Bladder Stimulation Technique for Clean Catch Urine Collection in Infants
Bladder Stimulation Technique for Clean Catch Urine Collection in Infants
Urinary tract infection is the most common serious bacterial infection among infants. Bladder
 catheterization is considered the gold standard for diagnosis, yet is painful and invasive.
 In contrast, the bladder stimulation technique has been shown to be a quick and non-invasive
 approach to collecting urine in young infants with a contamination rate similar to bladder
 catheterization. Previous research, however, relied upon trained study personnel thereby
 limiting the generalizability of their findings. By training staff in the pediatric emergency
 department, this study aims to evaluate the feasibility of incorporating this technique into
 routine clinical practice while also assessing its impact on parent and provider
 satisfaction.
Previous studies have demonstrated that the bladder stimulation technique is a quick and
 non-invasive approach to collecting urine in young infants with a contamination rate similar
 to the current more invasive gold standard, catheterization. This study, however, will be the
 first to demonstrate the feasibility of incorporating this technique into clinical practice
 in a busy, urban, academic pediatric emergency department (PED). In training over 120 PED
 staff, the investigators aim to demonstrate that minimal training is required to perform this
 technique. In addition, the investigators hypothesize that the bladder stimulation technique
 will be well tolerated by patients, and preferred by providers and parents when compared with
 catheterization. The results of this study may then lead to a change in practice where the
 bladder stimulation technique will be used preferentially for infants requiring a urinalysis
 and urine culture.

 Urinary tract infection (UTI) is the most common serious bacterial infection among febrile
 infants, occurring in 7% of children less than 24 months of age evaluated for fever without a
 source. The American Academy of Pediatrics (AAP) recommends obtaining a urine specimen for
 urinalysis and culture via suprapubic aspiration (SPA) or catheterization, particularly for
 infants requiring immediate antimicrobial therapy. These methods are painful and invasive,
 yet are considered the gold standard approaches to urine collection in infants as the culture
 obtained has a sensitivity and specificity of >95%. Alternative techniques, such as a urine
 collection bag attached to the perineum or a clean catch urine (CCU), offer non-invasive
 approaches to urine collection but are undesirable as cultures obtained using a bag have a
 false positive rate approaching 90% and CCU can be time consuming. As an alternative to these
 methods, Herreros et al described a new non-invasive technique for obtaining a mid-stream CCU
 sample in newborns. This approach couples feeding with bladder stimulation and was successful
 in 86% of newborns with a mean time of 57 seconds. Subsequent research has demonstrated that
 this technique is particularly effective for children ≤ 90 days with a contamination rate
 similar to that of catheterization. While previous studies have demonstrated the ease of this
 approach, without an increase in contamination rates compared with more invasive techniques,
 previous studies have relied upon trained study personnel, limiting the generalizability of
 the technique.

 The proposed study builds upon published literature. Herreros et al first described the
 bladder stimulation technique in newborn infants, which was successful in 86% of newborns
 with a mean time of 57 seconds. Altuntas et al subsequently demonstrated in a randomized
 controlled study that the bladder stimulation technique was effective in 78% of newborns,
 with urine collection occurring within a median time of 60 seconds. Tran et al then
 demonstrated that this technique is particularly effective for children ≤ 90 days presenting
 to the emergency department with a contamination rate similar to that of catheterization.
 Importantly, these findings were replicated by Labrosse et al who also noted that the
 contamination proportion is not statistically different from the rate seen with
 catheterization. Thus, while all the previous studies have demonstrated the ease of this
 approach, without an increase in contamination rates compared with more invasive techniques,
 previous studies have relied upon trained study personnel, limiting the generalizability of
 the technique to routine clinical care.

 This study will be conducted in the PED at the Children's Hospital of Michigan, an academic
 tertiary care facility in an inner city setting with approximately 90,000 PED visits
 annually.

 The investigators estimate a sample size of 92 patients to be recruited over the study
 period. This was based on a margin of error (e=0.10) obtained from the study by Labrosse et
 al. The investigators estimate a success rate of 40% for the bladder stimulation technique,
 with a 5% level of significance (p < 0.05).

 Following informed consent, demographic data will be obtained by a trained research assistant
 using a standardized form. The bladder stimulation technique will be performed by a trained
 PED nurse or technician using the procedure outlined below. Prior to the six month period of
 patient recruitment, all technicians and nursing staff in the PED will receive standardized
 training using a video module and print materials. The steps of the procedure will also be
 printed and available in the PED as reference material. The bladder stimulation technique
 will adhere to the protocol previously published by Herreros et al and replicated by Labrosse
 et al. The technique involves a combination of fluid intake and noninvasive bladder
 stimulation maneuvers. All infants will be encouraged to feed during a 20-minute period prior
 to the stimulation technique. Breast fed infants will feed ad libitum whereas formula fed
 infants will be offered an age and weight appropriate volume (1 day of age 10 ml; 2 - 7 days
 of age, add 10 ml / day of life to a maximum of 70 ml / feed; ≥ 8 days of age 25 mg / kg of
 formula). Infants who do not feed well will not be excluded. Infants who are determined to
 need intravenous fluids at the discretion of the treating physician will receive a standard
 10-20 ml / kg bolus of normal saline over < 30 minutes. Specimen collection using the bladder
 stimulation technique will be started 20 minutes after the initiation of oral feeding and/or
 intravenous fluids.

