normal saline bolus and a dose of ceftriaxone. He was admitted to the pediatric floor for treatment of febrile urinary tract infection and mild dehydration. Admission orders included maintenance IV fluids, anti-pyretics, and diet for age. Antibiotics were not continued because the urinalysis and urine culture results were suggestive of contamination. 

The patient remained afebrile with no signs of respiratory distress throughout his hospital stay. His oral intake improved and he maintained good urine output. He was deemed stable for discharge to follow-up with his pediatrician in one to two days.

There are a number of "red flags" that increase suspicion of serious bacterial infection, including inconsolability, cyanosis, poor peripheral circulation, tachypnea, petechial rash, and seizures. Selected use of laboratory testing and imaging may be necessary to identify serious bacterial infection. Urinalysis is particularly important because of the commonality of urinary tract infection. Although complete blood count is not always useful or predictive, current guidelines recommend obtaining CBC (complete blood count) and blood culture in febrile infants less than three months of age. Both C-reactive protein and procalcitonin have been and continue to be explored as useful markers of serious bacterial infection. Currently, procalcitonin appears to be the better choice, but expense and delay in obtaining results make it less practical. Chest x-ray is useful in young infants with respiratory symptoms and those with high fevers over 102.2F (39C). With the current vaccine schedule, meningitis is less common, but lumbar puncture is still indicated in infants one to three months of age with high risk findings such as ill appearance. Rapid viral testing may be useful during epidemics to prevent need for other testing. 

This male infant presented with fever at six months of age. Urinalysis in the office had some features of infection, enough for the pediatrician to refer the infant to the ED for further evaluation. Viral panel was also done in the office and was positive for parainfluenza. The infant was treated in the ED with a normal saline bolus (determined to have mild dehydration with CO2 19, moist mucous membranes, appropriate number of wet diapers, decreased intake) as well as a dose of ceftriaxone. Urine culture results were suspicious for contamination and did not meet criteria for urinary tract infection. The infant was overall hemodynamically stable, with no respiratory distress, no oxygen requirement, and no signs/symptoms of sepsis. He was appropriately managed in the ED, and could have safely been discharged home to follow-up with his pediatrician. Acute inpatient management was not medically necessary in this case.