Reducing contamination rates and catheter associated urinary tract infection associated with mid stream urine collection in Pediatrics

Greg Malt RN, BNurs, GradDipCNurs

Master of Clinical Science

Student Number a1060073

The Joanna Briggs Institute, Faculty of

Health Sciences The University of Adelaide

gregory.malt@adelaide.edu.au

October 2011

ii

Thesis declaration This work contains no material which has been accepted for the award of any other degree

or diploma in any university or other tertiary institution and, to the best of my knowledge and

belief, contains no material previously published or written by another person, except where

due reference has been made in the text. I give consent for a copy of my thesis to be

deposited in the University Library, being made available in all forms of the media, now or

thereafter.

Signature:

Date:

iii

Acknowledgements I thank my supervisors Professor Alan Pearson AM and Dr William Greer, for their guidance,

support and comments while undertaking this Master of Clinical Science. To my

colleague in Qatar – you are extremely hard working and diligent, and I wish you all the

best in your PhD. To my life, my wife, thank you for your constant encouragement; your

belief in me is never ending.

iv

TableofContents

REDUCING CONTAMINATION RATES AND CATHETER ASSOCIATED URINARY TRACT INFECTION ASSOCIATED WITH MID STREAM URINE COLLECTION IN PEDIATRICS­­­­­­­­­­­­­­­­­­­­­­­­I

THESIS DECLARATION­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­II

ACKNOWLEDGEMENTS­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­III

TABLEOFCONTENTS­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ IV

ABSTRACT­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­VIBACKGROUND‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIOBJECTIVES‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIINCLUSIONCRITERIA‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VITypesofparticipants­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­viTypesofintervention(s)/phenomenaofinterest­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­viComparison­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­viTypesofstudies ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­viTypesofoutcomes­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­vi

SEARCHSTRATEGY‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIIMETHODOLOGICALQUALITY‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIIDATACOLLECTION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIIDATASYNTHESIS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIIRESULTSANDDISCUSSION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIIKEYWORDS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐VIII

CHAPTER1:INTRODUCTIONTOTHESTUDY­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­1SITUATINGTHESTUDY‐AMATTEROFPATIENTSAFETY‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐1STRUCTUREOFTHESIS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐2ABBREVIATIONS:‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐2

CHAPTER2:BACKGROUNDTOTHESTUDY­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­3PERIURETHRALCLEANSING‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐3URINARYTRACTINFECTION(UTI)‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐4SOCIOECONOMICIMPLICATIONS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐7BAGCOLLECTION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐7MIDSTREAM‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐8URETHRALCATHETERIZATION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐9SUPRA‐PUBICASPIRATION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐9PROCESSINGOFURINECULTURES‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐10KEYDEFINITIONS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐10CONCLUSION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐12

CHAPTER3:STUDYDESIGNANDMETHODS­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­13JBI‐MASTARIMETHODOFCONDUCTINGASYSTEMATICREVIEWS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐13CRITICALAPPRAISALOFTHESTUDIESRETRIEVED, ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐14REVIEWOBJECTIVE‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐14INCLUSIONCRITERIA‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐14Typesofparticipants­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­14

v

Interventions­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­15Comparators­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­15PrimaryOutcome­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­15SecondaryOutcome:­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­15

TYPEOFSTUDIES‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐15EXCLUSIONCRITERIA‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐16SEARCHSTRATEGY‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐16DatabasesSearched­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­16UnpublishedstudiesorGreyLiterature­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­16Initialkeywordsused: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­17

METHODSOFTHEREVIEW‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐17Assessmentofmethodologicalquality­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­17

DATACOLLECTION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐18DATASYNTHESIS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐18CONFLICTSOFINTEREST‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐19CONCLUSION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐19

CHAPTER4:RESULTS­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­20INTRODUCTION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐20DESCRIPTIONOFSTUDIES ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐20

Figure1: Flow diagram of the search results and study selection of the studies­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­22METHODOLOGICALQUALITY‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐23SAMPLESIZES‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐23STUDYSETTING ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐24PEDIATRICPATIENTS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐24SOLUTIONS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐24TECHNIQUESOFPERIURETHRALCLEANSING‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐25

Figure 2: Results of meta-synthesis of quantitative research findings­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­27CONCLUSION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐27

CHAPTER5:DISCUSSIONANDCONCLUSIONS­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­28INTRODUCTION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐28IMPLICATIONSFORPRACTICE‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐29PERIURETHRALCLEANSINGPRIORTOURINARYCATHETERISATION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐29BACTERIALCONTAMINATIONOFMIDSTREAMURINECOLLECTION‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐29IMPLICATIONSFORRESEARCH‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐29CONCLUSIONS‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐30

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APPENDIXI:MASTARICRITICALAPPRAISALINSTRUMENT­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­35

APPENDIXII:FINALASSESSMENTOFINCLUDEDSTUDIES­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­38

APPENDIXIII:MASTARIDATAEXTRACTIONINSTRUMENTS­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­39

APPENDIXIV:LISTOFEXCLUDEDSTUDIES­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­41

