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Pad urine collection for ear ly childhood urinary-tract infection
RESEARCH LETTERS
Pad urine collection for ear ly childhood urinary-tract infection Peter I Macfarlane, Christine Houghton, Christopher Hughes Urine collected into absorbent pads is commonly contaminated, making this method unreliable for ruling out urinary-tract infection in young children. Bag samples are equally unhelpful, whereas clean-catch samples are least likely to need repeating.
Prompt treatment of urinary-tract infection in early childhood is important to prevent renal scarring.1 The difficulty of collecting an uncontaminated urine sample from young children has prompted a search for alternative collection methods. Absorbent urine collection pads (UCPs) placed inside a child’s nappy have been compared with bag urine collection, with encouraging results.2 We evaluated the UCP method over 3 months on a busy children’s inpatient unit. The UCP (NHS Supplies) was placed inside the front of the child’s nappy, the child’s nurse checked the pad every 15–20 min, removed it when wet, and aspirated urine from it using a 20 mL syringe. Faecally soiled pads were discarded. The sample was strip tested for nitrites and leucocytes (Nephur-Test+Leuco, Boehringer Mannheim, Mannheim, Germany) and sent to the microbiology laboratory for microscopy and culture or stored overnight at 4ºC before transport the next day. 88 children, all below 2 years of age, with various febrile illnesses were included. 56 UCP samples were reliably obtained (74% within 90 min, urine volumes between 0·5 mL and 15 mL); the remaining 32 samples failed for a variety of reasons (soiled pad, insufficient volume, lengthy collection time, sample obtained by other means) and are excluded from this analysis. Four children had urinary-tract infection, and of the remaining 52 urine samples, 18 showed no growth but 34 (65%) showed contamination with a mixed growth of bacteria (14 grew >105/mL and 20 grew <105/mL). 34 children in the same age range and in the same ward setting had bag urine collection done over the preceding 9 months, 23 (68%) of which showed a contaminated mixed growth (11 had >10 5/mL and 12 had <105/mL). In our practice, neither collection method was helpful for ruling out urinary-tract infection. Using attempted cleancatch urine samples (into a sterile foil container) from children of the same age, we found 27% (64 of 240) had a contaminated mixed growth (29 had >105/mL and 35 had <105/mL), over the same period. A previous publication reporting UCP collection (or equivalent nappy material), yielded 26% (10 of 39) mixed growth contamination, compared with 44% (17 of 39) for bag samples.2 Other studies have not reported details of contamination rates.3,4 We also found a discrepancy between detection of leucocytes by test-strip urinalysis and microscopy of UCP samples. Six samples indicated 10–500 leucocytes/mL by strip testing, but with none or less than 5 cells/mL on microscopy. A likely explanation is that the test strip is detecting the presence of soluble leucocyte esterase in aspirated urine, because intact cells are known to be retained in the matrix of the UCP.2 In our experience, UCPs were easy to use, but resulted in an unhelpfully high rate of contamination (65%) similar to bag samples (68%). Only 27% of clean-catch urine samples were contaminated. Sterile urine or urine with a low (<105/mL) mixed bacterial count is probably sufficient in most cases to rule out urinary-tract infection, whereas a sample contaminated by a heavy mixed growth (>105/mL) may hide infection. Such samples may need to be repeated.
THE LANCET • Vol 354 • August 14, 1999
Applying this principle to our series, we found that 14 (27%) of 52 pad samples, 11 (32%) of 34 bag samples, but only 29 (12%) of 240 clean-catch samples would have been repeated. Clean-catch sampling should therefore remain the usual method of urine collection in this age group unless suprapubic needle aspiration of urine is indicated. The need for an alternative quick, reliable, and painless method of urine collection is this age group remains. 1
Royal College of Physicians Research Unit Working Group. Guidelines for the management of acute urinary tract infection in childhood. J R Coll Phys Lond 1991; 25: 36–42. 2 Ahmad T, Vickers D, Campbell S, Coulthard MG, Pedler S. Urine collection from disposable nappies. Lancet 1991; 338: 674–76. 3 Lewis J. Clean catch versus urine collection pads: a prospective trial. Paediatr Nurs 1998; 10: 15–16. 4 Vernon S, Redfearn A, Pedler SJ, Lambert HJ, Coulthard MG. Urine collection on sanitary towels. Lancet 1994; 334: 612.
