536263

research-article2014

CPJXXX10.1177/0009922814536263Clinical PediatricsCoutinho et al

Article

Pediatrician Noncompliance With the American Academy of Pediatrics Guidelines for the Workup of UTI in Infants

Clinical Pediatrics 2014, Vol. 53(12) 1139­–1148 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814536263 cpj.sagepub.com

Karl Coutinho, MD1, Kristian Stensland, MD2, Ardavan Akhavan, MD3, Rajiv Jayadevan, BA2, and Jeffrey A. Stock, MD1

Abstract Background. The American Academy of Pediatrics (AAP) guidelines on the workup for urinary tract infections (UTIs) in infants discourages the use of bagged urine specimens for urine culture. We report the results of a survey to assess urine collection preferences and adherence to AAP guidelines in clinical practice. Methods. A 29-question survey was e-mailed to pediatrician AAP members to determine their preferred method of urine collection in hypothetical infant patients. Results. Data from 155 respondents were analyzed. In febrile, circumcised boys, up to 18% preferred bagged specimens for urine culture, against AAP recommendations. In febrile girls, 13% of respondents preferred bagged specimens. There was no significant relationship between adherence to AAP guidelines and respondent’s age, gender, years in practice, fellowship training, academic affiliation, or other demographic factors. Conclusions. Up to 18% of practitioners prefer bagged specimens over more sterile ones in the workup of febrile UTIs in infants, against AAP guidelines. Keywords urinary tract infection, urine sampling, pediatrics

Introduction Prompt diagnosis of urinary tract infection (UTI) in pediatric patients is important to prevent long-term complications such as renal scarring and pyelonephritis. However, urine collection in young children, especially infants, can present a challenge because of issues with patient cooperation and parental anxiety. Practitioners have several methods to sample urine in pediatric patients, including bagged specimens, urethral catheterization, and suprapubic aspiration (SPA). Each of these methods presents unique advantages and disadvantages in their invasiveness, convenience, adverse effects, and specificity. In 2011, the American Academy of Pediatrics (AAP) updated their clinical practice guidelines on the workup and management of UTIs in children 2 to 24 months of age.1 The guidelines recommend specific methods for collecting urine samples based on a patient’s risk factors for UTI. In febrile infants deemed to have a low likelihood of a UTI, clinical monitoring without testing is sufficient. However, for infants not in a low-risk group, the committee recommends obtaining a urine specimen

through urethral catheterization or SPA for bacterial culture. Bagged specimen collection is reserved for a urinalysis only, followed by catheterization or SPA if the specimen suggests a UTI. Barriers exist in implementing these guidelines in a clinical setting. A variety of factors, including availability of trained ancillary staff, patient temperament, parental anxiety, and adverse events associated with the invasive procedure may influence some clinicians to depart from the AAP’s guidelines. In our regional survey study, we investigate compliance with the 2011 AAP UTI guidelines among practitioners registered with the New Jersey Chapter AAP and the clinical and

1

Mount Sinai Medical Center, New York, NY, USA The Icahn School of Medicine at Mount Sinai, New York, NY, USA 3 Seattle Children’s Hospital, Seattle, WA, USA 2

Corresponding Author: Karl Coutinho, Department of Urology, The Kravis Children’s Hospital, Mount Sinai Medical Center, 1 Gustav Levy Place, New York, NY 10029, USA. Email: [email protected]

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demographic factors associated with their compliance or lack thereof.

Table 1.  Study Participant Demographics and Characteristics. Total Percentage (%)

Methods Between September 2012 and January 2013, a 29-question survey (see the appendix) was e-mailed to all 1650 registered members of the New Jersey Chapter of the AAP through Survey Monkey (Palo Alto, CA). Respondents who were not in clinical practice treating pediatric patients were excluded. The practitioners were questioned on their preferred methods of sampling urine in patients aged 2 to 24 months, both with and without risk factors associated with UTIs. These risk factors are defined by the AAP in both female (white race, age 24 hours, and absence of other source of infection.) Statistical analysis was performed using SPSS v 19 (IBM; Armonk, NY). χ2 and Fisher Exact tests were used for analysis of the responses. Statistical significance was defined as P < .05.