APPENDIXV:COMPREHENSIVESEARCHSTRATEGIES­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­42

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Abstract

BackgroundBest practice recommendations for the prevention of adult catheter associated urinary tract

infections are available from many international patient safety authorities such as the Cochrane

Library, Joanna Briggs Institute, National Health Service, The WHO guidelines and Centre for

Disease Control and Prevention. However, guidance for clinicians working with pediatric

patients is, limited. Similarly, there is a lack of consensus on if periurethral cleaning is an

important step in helping to reducing the contamination rates of midstream urine collection, and

if a solution other than potable water is needed to undertake this cleansing. In order to ensure

our pediatric population is receiving evidence based health care, as healthcare professionals it

is our responsibility to ensure that guidelines and or practice recommendations are as readily

available, as this not only impacts economic benefits but more importantly patients� quality of

life.

ObjectivesThe objective for this review was to synthesize the best available evidence related to the type

of solution used for periurethral cleansing in reducing the rate of contamination of mid stream

urine collection and catheter associated urinary tract infection in pediatric patients.

Inclusioncriteria

Typesofparticipants

This review considered studies involving children from the age of 1 month to 18 years with a

short-term indwelling urethral catheter and / or children who required midstream urine

sampling.

Typesofintervention(s)/phenomenaofinterest

Any cleansing solution e.g. Soap, 10% Providone-Iodine, Sterile Water, Chlorhexidine

Gluconate or Saline.

Comparison

Any alternate method (solution or no solution) to the intervention.

Typesofstudies

Randomized, quasi-randomized and non-randomized studies.

Typesofoutcomes

The primary outcome of interest was:

vii

• The presence of urinary tract infection, as determined by the patient’s urine culture

growing at least one organism with a colony count of >104 Colony Forming Units / ml

of urine.

Secondary Outcome:

• The presence of urethral meatus trauma i.e. burns, redness.

SearchstrategyThe search included both published and unpublished studies with an initial limited search of

MEDLINE and CINAHL databases undertaken to identify key words contained in the title or

abstract, and index terms used to describe relevant interventions. A second extensive search

used all identified key words and index terms. The third step included a search of the reference

lists and bibliographies of relevant articles. The databases searched included: CINAHL,

MEDLINE, and Embase. The Dissertation Abstracts International and Mednar database was

used to search for unpublished studies.

MethodologicalqualityMethodological quality was assessed using a standardised checklist. Critical appraisal and

data extraction were conducted by two independent reviewers; discrepancies were addressed

through discussion with a third reviewer as required.

DatacollectionData was extracted from clinical studies that fulfilled the protocol inclusion criteria. The JBI

Mastari standardized data extraction tool was used to assess the quality of included studies

and extract data for analysis.

DatasynthesisPooling of data for bacterial contamination and midstream urine collection was undertaken

using the JBI MAStARI Meta-Analysis program. Secondary outcomes were reported in a

descriptive way.

ResultsandDiscussionA total of three studies met the inclusion criteria for this review: one randomised control trial

(RCT) and two descriptive studies. The RCT compared periurethral cleansing with sterile water

versus 10% povidone-iodine prior to the insertion of an indwelling urinary catheter whilst the

descriptive studies measured the effect of meatal cleansing with 2% Castile soap on the rate of

bacterial contamination during midstream urine collection. Meta-analysis of the data was

viii

undertaken with the two descriptive studies. All three studies concluded that using a solution

other that sterile water does not significantly decrease the rate of bacterial contamination.

Given the small number of studies and sample size addressing the two topics, no firm

conclusions can be drawn from this review. However, the results suggest that a non-irritant

solution such as sterile water is acceptable for periurethral cleansing in children prior to urinary

catheterization and/or midstream urine collection.

KeywordsUrinary catheterization, cleaning solution, pediatrics, urinary tract infection, systematic review

1

Chapter1:IntroductiontotheStudy

SituatingtheStudy‐amatterofpatientsafetyWhen a patient is admitted to a healthcare facility or receives care from a healthcare

professional in the home or community, the expectation is that no additional harm (nosocomial

or iatrogenic) will occur. The Patient Safety literature however informs us that the rate of

nosocomial infections is alarming. External forces such as a climate of zero tolerance for

nosocomial infections and the establishment of national and international agencies focused on

patient safety have resulted in a flurry of clinical reviews; surveys and research attempting to

identify how to minimize hospital acquired infections.

Reducing the rate of nosocomial acquired infections has become a campaign adopted on a

global scale. Leading international institutions such as the Institute of Healthcare Initiatives

(IHI), Joanna Briggs Institute of Evidence Based Healthcare have developed evidence based

bundles aimed at reducing the rate of nosocomial infection that have been readily adopted by

healthcare institutions around the world. The success of these evidence-based bundles arises

from their simplicity. Typically comprised of no more than five to eight steps, these evidence

bundles inform the multidisciplinary team about what techniques, solutions, systems and

processes have significantly contributed to reducing the rate of nosocomial infection.