Departments of Child Health (P I Macfarlane FRCP, C Houghton RSCN ) and Microbiology (C Hughes MMed), Rotherham General Hospital, Rotherham S60 2UD, UK Correspondence to: Dr P I Macfarlane (e-mail: [email protected])
Patients’ perceptions of intensive care Bruno Simini Pain, noise, sleep deprivation, thirst, hunger, heat, cold, fear, anxiety, isolation, physical restraint, want of information, and absence of daylight were common memories of patients surviving intensive care.
How comfortable are patients receiving intensive care? To answer this question, all patients in the intensive care unit in Lucca, Italy from October, 1998, to March 1999 were assessed. Of 162 patients, 35 (22%) died. 51 patients were not interviewed (18 because of psychiatric or neurological disease, 13 were transferred to other hospitals, four went straight home, four died on the wards they were transferred to, and 12 left before interview). Within 3 days of discharge from the intensive-care unit, 76 patients were interviewed by an intensive-care specialist who had not seen them before. Medical and nursing staff on the intensive-care unit were unaware that patients would be interviewed. There were 50 men and 26 women, mean age 62 years (range 17–92 years). They stayed an average of 4·4 days (range 1–19). Admission diagnosis was postoperative care for 37 (49%), trauma for 18 (24%), acute exacerbation of chronic respiratory failure for 10 (13%), and other medical conditions for 11 (14%) patients. Patients not interviewed did not differ from those who were interviewed in age, sex, length of stay, or diagnosis. Pain was reported by 33 (43%) patients; of these patients, 31 (94%) said that analgesics requested did not yield the expected pain relief, 46 (61%) reported sleep deprivation, 48 (63%) recalled being thirsty, 10 (13%) had been hungry, and 28 (37%) and 21 (28%) had been uncomfortably hot and cold, respectively. 47 (62%) patients had been afraid or anxious, 35 (46%) had felt lonely or isolated, and 25 (33%) lacked information about their condition and procedures. Patients were asked to recall their worst memories. 21 (28%) patients had none, 55 (72%) patients reported the following (some reported more than one): thirst (nine), feeling lonely or abandoned (nine), unceasing noises (seven), tracheal and gastric tubes (seven), pain (six), being tied to the bed (six), seeing or hearing others suffer and die (six), insomnia (four), absence of windows and daylight
571
Pad urine collection for ear ly childhood urinary-tract infection Peter I Macfarlane, Christine Houghton, Christopher Hughes Urine collected into absorbent pads is commonly contaminated, making this method unreliable for ruling out urinary-tract infection in young children. Bag samples are equally unhelpful, whereas clean-catch samples are least likely to need repeating.
Prompt treatment of urinary-tract infection in early childhood is important to prevent renal scarring.1 The difficulty of collecting an uncontaminated urine sample from young children has prompted a search for alternative collection methods. Absorbent urine collection pads (UCPs) placed inside a child’s nappy have been compared with bag urine collection, with encouraging results.2 We evaluated the UCP method over 3 months on a busy children’s inpatient unit. The UCP (NHS Supplies) was placed inside the front of the child’s nappy, the child’s nurse checked the pad every 15–20 min, removed it when wet, and aspirated urine from it using a 20 mL syringe. Faecally soiled pads were discarded. The sample was strip tested for nitrites and leucocytes (Nephur-Test+Leuco, Boehringer Mannheim, Mannheim, Germany) and sent to the microbiology laboratory for microscopy and culture or stored overnight at 4ºC before transport the next day. 88 children, all below 2 years of age, with various febrile illnesses were included. 56 UCP samples were reliably obtained (74% within 90 min, urine volumes between 0·5 mL and 15 mL); the remaining 32 samples failed for a variety of reasons (soiled pad, insufficient volume, lengthy collection time, sample obtained by other means) and are excluded from this analysis. Four children had urinary-tract infection, and of the remaining 52 urine samples, 18 showed no growth but 34 (65%) showed contamination with a mixed growth of bacteria (14 grew >105/mL and 20 grew <105/mL). 34 children in the same age range and in the same ward setting had bag urine collection done over the preceding 9 months, 23 (68%) of which showed a contaminated mixed growth (11 had >10 5/mL and 12 had <105/mL). In our practice, neither collection method was helpful for ruling out urinary-tract infection. Using attempted cleancatch urine samples (into a sterile foil container) from children of the same age, we found 27% (64 of 240) had a contaminated mixed growth (29 had >105/mL and 35 had <105/mL), over the same period. A previous publication reporting UCP collection (or equivalent nappy material), yielded 26% (10 of 39) mixed growth contamination, compared with 44% (17 of 39) for bag samples.2 Other studies have not reported details of contamination rates.3,4 We also found a discrepancy between detection of leucocytes by test-strip urinalysis and microscopy of UCP samples. Six samples indicated 10–500 leucocytes/mL by strip testing, but with none or less than 5 cells/mL on microscopy. A likely explanation is that the test strip is detecting the presence of soluble leucocyte esterase in aspirated urine, because intact cells are known to be retained in the matrix of the UCP.2 In our experience, UCPs were easy to use, but resulted in an unhelpfully high rate of contamination (65%) similar to bag samples (68%). Only 27% of clean-catch urine samples were contaminated. Sterile urine or urine with a low (<105/mL) mixed bacterial count is probably sufficient in most cases to rule out urinary-tract infection, whereas a sample contaminated by a heavy mixed growth (>105/mL) may hide infection. Such samples may need to be repeated.