 The bladder stimulation technique is performed following genital cleaning with a 2% castile
 soap towelette, which is part of the sterile clean catch urine collection cup kit. For the
 technique, infants will be held under their armpits by a parent over the bed, with legs
 dangling in males and hips flexed in females. The nurse or technician will then alternate
 between bladder stimulation maneuvers: gentle tapping in the suprapubic area at a frequency
 of 100 taps per minute for 30 seconds followed by lumbar paravertebral massage maneuvers for
 30 seconds. These two stimulation maneuvers will be repeated until micturition begins, or for
 a maximum of 300 seconds. The nurse or technician performing the bladder stimulation
 technique or a resident or medical student caring for the patient will collect the urine in a
 clean catch specimen container. The research assistant will time the procedure from the start
 of the stimulation techniques to the start of micturition using a stopwatch. In accordance
 with current PED practices for pain control, non nutritive sucking on a pacifier with/without
 sucrose will be provided as an optional comfort measure, based on parental preference.

 Urine will be sent to the laboratory for urinalysis and culture in accordance with standard
 laboratory techniques. Failure to obtain a specimen after continued bladder stimulation
 maneuvers for > 300 seconds will necessitate obtaining a catheterized urine sample. When
 catheterization is required, this will be obtained by a technician or nursing staff in
 accordance with their established protocols for this procedure. To preserve the current
 standard of care, catheterization or SPA will also be performed when: (1) the urinalysis
 obtained using the bladder stimulation technique is positive and/or (2) the treating
 physician decides to prescribe antibiotics. Catheterization may also be performed at the
 discretion of the treating physician. When catheterization is performed, the research
 assistant will time the procedure from the start of catheter placement to urine collection
 using a stopwatch. In accordance with current PED practices for pain control, non nutritive
 sucking on a pacifier with/without sucrose will also be provided for this procedure as an
 optional comfort measure, based on parental preference.

 During the bladder stimulation technique, parental perception of pain will be assessed using
 the Numeric Rating Scale (NRS). The research assistant will administer the NRS to the parent
 immediately prior to the procedure (T0), during the bladder stimulation technique (T1), 1
 minute after completion of the bladder stimulation technique (T2) and 5 minutes after
 completion of the bladder stimulation technique (T3). For infants undergoing catheterization,
 parental perception of pain will also be assessed using the NRS at similar time intervals.

 After collection of the urine sample using the stimulation technique (whether successful or
 not), the parent and the nurse will complete a brief questionnaire (administered by the
 research assistant). The parent questionnaire aims to evaluate parental perception of
 discomfort and their satisfaction with the stimulation technique. The provider questionnaire
 evaluates their comfort with the procedure and their perception of patient discomfort.
 Similar questionnaires will be distributed to the parent and the nurse following
 catheterization when this procedure is performed. Following the clinical encounter, the
 research assistant will review participants' electronic medical record to obtain the final
 results of the urinalysis and urine culture to complete the standardized data collection form
 for the participant.

 A successful urine specimen obtained using the bladder stimulation technique will be defined
 by the collection of at least 1 mL of urine within 300 seconds of initiating the bladder
 stimulation maneuvers. Laboratory definitions of a positive urinalysis and urine culture are
 defined below based on definitions published by the American Academy of Pediatrics and
 previous authors investigating the bladder stimulation technique. As per Labrosse et al, poor
 oral intake will be defined as <25% of regular fluid intake during the feeding period prior
 to the bladder stimulation technique, based on parental assessment. Finally, the cost of the
 procedures (invasive versus non-invasive) will be based on the cost of material required for
 a clean catch urine specimen versus the cost of material required for bladder
 catheterization.
Inclusion Criteria:

 - Infants less than 6 months of age who require a urine sample for urinalysis and culture
 as part of their PED visit (as determined by the treating physician) are eligible for
 inclusion

 Exclusion Criteria:

 -  Parents / caregivers do not speak English

 -  Parents / guardian unavailable to sign consent

 -  Evidence of injury / infection to the abdomen / back precluding completion of the
 bladder stimulation technique

 -  Known medical condition rendering it impossible to obtain a sample using the
 stimulation technique (e.g. urostomy)

 -  Critical illness and/or hemodynamic instability

 -  Current antibiotic therapy or antibiotics within 14 days of enrollment

 -  Previous enrollment.