Urinary tract infections are the most common bacterial infections among pediatrics patients.[1]

The majority of evidence bundles for UTI’s are informed on research conducted on adult

populations. In the 1950’s Kass developed criteria that were to become the universal definition

of a urinary tract infection: a “pure urine culture of ≥ 105 cfu/mL of a uropathogen.[2, 3] As

healthcare agencies throughout the world attempted to implement best practice guidelines to

reduce the rate of nosocomial infections it became important to establish a shared

understanding of key performance indicators (KPI’s) with which they could benchmark across

institutions. These KPI’s for Urinary Tract Infection’s (UTI’s) were established by the Centers

for Disease Control and Prevention (CDC) in 2009 for defining a urinary tract infection, see

appendix 7. In the literature prior to 2009, bacterial contamination of urine specimens is

discussed in one of three ways: sterile, contaminated or positive. A sterile culture is described

as producing no growth. However, when interpreting results of contaminated or positive

cultures there is a significant difference amongst authors primarily because the number of

Colony Forming Units (CFU) used to confirm the presence of a uropathogen is often dependent

2

upon the institution’s microbiology protocol for processing urine cultures. This review only

included data from positive samples.

The Joint Commission National Patient Safety Goals for 2012 include the implementation of

best practice recommendations to reduce the rate of nosocomial infections arising from urinary

catheterization. These best practice recommendations arise from the work undertaken by IHI to

collate the evidence from clinical research (predominately on adult patients) into evidence

bundles.[4-6] There has only been one published study in a pediatric population that assessed

the effectiveness of different solutions in cleansing the periurethral meatus prior to urethral

catheterization.[7] Additional research is urgently needed to ensure best practice

recommendations are available to guide clinicians in the care of the pediatric patient.

StructureofThesisHaving positioned the relevance of this research to the reader the remainder of this thesis

occurs in four additional chapters. Chapter two establishes the importance for the review and

highlights the many recommendations to prevent catheter associated urinary tract infections

and contamination of midstream urine samples. It examines the extant of the literature

regarding adult patients’ best practice recommendations and in doing so demonstrates the

dearth of research on this topic for the pediatric population. Chapter three describes the

protocol for the systematic review as defined by Joanna Briggs Institute standards. Chapter

four provides the reader with a breakdown of the data from each of the included studies both in

graphic (meta-analysis) and narrative form. The final chapter interprets the data and discusses

the implications for practice; and draws a set of conclusions to guide the healthcare provider

about the status of the evidence related to this subject.

Abbreviations:CAUTI: catheter associated urinary tract infections

CFU / mL urine: Colony forming units

CCU: clean catch urine

Non-CCU: non clean catch urine

3

Chapter2:BackgroundtotheStudyThis chapter provides an overview of the healthcare literature and research as it relates to

techniques that minimize the contamination of urinary catheters during insertion and of the

urine sample during mid stream urine collection. The literature spans four decades and

subsequently demonstrates a change in practice as new knowledge emerges. The

methodological quality and report of research varies significantly.

Acquisition of a Urinary Tract Infection (UTI) in children is associated with numerous factors

such as faecal incontinence; children less than one year of age which is generally linked to a

developing immune system; anatomical features i.e. foreskin; voiding dysfunction

(unrecognized urostasis) and periurethral colonisation.[8-11] Gender has been identified as

another risk factor for example males less than one year of age are more prone to experience

urinary tract infections than females of the same age group, however after the age of one the

odds are reversed.[12] Periurethral colonisation occurs when there is a disturbance of the

normal microbial flora by a virulent organism.[13] During the initial months of a child’s life,

periurethral colonisation is at its highest.[14] Evidence suggests that older children who present

with repeated urinary tract infection suffer persistent periurethral colonisation.[15]

PeriurethralCleansingPeriurethral cleansing is a process in which tissue surrounding the urethra is cleansed prior to

sample collection or urethral catheterisation. Periurethral cleansing is important to reduced

contamination of midstream urine collection and contamination of urinary catheter during

insertion. The literature is divided in determining the optimum approach to periurethral

cleansing prior to urinary catheterisation and/or specimen collection. On the one hand the

recommendation is to use a strict aseptic technique whilst others suggest that a simple clean

non-sterile procedure is sufficient. Solution recommendations range from soap and water to

antiseptic solution i.e. Chlorhexidine Gluconate or Povidone-iodine.[4, 6, 7, 16, 17] Antiseptics

solutions are valued for their ability to destroy microbes or hinder their growth. However such

solutions have their inherent limitations in particular the damage they cause to the delicate

mucosa of the child’s periuthera.[18] The antiseptic solutions may irritate the skin and result in

either a skin burn or superficial ulceration and result in discomfort during insertion all of which

damages the inherent physiological barriers to infection. Antiseptics solutions have also been

documented to bring about residual contamination of urine that in turn affects the accuracy of

bacterial counts.[19]

