Urinary tract infections in young children: optimising diagnosis with effective and cost-effective urine sample collection
Document TypePhD thesis
Access StatusThis item is embargoed and will be available on 2022-08-14.
© 2020 Jonathan Kaufman
BACKGROUND Urinary tract infections (UTIs) are very common in young children, but hard to diagnose, and easily missed. Diagnosis is important: if untreated UTI can cause sepsis and permanent kidney scarring. Many young children with unexplained fever must have a urine sample tested to check for potential UTI. The problem is that collecting urine samples from young pre-continent children is extremely difficult. Existing collection methods all have limitations. Standard care in Australia of waiting for a clean catch is time-consuming and often unsuccessful. Urine bags have unacceptably high contamination. Catheter and needle procedures are painful and distressing, and require expertise and equipment to perform. Suboptimal practice compromises patient care and wastes healthcare resources. AIMS & METHODS The doctoral research had the overall objective to improve non-invasive urine sample collection for young pre-continent children. Specific aims were to discover: 1. A quick, simple and effective non-invasive collection method 2. Cost-effectiveness of current and new collection methods 3. Which collection methods are practical in the primary care setting 4. Knowledge translation of findings into practice These aims were examined with the following research methodologies: 1. Two clinical trials of a novel voiding stimulation method 2. Economic evaluation of existing and new collection methods 3. Qualitative study in Australian general practice 4. Local guideline update and development of consumer resources RESULTS The novel Quick-Wee voiding stimulation method was conceptualised, using cold wet gauze to gently rub the suprapubic region. This triggers cutaneous bladder reflexes for faster and more successful urine sample collection. A pilot study (n=40) demonstrated the method was feasible. A randomised trial (n=354) demonstrated significantly higher success in collecting a urine sample within 5 minutes, and significantly higher parental and clinician satisfaction, compared to standard clean catch practice. An economic evaluation comprehensively modelled the costs and cost-effectiveness to collect a definitive sample for all common urine sample collection methods. Overall, catheterisation was the favoured collection method, Quick-Wee the favoured non-invasive method, and urine bags were the most expensive method. This is the first cost-effectiveness analysis of its kind, filling a significant evidence gap, and identifying potential cost savings. A qualitative study explored the barriers and enablers to collecting urine samples from young children in Australian general practice. Non-invasive methods were strongly favoured and invasive methods were rarely used. Key barriers included time and space constraints in clinics. Key enablers included parental motivation, education handouts and voiding stimulation methods. These important insights can inform policy, education and future research. Knowledge translation activities were undertaken including updating statewide guidelines and creating consumer resources. The Quick-Wee method is now recommended in guidelines across a range of settings internationally. CONCLUSION This body of work developed the new Quick-Wee voiding stimulation method and has shown it is more effective, more cost-effective, and more acceptable than standard care. It is gentle for children and simple for clinicians. This research has addressed key evidence gaps, contributing new knowledge to optimise investigation of UTI in young children. Findings have changed practice and been implemented in policies and guidelines internationally.
Keywordsurinary tract infection; diagnosis; infant; children; urine specimen collection
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