Results There were 160 respondents in all, giving a response rate of 10.3%. Of these respondents, 155 (97%) were pediatricians in clinical practice and thus eligible for the survey. Table 1 illustrates the demographic and professional breakdown of the survey respondents; 39% were in practice for 20 years or more, and 59% were female. Most (77%) practitioners were in private practice; however, 45% had at least a part-time academic affiliation. Of those surveyed, 88% were in District III of the AAP, representing Delaware, the District of Columbia, Maryland, New Jersey, Pennsylvania, and West Virginia; 22 (15%) practitioners were fellowship trained, with the majority of these practitioners reporting specialization in emergency medicine (27%), infectious diseases (27%), endocrinology (18%), and allergy and immunology (14%); 80% considered themselves familiar with the AAP 2011 guidelines for UTIs in children 2 to 24 months old, whereas 85% were familiar with the previous 1999 AAP guidelines. Following its introduction, 42% of respondents indicated that they “only sometimes” changed their practice patterns to fit the 2011 AAP UTI guidelines, depending on the clinical scenario, whereas 3% indicated that they did not modify their practice at all to fit current recommendations. Comparatively, 29% of practitioners revised their practice patterns to completely adhere to the 2011 AAP UTI guidelines, and 17% indicated that their

Number of eligible respondents   Number of 25   Age, years 56   Gender, n Male Female   Affiliation, na Academic Private  Academic Clinical instructor appointment Assistant professor status, n Associate professor Professor None  BoardNo certified in Yes pediatrics, n  Fellowship ER training, n Endocrine Infectious Allergy/Immunology Others   AAP district II distribution, III n Others

155 33 20 21 20 19 42 32 43 35 46 64 92 70 120 31 20 8 5 77 23 130

100 21.3 12.9 13.5 12.9 12.3 27.1 20.5 27.6 22.4 29.5 41.0 59.0 — — 22.0 14.2 5.2 3.5 54.6 15 85

6 4 6 3 4 9 128 7

27.3 18.2 27.3 13.6 18.2 6.2 88.3 4.9

Abbreviations: ER, emergency room; AAP, American Academy of Pediatrics. a Some participants had both academic and private practices.

practice was already in compliance with the guidelines prior to its introduction. Figure 1 illustrates our respondents’ preferred method of urine collection for an average pediatric patient who requires a urine culture. Almost half of the practitioners (46%) preferred to start with urethral catheterization, and more than a third (35%) reported that the method of urine collection would depend on the specific clinical scenario and temperament of the child. Other methods, such as SPA as an initial test or bagged specimen for culture, were utilized by a small minority of respondents (3% and 8%, respectively). Of note, 84% reported that parental influence only mildly affects their choice of urine sampling method.

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Coutinho et al Bagged culture 8%

Depends on clinical scenario 35%

Others 3%

A

Others 3%

UC 35%

Bagged urine, then UC or SPA 20%

Urethral Catheralizaon (UC) 46%

Would not collect urine 21% Bagged urine 21%

B

Bagged culture, then UC or SPA 8%

Figure 1.  Practitioner preferred method of urine culture collection (any child).

Others 3%

Abbreviations: UC, urethral catheterization; SPA, suprapubic aspiration.

Figure 2A demonstrates the responses for preferred method of urine collection in febrile, circumcised males without any risk factors for UTI. More than a fifth of respondents (21%) would utilize bagged urine collection alone for culture, with an equal number of respondents not collecting urine at all. Urethral catheterization was the most preferred (35%), with SPA and other techniques (such as sending to a urologist or emergency room) making up just a small minority (3%) of respondents’ preferences. For girls with no risk factors for UTI (Figure 2B), urethral catheterization was preferred by a larger percentage of practitioners than with male patients (49% vs 35%). Bagged specimens for culture were still preferred by 14% of practitioners. Also, 17% of practitioners would not collect urine specimens at all. Again, other techniques, including SPA, were utilized by a small minority of practitioners (3%). Figures 3A to 3C outline the preferred methods of urine collection for boys and girls with varying amounts of risk factors for UTI. In febrile, uncircumcised boys (Figure 3A) with 1, 2, 3, or 4 additional risk factors for UTI, urethral catheterization was increasingly preferred as the number of risk factors grew: 61%, 71%, 76%, and 78%, respectively. Conversely, bagged specimens were preferred with decreasing frequency in terms of the number of risk factors present: 7%, 7%, 4%, and 3%, respectively. In febrile, circumcised boys (Figure 3B) with 1 to 4 risk factors for UTI, bagged specimens specifically for urine culture were collected, against the 2011 AAP guidelines, by 18%, 10%, 7%, and 6% of practitioners, respectively, according to the number of risk factors. In febrile girls (Figure 3C) with 1, 2, 3, or 4 risk factors for UTI, catheterized specimens were preferred by