4

The approach to urine collection and sampling varies across healthcare institutions. The cost

and/or invasive nature of the device typically influence the choice. The practice in many

institutions is to cleanse the periurethral area with some form of antiseptic solution e.g. 10%

povidone iodine or Chlorhexidine Gluconate which are irritating to the periurethral and urethral

mucus membrane, particularly in children, often causing skin ulceration, burns and

inflammation.[18] Principle collection methods for mid stream urine sampling for the pediatric

patient include adhesive bag sampling, urine collection pads, clean catch sampling, urethral

catheterization, and suprapubic aspiration.[20]. Urine collection devices are somewhat

challenging in terms of leakage and patient comfort. Prolonged exposure of a urine sample

within a pad and the perineal flora and or periurethral colonization (which is at its highest during

the first few months of a child’s life) are thought to significantly attribute to the urine

contamination rates.[14, 20]

Concern exists over the potential for some collection techniques to mask infection i.e. the urine

collection pad, by enabling heavy mixed growth of bacteria.[21] Such contamination rates can

result in unnecessary investigation, i.e. greater need for re-sampling, thus increasing the child’s

exposure to prolonged infection and risk of long-term renal disease.[21] The clean catch

midstream technique has been reported to be time consuming to explain, error prone and

therefore costly.[22] Data from adult studies have reported that there is no statistical difference

between midstream clean catch and midstream non-clean catch urine samples.[23-25]

Catheterisation and suprapubic aspiration as a rule are considered the most consistent method

to obtain an uncontaminated urine specimen.[26] However, both methods are considered

invasive and are most frequently performed on patients who are considered critically ill.

Aspiration has been labeled as the gold standard method for urine collection.[27] Its popularity

as a comparison to collecting methods was evident by the number of citations found in the

initial literature review.

UrinaryTractInfection(UTI)Urinary tract infection is one of the most common bacterial infections in children and can lead

to significant morbidity, long-standing health related problems into adulthood and potential

mortality.[1, 28] If the infection results in renal scarring, various long-term risks include

hypertension, renal insufficiency and may proceed to terminal renal failure. Urinary tract

infection therefore negatively impacts the individual’s quality of life with associated long-term

health care cost.[29-34]

5

A urinary tract infection is a microbial infection of one or more components / organs comprising

of the renal system, i.e. bladder, kidneys, urethra or ureters. Early diagnosis of urinary tract

infection is paramount to preserve kidney function. The goal or primary focus of medical

management is for prompt diagnosis, upon confirmation it is essential that treatment is

commenced without delay.[35] Delays in confirmation of diagnosis and treatment expose the

child to greater chances of permanent renal damage. [35] The severity of the child’s illness

generally determines the course of medical management. Lindert et al based the need for

hospitalized management on the following criteria, a child less than three months of age or

unable to tolerate oral fluids / medications, immunocompromised, or dehydrated, as an

inpatients they should commence treatment with parenteral antibiotics and rehydration

therapy.[12] The pharmaceutical cost associated with inpatient management is reported to be

double that of outpatient management.[36] Hospitalization of children diagnosed with urinary

tract infection is necessary in up to 2-3% of all cases.[30]

The literature suggests that children’s renal status should be investigated after their first

confirmed urinary tract infection.[27, 37] Recurrent urinary tract infections may suggest

abnormalities within the renal system or undiagnosed complications. The literature also

suggests that the probability of infants (as opposed older children) presenting with underlying

congenital genitourinary malformation are more likely to require additional medical follow

up.[38] The following three examples are discussed most extensively throughout the literature,

urinary stasis, renal scarring and reflux.[8-11]

Urinary stasis commonly refers to the obstruction to the flow of urine at any point within the

renal system. Causative factors listed as being outflow obstruction, constipation, renal stones

or bladder dysfunction.[35]

Renal scarring, in some children renal scarring is link with future health complication i.e. poor

renal development, recurrent infections, hypertension and end stage renal disease.[39] Lindert,

et al postulate that the degree of scarring is “dependent upon the age at which the child first

sustained a urinary tract infection”.[12] In a study conducted by Ditchfield et al they concluded

that renal scarring was two times more likely in children with urinary tract infections under the

age of two years.[40] Jacbson et al conducted a retrospective study of 30 children diagnosed

with renal scarring; ten percent of these children had progressed to end stage renal

disease.[41]

Reflux is a condition when urine moves from the bladder retrograde into the ureters or

6

kidneys.[42]

Urinary tract infections in children are often hard to diagnose as symptoms are generally non-

specific, consequently such infections are easily missed.[35] General clinical sign and

symptoms for children less than two years of age are described as fever or pyrexia of unknown

origins, irritability, nausea and vomiting, diarrhea, failure to thrive.[12] Children older than two

are generally able to communicate symptoms such as supra-pubic tenderness or urine

frequency.[12] Similarly a child could present to a health care facility with an infection of the

urinary tract however present as asymptomatic, i.e. with no clinical symptoms suggestive of

infection.[2] Infants who present to health care facilities with atypical symptoms of urinary tract

infection are confronted with a greater chance in the delay of diagnosis. Therefore the younger

patient populations are at greater risk in developing complications at result in aggressive

medical management.[43] A study undertaken in the United States in 2001 looked at using a

clinical decision rule, i.e. the presence of 2 or more of 5 predetermined variables, a score of 2

or more lead to identification of 95% of children with UTI and removal of 30% of unnecessary

urine cultures.[44]

