Bag urine specimens still not appropriate in diagnosing urinary tract infections in infants

Collecting the golden water: Quality assessment on approach of diagnosing urinary tract infections in 0 to 36 months old children

OBJECTIVE

The study aimed to assess current practices of a community hospital for collection of urine sample when diagnosis of urinary tract infection (UTI) is suspected in children aged 0 to 36 months old.

METHODS

An analysis of paediatric patients aged 0 to 36 months old was performed in two separate audits to assess the quality of urine sampling. The first, retrospective analysis comprised of urine collections techniques in a community hospital for diagnosis of UTI followed by an education intervention in which the hospital staff was briefed regarding the Canadian Paediatric Society (CPS) position statement for diagnosis and management of UTI. CPS recommendations were transposed using PowerPoint presentations, reminders at unit huddles, and other educational forums. Second audit was a prospective analysis which was conducted 6 months after the educations intervention.

RESULTS

Bagged sampling had higher sensitivity and lower specificity due to sample contamination, versus transurethral bladder catheterization and suprapubic aspiration. The first audit showed that while 66% of culture-positive urine sampling was performed via the bagging, only 26% those positive cultures were repeated before treatment. In the second audit, after educational intervention, 33% of culture-positive urine collection was done via the bagging method and repeat testing was done in 83% of positive results on a bagged sample before initiating treatment. The false-positive rate for the diagnosis of UTIs in the first and second audit was 65.7 and 60%, respectively.

CONCLUSION

Our study recognizes the flaws in community hospital practices in the diagnosis of UTI in children and validates the significance of educational intervention in improving health care.

Urinary tract infections in infants and children: Diagnosis and management

Recent studies have resulted in major changes in the management of urinary tract infections (UTIs) in children. The present statement focuses on the diagnosis and management of infants and children >2 months of age with an acute UTI and no known underlying urinary tract pathology or risk factors for a neurogenic bladder. UTI should be ruled out in preverbal children with unexplained fever and in older children with symptoms suggestive of UTI (dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence). A midstream urine sample should be collected for urinalysis and culture in toilet-trained children; others should have urine collected by catheter or by suprapubic aspirate. UTI is unlikely if the urinalysis is completely normal. A bagged urine sample may be used for urinalysis but should not be used for urine culture. Antibiotic treatment for seven to 10 days is recommended for febrile UTI. Oral antibiotics may be offered as initial treatment when the child is not seriously ill and is likely to receive and tolerate every dose. Children <2 years of age should be investigated after their first febrile UTI with a renal/bladder ultrasound to identify any significant renal abnormalities. A voiding cystourethrogram is not required for children with a first UTI unless the renal/bladder ultrasound reveals findings suggestive of vesicoureteral reflux, selected renal anomalies or obstructive uropathy.

The age-related risk of co-existing meningitis in children with urinary tract infection

Objective

The primary aim of this study was to determine age-stratified rates of co-existing bacterial meningitis in children with urinary tract infection (UTI). The secondary aims of this study were to determine the causative pathogens of UTI, and the clinical features and outcome of children with co-existing meningitis.

Methods

Analysis of data collected over a nine-year period at a tertiary pediatric hospital in Australia. Study population: children below 16 years of age with culture-confirmed UTI and a paired CSF sample.

Results

A total of 748 episodes in 735 cases were included in the final analysis. The commonest pathogens causing UTI were Escherichia coli (67.4%), Enterococcus faecalis (8.4%), Klebsiella oxytoca (3.5%) and Klebsiella pneumoniae (3.5%). Only two (1.2%; 95% CI: 0.15–4.36%) of 163 neonates (between 0 and 28 days of age) with UTI had co-existing meningitis. Both presented with pyrexia, irritability and lethargy, and recovered uneventfully with antibiotic treatment. There were no cases of co-existing meningitis among 499 infants (between 29 days and 12 months of age) with UTI (95% CI: 0.00–0.74%), or any of the 86 children aged 12 months or over (95% CI: 0.00–4.20%).

Conclusions

These findings indicate that clinicians should have a low threshold to perform a lumbar puncture in neonates with UTI, as the risk of co-existing meningitis is not insignificant in this age group. In contrast, beyond the neonatal period, the risk is small and a more selective approach is warranted.