UC 49%

Bagged urine 14%

Will not collect urine 17%

Bagged urine then UC or SPA 17%

Figure 2.  A. Preferred method of urine collection in a febrile, circumscised boy with no risk factors. B. Preferred method of urine collection in a febrile girl with no risk factors. Abbreviations: UC, urethral catheterization; SPA, suprapubic aspiration.

62%, 73%, 81%, and 81% of practitioners, respectively. For these same patients, bagged specimens for culture were preferred by 13%, 8%, 3%, and 3% of practitioners surveyed, respectively. SPA was rarely preferred as a primary means of urine sampling for any of the hypothetical patients, with a maximum surveyed use by only 4 practitioners (3%) and, this, only in the highest-risk male patients. Analyses showed that there was no significant relationship between the use of only bagged specimens for urine culture and respondent age (P = .59), gender (P = .80), years in practice (P = .13), fellowship training (P = .19), academic affiliation (P = .84), or perceived familiarity with the 2011 AAP guidelines (P = .90).

Discussion The AAP practice guidelines recommend urine collection through urethral catheterization or SPA for the workup of potential UTI in children 2 to 24 months old. Alternatively, bagged specimens may be used for urinalysis only and must be followed by catheterization or SPA if the results are suggestive of a UTI. In a patient who is considered to be at low risk for UTI by a clinician, follow-up without testing is recommended. All are

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UC

% of praconers surveyed

A

77.7

61.4

7.1

6.5

1.4

3 risk factors

UC

Urine bag

4 risk factors

SPA 73.2

70.2

66.1

2.9 2.9

3.6 2.9

1.4

2 risk factors

B % of praconers surveyed

SPA 75.5

71.0

1 risk factor

49.2

18.3

10.2 1.6

1 risk factor

0.8 1 risk factor

8.3

0.8

2 risk factors

3.1

4 risk factors

SPA 81.1

80.8

73.3

13.1

Urine bag

5.5

3.2

3 risk factors

UC

61.5

7.3

1.6

2 risk factors

C % of praconers surveyed

Urine bag

2.5 2.5 3 risk factors

2.5 2.5 4 risk factors

Figure 3.  A. Urine collection in uncircumcised boys. B. Urine collection in circumcised boys. C. Urine collection in girls. Abbreviations: UC, urethral catheterization; SPA, suprapubic aspiration.

strong recommendations based on level “A” evidence.1 Therefore, the use of bagged specimens for urine culture in any infant not in a low-risk group goes against these AAP recommendations. Despite these recommendations by the AAP, in 1 example, when questioned about circumcised, febrile boys with at least 1 risk factor for UTI, more than 18% of pediatric practitioners preferred a bagged specimen for urine culture. As expected, the percentage of practitioners continuing to recommend bagged specimens for culture decreased as the number of UTI risk factors

increased in our hypothetical patients. However, even in the highest-risk groups (febrile children with 4 simultaneous risk factors for UTI), some practitioners continued to prefer a bagged urine specimen alone for urine culture. Practitioner demographic variables such as years in practice, type of practice, age, gender, and perceived familiarity with the 2011 AAP guidelines had no significant relationship with compliance to the guidelines. Given the lack of associations seen, the causes for this lack of compliance are unclear but are likely