The internationally recognized standard for diagnosis of urinary tract infection is a urine

culture.[45] However collecting uncontaminated urine samples from children is often

problematic. There are many clinical procedures / interventions that can be carried out to

obtain urine sample for bacterial analysis. From invasive procedures such as supra-pubic

aspiration, urethral catheterisation, to the less invasive techniques for example the clean catch

or bag method.[46] The different methods for urine sampling / collection are not without faults

as all are just as susceptible to contamination. Pryles writes that in 1922 Helmholz and

Milleken were among the first to conclude that the risk of urine specimen contamination during

the collection process was “so great that the presence of organisms in the urine” was

inconclusive of true urinary tract infection.[47] The fundamental principle of all procedures is to

ensure that the urine sample is not contaminated, by bacteria/viruses that are external to the

body. The most effective approach to minimising contamination is performing periurethral

cleansing.

The negative implications associated with contamination of urine samples are the false-positive

or false negative results. Inaccurate urine collection may result in miss or over diagnosis of

urinary tract infection and result in inappropriate hospital admissions for the non infected

child.[11, 27] Of greatest concern is that we therefore expose children to either unnecessary

7

treatment / investigations or children fail to receive appropriate evidenced based health care in

a timely manner to prevent renal damage.[48, 49] Both scenarios result in additional

psychological stress to both child and family.[46] Contaminated specimens can fail to reveal

true infections, resulting in the need to repeat the procedure and impacting the organisational

financially.

SocioeconomicImplicationsAccording to Spencer and colleagues the socioeconomic implication of pediatric urinary tract

infections within the United States is considerable and rising at a rapid rate.[43] Within the last

decade hospital admission rates (50,000 admission / year and length of stay (3.1 days ± 0.1

days) have stayed comparatively constant. From 2002 approximately 2% of all pediatric

hospital admissions are directly linked to a urinary tract infection. [43] Data was extrapolated

from the Kid’s Inpatient Database (KID) to produce a retrospective analysis of urinary tract

infection with in the United States for children less than 18 years of age admitted to a health

care setting with the primary diagnosis of urinary tract infection.

The KID data reports that there is a higher incidence of females requiring hospitalization than

their counterpart. Additionally the probability of children less than I year of age requiring

hospitalization is 2.5 time more than older children.[43] This was substantiated by two

independent community studies that stated children less than 1 year of age are more

predisposed to developing a urinary tract infection than older children.[50, 51] Boys less than 1

year of age have a greater risk for urinary tract infections than girls (2.7% versus 0.7%) cited in

Lindert.[12] Uncircumcised infants are 10 times more likely to develop a urinary tract infection

before 6 months of age when compare to circumcised boys.[52] Major causes contributing to

the expanding health care costs have been linked to avoidable hospitalization and

inappropriate or delays to commencement of treatment. The financial impact for United States

hospitals and pediatric inpatient urinary tract management in 2006 exceeded $520 million.[53]

BagCollectionThe bag collection method is where a sterile urinary collection bag is attached to the child’s

perineum, this technique is generally reserved for babies and infants. Once the child has

voided the bag is removed and the urine is collected for analysis. Bagged urine collections are

clearly the most convenient and without question the least invasive however, contamination

rates are as high as 10%.[54] False positive rates have been reported as high as 50-60 %.[55]

Regardless of meticulous periurethral cleansing and timely removal of the collect bag, Crain et

8

al state “this method for urine collection is unacceptable”.[56]

In 1976, a group of 30 sick infants and children were enrolled into a study that over a course of

6 hours collected three urine specimens (bag, clean catch and supra-pubic aspiration).

Following microbiological analysis of the specimens the authors concluded that bag collection

was considerably inferior to clean catch and supra-pubic urine sampling techniques.[27] A

study conducted by Al Orifi et al comparing contaminated urine specimens obtained by clean

void bag method versus urethral catheterisation concluded that risks associated with bag urine

cultures fails to surpass the benefits.[48] Additionally they were able to demonstrate that

despite close monitoring i.e. timely removal of collected specimen, it did not reduce the

contamination rate.

MidstreamMidstream urine sampling was introduced into the health care arena during the later part of the

1950�s. Prior to that urinary catheterisation was seen to be the customary approach for urine

specimen collection.[57] Midstream urine sampling procedure commenced as the result of two

publications challenging the benefits associated with urinary catheterisation.[57] Midstream

urine sampling techniques have been reported in the literature as either clean catch or non-

clean catch. Clean catch urine specimen involves periurethral cleansing prior to specimen

collection. Non-clean catch urine collection is without periurethral cleansing. Both midstream

urine collection methods require the child to void into a sterile specimen container. It is

commonly acknowledged that despite how meticulous the technique / procedure is undertaken,

these specimens are commonly contaminated by periurethral flora.[12] This urine collection

technique is not easy to perform on young child and is generally set aside for older children

who are able to follow set instructions.[58] Contamination risk associated with midstream

procedures is parents or the child inadvertently contaminating the interior of the sterile

collection container.[59]

