Accuracy of clean-catch urine collection in infancy

doi:10.1016/S0022-3476(99)70099-5

The Journal of Pediatrics

Volume 135, Issue 6, December 1999, Pages 765-767

https://doi.org/10.1016/S0022-3476(99)70099-5 Get rights and content

Abstract

Objective: To compare the accuracy of cultures of urine obtained by clean-catch urine (CCU) collection and suprapubic aspiration (SPA) in infants. Design: Prospective case series undertaken in a pediatric teaching hospital and associated neonatal unit. Fifty-eight paired urine cultures (CCU collection and SPA) were obtained from 49 infants with suspected urinary tract infection. The primary outcome measure was the presence or absence of significant bacteriuria on both CCU collection and SPA; secondary outcome measures were the success of SPA with ultrasound guidance compared with aspiration without ultrasound guidance. Statistical analysis was done by using a χ² test. Results: A false-positive rate of 5% and a false-negative rate of 12% were recorded. Sensitivity was 88.9% (95% CI 65.3-98.6), and specificity was 95.0% (95 CI% 83.1-99.4). Ultrasound-assisted SPA was successful in 26 of 28 patients (93%) and in 13 of 21 patients (62%) when SPA was performed without ultrasound (χ² = 7.08, P = .008). Conclusions: We conclude that there is a good association in results of culture of urine obtained by CCU collection and SPA and would encourage the use of the CCU technique. (J Pediatr 1999;135:765-7)

Section snippets

PATIENTS AND METHODS

After local ethics committee approval was obtained, patients younger than 24 months in whom urine culture was indicated were identified from The Royal Hospital for Sick Children, Glasgow, and its associated neonatal unit. Infants with paired urine cultures obtained by both SPA and CCU collection within a 48-hour period, in the absence of prior or intervening antibiotic therapy, were recruited.

Urine was collected by SPA with the technique described by Nelson and Peters.⁸ Clean-catch specimens

RESULTS

The results of both CCU and SPA cultures are shown in the Table.

Table. Urine culture results

Empty Cell	SPA positive	SPA negative
CCU positive	16	2
CCU negative	2	38
Total	18	40

A false-positive rate of 5% and a false-negative rate of 12% were recorded, with a sensitivity of 88.9% (95% CI 65.3-98.6) and a specificity of 95.0% (95% CI 83.1-99.4).

Of 16 cultures in which SPA and CCU were positive, Escherichia coli was identified in 14, Pseudomonas aeruginosa in 1, and Candida albicans in 1. The 2 specimens that were

DISCUSSION

Rapid and accurate diagnosis of UTI is extremely important in view of the prevalence in the febrile infant.⁹ However, difficulty in specimen collection and interpretation of inadequately collected specimens may contribute to the underdiagnosis and underinvestigation of UTI in childhood, both in the hospital⁷ and in the office environment.¹⁰ This may result in an increased risk of renal scarring,¹¹ especially in infants with underlying abnormalities of the urinary tract. Similarly, a

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Cited by (69)

Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial
2022, European Urology
Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this.
To determine the effect of circumcision on the risk of fUTIs in boys with PUVs.
A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1–28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision.
Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr.
The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method.
In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3–82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age.
Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs.
In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.
Urinary Tract Infections
2019, Pediatric Clinics of North America
Citation Excerpt :
If UTI is suspected based on bag specimen, urine should be recollected via catheterization or SPA. Some studies have suggested that a clean-catch specimen can be obtained from infants and young children using suprapubic and sacral stimulation procedures.22–24 Although this is an attractive option to avoid invasive procedures and can be done without special equipment in the clinical setting, there is a high risk of culture contamination.
Urine collection methods used for non-toilet-trained children in pediatric emergency departments in France: A medical practice analysis
2019, Archives de Pediatrie
Since April 2015, the French Society of Pediatrics has encouraged suprapubic aspiration (SA) and urethral catheterization (UC) for urine collection in non-toilet-trained children suspected of having urinary tract infections (UTIs) and has tried to reduce the use of urine bag (UB).
To analyze the medical practices concerning urine collection methods used for non-toilet-trained children in pediatric emergency departments in France.
We conducted a descriptive medical practice study in October 2017. All members of the French Society of Pediatric Nephrology received two questionnaires about urine collection methods used for non-toilet-trained children, distinguishing between male and female patients, and about the corresponding analgesic protocols used in their pediatric emergency departments.
In total, 26 centers completed questionnaires concerning female patients. UC was performed in cases of fever associated with urinary tract malformations in 14 of 26 centers (54%). UB was used in cases of fever of unknown origin lasting for more than 48 h in 17 of 26 centers (65%), in cases of fever associated with UTI symptoms in 14 of 26 centers (54%), and in cases of fever in infants under 3 months of age in 16 of 26 centers (61%). The questionnaires concerning male patients were completed by 30 centers. UB was the initially used urine collection method in all situations with, respectively, 22 of 30 (73%), 27 of 30 (90%), 23 of 30 (77%), and 22 of 30 (73%) centers. The analgesic protocol for urine collection is not well established in France.
UC for urine collection in pediatric emergency departments in France is underused despite the national recommendations and the greater diagnostic power of this method compared with UB.
The method of urine sampling is not a valid predictor for vesicoureteral reflux in children after febrile urinary tract infections
2017, Journal of Pediatric Urology
Citation Excerpt :
Suprapubic aspiration (SPA) and catheterization represent the standard methods of urine collection in younger children [3,6,8]. Clean-catch urine can be an equivalent method for older children with acceptable correlation of urine culture results [9]. Conversely, Lau et al. [10] report that contamination rates of urine collected by catheterization are as prone to contamination as bag urine samples are, albeit only in uncircumcised boys and with fewer colony-forming units (CFUs).
The likelihood of detecting vesicoureteral reflux (VUR) after febrile urinary tract infections (UTI) in children logically should correlate with the correct diagnosis of the UTI. Beneath the unspecific symptoms of fever urine analysis is the main diagnostic criterion for the exact diagnosis of febrile UTIs in children. Use of inadequate urine sampling techniques during diagnosis may lead to impaired accuracy in UTI diagnosis. This could lead to the assumption that children, having diagnosed their UTI by the use of possibly inadequate urine sampling techniques should not be evaluated as consequently compared to those, where the diagnosis relied on sterile urine sampling techniques. We hypothesized that children with possibly contaminated urine samples during the initial diagnosis may show a lower rate of VUR in subsequent VCUGs because of a wrong diagnosis initially compared to children, where accurate urine sampling techniques were used.
Between 2009 and 2014, a total of 555 patients underwent a primary VCUG at our department indicated because of febrile UTIs. Patients with urine collection methods other than bag urine and catheter/suprapubic aspiration (SPA) were excluded from this study (mid-stream urine, potty urine, n = 149). We evaluated 402 patients (male/female 131/271, mean age 1.91 years), VUR rates and grades were compared between patients where urine was sampled by the use of a urine bag only at the time of diagnosis (n = 296, 73.6%) and those where sterile urine sampling (catheter, suprapubic puncture) was performed (n = 106, 26.3%). 4 patients were excluded due to equivocal data on urine sampling.
VUR rate in children after sterile urine sampling using a catheter or SPA accounted to 31.1%. In those where urine samples acquired by the use of urine bags were used, 33.7% showed VUR on subsequent VCUG (p = 0.718). There were no significant differences as to VUR grades or gender, although VUR was much more commonly diagnosed in female patients (37.0% vs 28.2%, p = 0.227) (Figure).