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Coutinho et al multifactorial. Potential reasons include patient temperament, parent sentimentalities, and the presence of trained ancillary staff and resources. SPA is the cleanest method for obtaining urine and is considered by the AAP as the gold standard for detecting UTI.2 However, we found it to be the least popular, with only 4 of 155 respondents preferring it as an initial test. All these practitioners were men older than 55 years, and all were in practice for more than 10 years. Although previous research3,4 has documented the success rates of SPA for obtaining urine in infants to be as high as 79% to 96%, recent studies show that the success rate of SPA in “real-life” nonstandardized clinical practice is 53% overall, even with the use of real-time ultrasound.5 In the aforementioned study, a successful SPA was defined as ≥0.5 mL of urine aspirated, the minimum volume required for culture at the study hospital. Furthermore, a prospective study measuring facial grimacing as a marker for pain showed a significant increase in grimacing associated with SPA over urethral catheterization.6 Additionally, complications such as bleeding, abscess, and bowel injury have been reported in the literature, all possible reasons why SPA is an unpopular choice in typical clinical practice. Urethral catheterization, while being preferred by the majority of pediatricians surveyed, is not without its shortcomings. Catheterization discomfort and patient temperament may deter some practitioners. Mild sedation and viscous anesthetics have been evaluated as methods of reducing pain and anxiety during catheterization, with conflicting results.7-10 Furthermore, the risk of urethral trauma, hematuria, or introduced infection, although small, may also dissuade some pediatricians. Our study demonstrates that some pediatricians still prefer bagged urine collection despite the high rate of contamination. Bagged specimen collection has the advantage of being the least-invasive method while maintaining a high sensitivity for excluding infection. Apart from possible allergic reaction to the adhesive or bag itself, there are no real adverse effects in children who are not yet toilet trained. However, even after washing and cleaning the perineum, false positive rates with bagged specimens range from 37% to 87%,11,12 often leading to overtreatment with antibiotics and expensive imaging. In a study comparing urine contamination rates using noninvasive techniques, midstream clean-catch urine collection yielded the least amount of contamination when compared with sanitary pads and urine bags (14.7% contamination rate for clean catch vs 29% and 26.6% for pads and bags, respectively; P < .01).13 However obtaining a midstream urine sample from a

non-toilet-trained child may be time-consuming and impractical in a busy clinical practice. New techniques for urine collection involving fluid intake and noninvasive bladder stimulation to collect an on-demand midstream specimen have shown promise.14 However, these methods may have limited utility in clinical practice because of both the time required between feeding and collection of the specimen (25 minutes) as well as the strain on ancillary nursing staff. Nevertheless, with appropriate previsit counseling, the lower rates of contamination with this type of collection may be an improvement from conventional bagged methods. Still, even midstream noninvasive urine collection has been shown to have a higher rate of false positivity than simple urethral catheterization.15 Also promising are improvements in the design of urine collecting bags that reduce false positivity caused by contamination. In 2007, a prototype urine collection bag was demonstrated, with an absorptive layer that removed the first portion of the urine stream (often the most contaminated) as well as a 1-way valve that prevents collected “mid-stream” urine from refluxing back to the patient’s perineum. In a study evaluating its specificity in healthy children 24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in an uncircumcised boy with fever with 0 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 11) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in an uncircumcised boy with fever with 1 risk factor in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 12) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in an uncircumcised boy with fever with 2 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive

e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 13) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in an uncircumcised boy with fever with 3 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 14) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in an uncircumcised boy with fever with 4 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 15) When considering the risk factors for UTI in boys 2-24 months old (nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in a circumcised boy with fever with 0 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine

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16) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in a circumcised boy with fever with 1 risk factor in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 17) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in a circumcised boy with fever with 2 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 18) When considering the risk factors for UTI in boys 2-24 months old (Nonblack race, temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in a circumcised boy with fever with 3 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 19) When considering the risk factors for UTI in boys 2-24 months old (nonblack race,

temperature ≥39, fever >24 hours, absence of other source of infection), how would you recommend obtaining a urine culture in a circumcised boy with fever with 4 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine Next we are asking you about urine collection in girls. 20) When considering risk factors for UTI in girls 2-24 months old (Caucasian race, age < 12 months, temperature ≥39, fever >2 days, absence of other infection) how would you recommend obtaining a urine culture in a girl with fever with 0 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 21) When considering risk factors for UTI in girls 2-24 months old (Caucasian race, age 2 days, absence of other infection) how would you recommend obtaining a urine culture in a girl with fever with 1 risk factor in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 22) When considering risk factors for UTI in girls 2-24 months old (Caucasian race, age 2 days, absence of other infection) how would you