A study conducted by Amir et al compared results of urine cultures from midstream urine

collection to that of supra-pubic aspiration from circumcised male infants.[60] Prior to collecting

the midstream urine sample the penis was cleansed with an antiseptic solution 0.05% cetrimide

plus 0.01% chlorhexidine gluconate. Interestingly the results produced more or less identical

finding. However, it is emphasized that the reliability is limited to only circumcised males as

results of from uncircumcised infants were noted to be erroneous.[60] Lohr et al conducted a

study to review the effects of meatal cleansing and midstream urine contamination rates from

9

girls.[61] The study compared clean catch and non-clean catch technique and concluded that

neither form of periurethral cleansing had significant effect on the rate of positive cultures.[61]

These results are further supported by a study conducted on females aged 14 years and

above. Participants were either assigned to a clean catch or a non-clean catch midstream

collection technique. The results demonstrated that periurethral urethral cleansing failed to

significantly lower contamination of midstream urine samples from perineal flora.[45]. However

results of a study undertaken by Vaillancourt et al whom like Lohr et al compared clean catch

and non-clean catch in toilet trained children, suggest that the perineum should be cleaned with

soap prior to midstream urine collection.[22]

UrethralCatheterizationUrethral catheterization requires that a drainage tube (catheter) to be inserted via the urethra

into the bladder. Urethral catheterization is frequently performed on those patients unable

follow instruction on performing midstream urine collection. The advantage of performing

urinary catheterisation to acquire urine sample is that the success rate come within reach of

100%.[62] Similarly urine specimens collected from urinary catheterization are not without risk

of contamination from periurethral flora. It is recommended that the first few milliliters of urine

be discarded.[12] A risk factor associated with urinary catheterization is that as a direct result of

the insertion process the sterile bladder maybe become inoculated with bacteria, resulting in an

iatrogenic urinary tract infection.[12] There is a high correlation with this iatrogenic infection and

the catheterisation of uncircumcised boys.[63] Lindehall et al identify urethral trauma in boys as

a major complication to urinary catheterisation.[64] Although the incidence is minimal, Turner

reports of catheter knotting as a complication to urinary catheterisation. [65] Generally the

procedure is regarded as unpleasant, painful and challenging to carry out on young children, all

of which exacerbates child and parental anxiety.[11] Adult data suggests that each day a

urinary catheter remains insitu there is in the region of a 5% increase risk for the development

of a bacteriuria.[66] To date there has only been one study conducted on the pediatric

population that compares urinary infection rates with two types of cleansing solutions.[7]

However significant research has been undertaken to determine the effects within the adult

population. Three studies, two relatively recent [4, 67] compared periurethral cleansing in

adults with water and a antiseptic solution, the results demonstrated that later does not reduce

the incidence or risk of urinary tract infection.[4, 6, 67]

Supra‐pubicAspirationIn order to collect a urine sample from the bladder via supra-pubic aspiration, a needle is

10

inserted just above the symphysis pubis. This technique was first reported in 1956 by Guze et

al.[68] Supra-pubic aspiration is frequently referred to as the reference or gold standard

method for urine collection.[69, 70] The success rate associated with blind aspirations varies

between 25 to 60%. As a means to overcome the low success rate, O’Callaghan

recommended the use of portable ultrasound.[71] Additional shortcomings are firstly the

procedure is painful and secondly it is not without complication. The most frequently identified

complication is bleeding and supra-pubic hematoma.[72-74] Additional complications reported

have been identified as the following, supra-pubic abscess and bowel perforation.[75-77] Urine

sample collected from this technique cannot be considered contaminated from periurethral flora

as the needle is introduced directly into the bladder rather than being exposed to the

urethra.[12] Consequently, the detection of any micro-organisms in a urine sample collected

from a supra-pubic aspirate is commonly referred to or diagnosed as significant bacteriuria.[70]

The likelihood of a confirmed diagnosis of urinary tract infection from urine obtained from

supra-pubic aspiration is approximately 99%.[11]

ProcessingofUrineCulturesIt is recommended that once a urine sample is collected then the specimen is transported to a

microbiology facility for processing within two hours, or stored at 4°C during the transportation

to a testing facility. Without careful attention being paid to these guidelines on sample transport

and storage, proliferation of pre-existing bacteria within the urine, resulting in inaccurate colony

counts can result. In order to inoculate the urine specimen onto the agar plate, laboratory staff

use calibrated loops. It is essential that these loops are routinely inspected and calibrated, as

even fine adjustments can result in considerable errors.[78] Cultures are generally examined

from anywhere between 18 to 24 hours and at 48 hours of incubation. Results of the culture

are expressed as colony forming units per milliliter (cfu/mL.). Clinician’s engage in research are

beginning to challenge the universally accepted diagnostic threshold developed by Kass in

1957. A recent report makes reference to Kass’s criteria being too low and as a consequence

there is a ~ 7.2 % false positive rate. The recommendation is to increase the threshold from

≥105 to ≥106 cfu/ml which could help to reduce the rate of false-positives samples and their

associated costs (fiscal and quality of life) to the patient and healthcare institution.[78]

KeyDefinitionsThe CDC defines UTI�s as, when a patient presents with either symptomatic urinary tract

infection or asymptomatic bacteremic urinary tract infection criteria.[29] In the United States in