Children diagnosed with their UTI by use of bag urine in our experience carried the same risk of showing a VUR in a subsequent VCUG compared to those, where the initial diagnosis relied – beneath clinical criteria – on urine samples acquired by suprapubic puncture or catheterization. Consequently urine-sampling technique during initial UTI diagnosis alone should not be used as predictor for the reliability of UTI diagnosis and should not influence the further management after UTI.
Prospective evaluation of a cutaneous stimulation technique to induce on-demand urination in non-toilet-trained infants
2016, Archives de Pediatrie
When a urinary tract infection is suspected, it is recommended to capture a midstream sample of urine for analysis, but this strategy is difficult to apply before successful toilet training. A cutaneous stimulation technique has been reported to be effective in provoking micturition in newborns.
To evaluate the feasibility and the efficacy of this technique in a population of non-toilet-trained infants.
Fifty infants were enrolled in this prospective non-controlled study in three pediatric emergency departments. The bladder was stimulated through suprapubic and paravertebral cutaneous stimulation as previously reported in newborns. The evaluation criterion was the proportion of patients from whom urine had been collected within the first 5 min of the procedure.
Forty-eight patients (21 boys) were evaluated. The procedure was successful in 27% of the cases overall, but reached 46% for children aged less than 3 months. Elevated weight was associated with failure of the procedure.
Despite promising results in newborns, the cutaneous stimulation technique to provoke micturition appears to encounter limitations in older children. Nevertheless, the technique is an attractive alternative to urethral catheterization or suprapubic aspiration for infants younger than 3 months.
En cas de suspicion d’infection urinaire, une analyse des urines de milieu de jet est recommandée. Chez les enfants non continents, l’obtention d’urines de milieu de jet est souvent difficile. Une technique de stimulation vésicale pour déclencher la miction a été rapportée chez les nouveau-nés.
Évaluer la faisabilité et l’efficacité de cette technique chez des nourrissons non continents au service d’accueil des urgences pédiatriques.
Sur les trois centres hospitaliers participants, 50 nourrissons ont été inclus dans cette étude prospective non contrôlée. La vessie était stimulée par des manœuvres de stimulation lombaire et sus-pubienne comme cela avait été réalisé chez les nouveau-nés. Le critère de jugement principal était l’obtention d’urine de milieu de jet en moins de cinq minutes après le début de la manipulation.
Quarante huit patients (21 garçons) ont été évalués. La technique de stimulation a été un succès dans 27 % des cas, mais ce pourcentage s’élevait à 46 % chez les enfants âgés de moins de trois mois. Un poids élevé était associé à l’échec de la manipulation.
Cette technique de stimulation vésicale appliquée aux nourrissons présente des résultats moins satisfaisants que chez les nouveau-nés. Cependant, elle pourrait être une alternative intéressante au sondage urétral ou à la ponction sus-pubienne chez les nourrissons de moins de 3 mois.
High prevalence and antimicrobial resistance of urinary tract infection isolates in febrile young children without localizing signs in Taiwan
2016, Journal of Microbiology, Immunology and Infection
Antimicrobial susceptibility and prevalence of pediatric urinary tract infection (UTI) is very useful for pediatricians in selecting effective antibiotics in time to improve outcomes in patients. This study aimed to determine the prevalence rate, bacterial distribution, and antimicrobial susceptibility of UTI in febrile young children at a teaching hospital in northern Taiwan.
From January 2011 to December 2011, all urinary isolates from suspected cases of UTI in febrile young children aged from 1 day to 36 months visiting the Pediatric Emergency Room of Chang Gung Children's Hospital, Taoyuan, Taiwan were identified by conventional methods. Antibiotic susceptibility was determined according to the Clinical and Laboratory Standards Institute.
A total of 5470 (78%) from 7009 eligible children were enrolled in the study, and 619 (11.3%) had a diagnosis of UTI. The most prevalent bacterium was Escherichia coli (68%) followed by Klebsiella pneumoniae (8.1%) and Proteus mirabilis (6.8%). Ampicillin, piperacillin, and trimethoprim-sulfamethoxazole (TMP-SMX) showed a higher resistance rate in the three predominant bacteria. All tested bacteria showed higher resistance to ampicillin (79.3%) and TMP-SMX (44.1%), and lower resistance to cefazolin (17.7%) and gentamicin (13.0%). Fourteen percent of the isolates produced extended spectrum β-lactamase (ESBL), among which 93.33% were E. coli isolates.
The overall prevalence of UTI in this study was higher than previously reported in febrile children. Higher antimicrobial resistance was found in ampicillin and TMP-SMX. Among commonly used antibiotics, cefazolin and gentamicin are recommended to treat UTI in febrile children aged < 3 years without localizing signs.

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^☆: Reprint requests: Ian J. Ramage, MBChB, MPCP(UK), MRCPCH, Renal Unit, Royal Hospital for Sick Children, Glasgow, Scotland, UK G3 8SJ.

^☆☆: 0022-3476/99/$8.00 + 0 9/22/102408

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Accuracy of clean-catch urine collection in infancy☆,☆☆

Abstract

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

J Pediatr

J Pediatr

J Pediatr

Combined suprapubic aspiration and clean voided urine examination in infants and children

Acta Paediatr

Comparison of sterile bag, clean catch and suprapubic aspiration in the diagnosis of urinary infection in early childhood

Br J Urol

Suprapubic bladder puncture in a private pediatric practice

Postgrad Med

Studies of urinary tract infections in infancy and childhood. II. Quantitative estimation of bacteriuria in unselected neonates with special reference to the occurrence of asymptomatic infections

Acta Paediatr

The reliability of midstream urine culture from circumcised male infants

Am J Dis Child