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Coutinho et al recommend obtaining a urine culture in a girl with fever with 2 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 23) When considering risk factors for UTI in girls 2-24 months old (Caucasian race, age 2 days, absence of other infection) how would you recommend obtaining a urine culture in a girl with fever with 3 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture d.  Bagged culture for urinalysis and then catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 24) When considering risk factors for UTI in girls 2-24 months old (Caucasian race, age 2 days, absence of other infection) how would you recommend obtaining a urine culture in a girl with fever with 4 risk factors in your practice? a.  Catheterized specimen b.  Percutaneous aspiration c.  Bagged culture Bagged culture for urinalysis and then d.  catheterized specimen or percutaneous aspiration if urinalysis is positive e. Send to urologist/ER/another specialist for collection f.  Will not collect urine 25) Do you consider yourself familiar with the 1999 guidelines on UTIs in children 2-24 months? a. Yes b. No 26) Do you consider yourself familiar with the 2011 guidelines on UTIs in children 2-24 months? a. Yes b. No

27)  How much do parent preferences influence how you collect a urine specimen? a. Mildly—if the parents refuse, I do my best to convince them that my recommended collection techniques are most appropriate. b. Somewhat—if the parents refuse, I make a minimal effort to convince them that my recommended collection techniques are most appropriate. c. Greatly—if the parents refuse, I do not try to convince them otherwise. 28) Will the new guidelines change your practice pattern? a.  Yes, I will change my practice b.  No, I will not rely on the guidelines c.  Sometimes depending on the clinical scenario d.  No, I already practice the guidelines e.  I am not familiar with the guidelines Acknowledgement We would like to acknowledge and thank the New Jersey chapter of the American Academy of Pediatrics for their assistance in performing this survey.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128:595-610. 2. Finnell SME, Carroll AE, Downs SM; Subcommittee on Urinary Tract Infection. Technical report: diagnosis and management of an initial UTI in febrile infants and young children. Pediatrics. 2011;128:e749-e770. 3. Kiernan SC, Pinckert TL, Keszler M. Ultrasound guidance of suprapubic bladder aspiration in neonates. J Pediatr. 1993;123:789-791. 4. Gochman RF, Karasic RB, Heller MB. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Ann Emerg Med. 1991;20:631-635.

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5. Buntsma D, Stock A, Bevan C, Babl FE. Success rate of BladderScan-assisted suprapubic aspiration. Emerg Med Australas. 2012;24:647-651. 6. El-Naggar W, Yiu A, Mohamed A, et al. Comparison of pain during two methods of urine collection in preterm infants. Pediatrics. 2010;125:1224-1229. 7. Vaughan M, Paton EA, Bush A, Pershad J. Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial. Pediatrics. 2005;116:917-920. 8. Gerard LL, Cooper CS, Duethman KS, Gordley BM, Kleiber CM. Effectiveness of lidocaine lubricant for discomfort during pediatric urethral catheterization. J Urol. 2003;170:564-567. 9. Boots BK, Edmundson EE. A controlled, randomised trial comparing single to multiple application lidocaine analgesia in paediatric patients undergoing urethral catheterisation procedures. J Clin Nurs. 2010;19: 744-748. 10. Chung S, Lim R, Goldman RD. Intranasal fentanyl versus placebo for pain in children during catheterization

for voiding cystourethrography. Pediatr Radiol. 2010;40:1236-1240. 11. Li PS, Ma LC, Wong SN. Is bag urine culture useful in monitoring urinary tract infection in infants? J Paediatr Child Health. 2002;38:377-381. 12. Bonadio WA. Urine culturing technique in febrile infants. Pediatr Emerg Care. 1987;3:75-78. 13. Alam MT, Coulter JBS, Pacheco J, et al. Comparison of urine contamination rates using three different methods of collection: clean-catch, cotton wool pad and urine bag. Ann Trop Paediatr. 2005;25:29-34. 14. Herreros Fernández ML, González Merino N, Tagarro García A, et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-29. 15. Lau AY, Wong SN, Yip KT, Fong KW, Li SPS, Que TL. A comparative study on bacterial cultures of urine samples obtained by clean-void technique versus urethral catheterization. Acta Paediatr. 2007;96:432-436. 16. Perlhagen M, Forsberg T, Perlhagen J, Nivesjö M. Evaluating the specificity of a new type of urine collection bag for infants. J Pediatr Urol. 2007;3:378-381.

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Pediatrician noncompliance with the American Academy of Pediatrics guidelines for the workup of UTI in infants.

The American Academy of Pediatrics (AAP) guidelines on the workup for urinary tract infections (UTIs) in infants discourages the use of bagged urine s...
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