2002, adults and children outside of intensive care units represented 32% of all healthcare

11

associated UTI�s. UTI can be classified as being associated with or without urinary catheter

placement (see appendix 7 for UTI criteria). According to the Center for Disease Control and

Prevention (CDC), 30% of all infections reported by acute care hospitals are urinary tract

related, with the majority of these associated with urinary catheterisation.[79, 80] Urinary

catheterisation occurs when a drainage tube (catheter) is inserted via the urethra into the

bladder. Urinary catheters are connected to a closed collection system and the duration of

placement is generally dependent upon catheter selection. Urinary catheter placement falls

within two categories - short term or long-term urethral catheters. Catheter placement less than

30 days is generally considered short-term catheterisation. Additionally urinary catheterisation

can be performed as an intermittent procedure. A disposable urinary catheter is inserted into

the bladder, which allows for urine to drain. This procedure is repeated several times a day and

is generally undertaken by the patient as a clean technique.

Nosocomial urinary tract infections in children occur with varying frequency, with approximately

60-80% of these infections being strongly correlated with urethral instrumentation.[8, 9, 34]

Infections which develop as a direct result of urethral catheterisation are commonly referred to

as Catheter Associated Urinary Tract Infections (CAUTI). Catheter associated urinary tract

infections continue to be a major cause of mortality in hospitalized patients.[28] Statistics from

the 2006 National Health & Safety Network identified the mean CAUTI rate to be 3.1-7.5

infections per 1000 catheter days.[81] Statistics comparing Healthcare Associated Infection

(HAI) and mortality in 2002 demonstrated that UTI equates to the greatest number of infections

of all HAI.[79] Risk factors associated with the development of a nosocomial urinary tract

infection have been identified as duration of catheter placement, females, no systemic

antibiotic cover and catheter and drainage bag disconnection.[82] The literature search

identified the few studies have published on the incidence of nosocomial urinary tract infection

within the pediatric population.[83, 84]

Escherichia Coli and Candida species of bacteria continue to be identified as the two major

pathogens associated with pediatric UTI’s.[85] Whether from endogenous or exogenous

sources, the infecting microorganisms gain access to the urinary tract by several routes. The

normally sterile urinary tract is defended from infection by several complementary activities:

“normal flora” living on intact mucosa; a competent immune system; and frequent and complete

voiding of urine.[34, 86, 87] Microorganisms that comprise the “normal flora” of the meatus or

distal urethra can be introduced directly into the bladder when a catheter is inserted. With

indwelling catheters, infecting microorganisms can migrate to the bladder along the internal

12

lumen of the catheter after the collection bag or the catheter-drainage tube junction has been

“compromised” and contaminated in the process i.e. during drainage bag changes or

accidental dislodgement etc.[88]

International consensus on infection prevention recommendations focus on prevention

strategies such as limiting urinary catheter use, adhering to aseptic technique during catheter

insertion and care and maintenance of a closed system with unobstructed urinary flow.[8-10,

34, 86] The implementation of the above recommendations in reducing CAUTI in terms of

infections and mortality equates to 380,000 less infections and 9000 preventable deaths

annually.[89] Saint and colleague’s research in 1998 look at the efficacy of silver alloy-coated

urinary catheters in preventing urinary tract infections. The results from a meta-analysis

demonstrated these catheters to be effective in preventing bacteriuria.[90] Silver alloy-coated

urinary catheters are not routinely placed in children, consequently there are no report studies.

To date considerable research has been published regarding adults and CAUTI best practice

recommendations. However, when reviewing the literature regarding the procedures for

catheter insertion, there is a lack of quality, summarized evidence related to periurethral

cleansing for the prevention of catheter-associated urinary tract infections in pediatric patients

and further research is recommended.[34] Likewise there is no general consensus where to

clean or not to clean and the overall effects on contamination rates of midstream urine

collection.

ConclusionFollowing a search of Medline, Cinahl, Cochrane and the JBI library of systematic reviews, no

systematic reviews regarding pediatric urinary catheterization or midstream urine collection

were identified as being published or underway on this topic.

In order to ensure our pediatric population is receiving evidence based health care, it is prudent

to systematically review the existing research to determine the most suitable periurethral

solution to be utilised in the process of midstream urine collection and urinary catheterisation.

Determining what the evidence base is has long-term benefits towards reducing the rates of

UTI and contaminated urine samples. All of which helps to reduce the cost (fiscally and quality

of life) associated this area of care for the pediatric patient.

13

Chapter3.StudyDesignandMethodsThis chapter provides detail about the JBI-MAStARI method used to conduct this systematic

review. This reviews objectives, inclusion and exclusion criteria, as well as primary and

secondary outcomes are discussed in the following sections. Of note is the change in practice

across the decades in how to best define UTI and therefore measure the effectiveness of

various interventions on reducing UTI and/or contamination of mid stream urine samples. In the

1980�s a positive urine culture was defined as growing at least one urinary tract pathogen

with a colony count of > 104 CFU/ml of urine.[61] In 2009 the CDC�s definition reflects a

greater appreciation of the complexity in measuring a UTI. The CDC standards are broken into

5 categories as detailed in Appendix 7. Discussed is the impact that this variance in the

measurement of UTI (the primary outcome of interest for this review) has had on the number of

research studies that met the stated inclusion criteria for this review.