THE LANCET • Vol 354 • August 14, 1999
Applying this principle to our series, we found that 14 (27%) of 52 pad samples, 11 (32%) of 34 bag samples, but only 29 (12%) of 240 clean-catch samples would have been repeated. Clean-catch sampling should therefore remain the usual method of urine collection in this age group unless suprapubic needle aspiration of urine is indicated. The need for an alternative quick, reliable, and painless method of urine collection is this age group remains. 1
Royal College of Physicians Research Unit Working Group. Guidelines for the management of acute urinary tract infection in childhood. J R Coll Phys Lond 1991; 25: 36–42. 2 Ahmad T, Vickers D, Campbell S, Coulthard MG, Pedler S. Urine collection from disposable nappies. Lancet 1991; 338: 674–76. 3 Lewis J. Clean catch versus urine collection pads: a prospective trial. Paediatr Nurs 1998; 10: 15–16. 4 Vernon S, Redfearn A, Pedler SJ, Lambert HJ, Coulthard MG. Urine collection on sanitary towels. Lancet 1994; 334: 612.
Departments of Child Health (P I Macfarlane FRCP, C Houghton RSCN ) and Microbiology (C Hughes MMed), Rotherham General Hospital, Rotherham S60 2UD, UK Correspondence to: Dr P I Macfarlane (e-mail: [email protected])
Patients’ perceptions of intensive care Bruno Simini Pain, noise, sleep deprivation, thirst, hunger, heat, cold, fear, anxiety, isolation, physical restraint, want of information, and absence of daylight were common memories of patients surviving intensive care.
How comfortable are patients receiving intensive care? To answer this question, all patients in the intensive care unit in Lucca, Italy from October, 1998, to March 1999 were assessed. Of 162 patients, 35 (22%) died. 51 patients were not interviewed (18 because of psychiatric or neurological disease, 13 were transferred to other hospitals, four went straight home, four died on the wards they were transferred to, and 12 left before interview). Within 3 days of discharge from the intensive-care unit, 76 patients were interviewed by an intensive-care specialist who had not seen them before. Medical and nursing staff on the intensive-care unit were unaware that patients would be interviewed. There were 50 men and 26 women, mean age 62 years (range 17–92 years). They stayed an average of 4·4 days (range 1–19). Admission diagnosis was postoperative care for 37 (49%), trauma for 18 (24%), acute exacerbation of chronic respiratory failure for 10 (13%), and other medical conditions for 11 (14%) patients. Patients not interviewed did not differ from those who were interviewed in age, sex, length of stay, or diagnosis. Pain was reported by 33 (43%) patients; of these patients, 31 (94%) said that analgesics requested did not yield the expected pain relief, 46 (61%) reported sleep deprivation, 48 (63%) recalled being thirsty, 10 (13%) had been hungry, and 28 (37%) and 21 (28%) had been uncomfortably hot and cold, respectively. 47 (62%) patients had been afraid or anxious, 35 (46%) had felt lonely or isolated, and 25 (33%) lacked information about their condition and procedures. Patients were asked to recall their worst memories. 21 (28%) patients had none, 55 (72%) patients reported the following (some reported more than one): thirst (nine), feeling lonely or abandoned (nine), unceasing noises (seven), tracheal and gastric tubes (seven), pain (six), being tied to the bed (six), seeing or hearing others suffer and die (six), insomnia (four), absence of windows and daylight
571