JBI‐MAStARImethodofconductingaSystematicReviewsThe Joanna Briggs Institute for Evidence Based Healthcare has been a constructive voice

amidst the global conversation on evidence based healthcare. The JBI Institute promotes a

broader view of evidence, and in doing so has developed theories, methodologies and rigorous

processes for the critical appraisal and synthesis of these diverse forms of evidence in order to

aid in clinical decision- making in health care. These processes relate to the synthesis of

quantitative evidence, qualitative evidence, the results of economic analyses and expert

opinion and text.

The JBI-CReMS software has a number of analytical modules which are chosen according to

the type of research methods accepted to be in the review. The primary outcome of a

systematic review is the presentation of the best available evidence for the question being

asked. To achieve this outcome requires a concise question that has been structured

according to the acronym PICO which stands for Patient/Intervention/Comparison/Outcome.

The question in turn structures the review protocol which includes a clearly stated objective(s),

inclusion and exclusion criteria plus primary and secondary outcomes of interest. The existing

literature and research on the subject should inform the content of the protocol. Nevertheless, a

common experience for authors conducting systematic reviews is determining which

outcome(s) best demonstrate the effectiveness of the intervention under review.

Given that this review questions was about determine the evidence base for the effectiveness

of an intervention: ‘type of solution used to cleanse the periurethral area prior to insertion of a

14

catheter or collection of urine sample’ the research methods best able to answer this question

are experimental in design. The JBI-CReMs analytic module recommended for analyzing the

data from experimental studies is JBI-MAStARI. JBI-MAStARI is designed to assist with the

following critical steps of a systematic review.[91]:

Criticalappraisalofthestudiesretrieved,·Extracting data from the primary research regarding participants, the intervention, the outcome

measures and results.

Pooling the results. Statistical analysis (meta-analysis) occurs according to the quality of the

included studies. If pooling of data from different studies is not possible then the JBI-MAStARI

recommended approach is to provide a narrative summary of the results. This narrative

summary is critical for informing the reader about the current state of evidence for the question

in hand.

The following headings are reflective of the protocol structure and standards as set out in the

JBI- CReMS software for systematic reviews. The software guides the reviewer to conduct their

review according to the rigorous standards held by the JBI Institute. The JBI systematic review

process begins with the development of a proposal or protocol that is peer reviewed and

approved by the Institute. A rigorous and extensive search of the international literature on the

review question is undertaken, which are then assessed for their applicability to the question

and appraised using standardised tools to ensure that only the results of the highest quality

research are included in the final review. Formal training is required for the successful use of

the JBI-CReMs software. This training occurred as part of the course work for the successful

completion of the Masters of Clinical Science, of which this thesis is the final assessment.

ReviewObjectiveThe objective of this review was to synthesize the best available evidence related to

periurethral cleansing solutions to prevent contamination of mid stream urine collection and/or

catheter associated urinary tract infection in pediatric patients.

Inclusioncriteria

Typesofparticipants

There is no general consensus regarding the upper age range when defining pediatrics. The

American Academy of Pediatric policy identifies pediatrics from the foetus to 21 years of

age.[92] This review considered:

15

• Studies involving children from the age of 1 month to 18 years with a short-term

indwelling urethral catheter. Short-term catheterisation is defined as less than 30 days

of catheterisation in any hospital setting.

• And / or children from the age of 1 month to 18 years who require midstream urine

sample in any controlled environment supervised by medical personnel.

Interventions

Any cleansing solution e.g. Soap, 10% Povidone-Iodine, Sterile Water, Chlorhexidine

Gluconate or saline.

Comparators

Any alternate method (solution or no solution) to the intervention.

PrimaryOutcome

The primary outcome of interest was the incidence of urinary tract infection, as determined by

urine culture.

For the purposes of this review, urinary tract infection is defined as:

• >105 colony forming units (CFU)/mL of urine

• >104 CFU/mL, with clinical indicators of UTI i.e. Pyrexia (≤38°C) or suprapubic

tenderness.

• Bacteriuria >103 CFU/mL. [93]

Or

For studies completed after January 2009, use of the criteria established by the CDC

(Appendix 8).[29] For the purpose of this review bacterial contamination is defined as:

• A culture growing one organism with >104 CFU/mL urine is defined as a positive

culture.

SecondaryOutcome:

The presence of urethral meatus trauma i.e. burns, redness

TypeofstudiesThis review considered randomised controlled trials that report the incidence of catheter

associated urinary tract infections and compare periurethral cleansing solutions prior to

catheterisation. Meatal cleansing and the rate of bacterial contamination of midstream urine

samples. In the absence of RCTs other research designs, such as non-randomised controlled

16

trials, surveys, case control, and observational, will be considered for inclusion to enable the

identification of current best evidence regarding the effects of periurethral cleansing on urinary

tract infection and specimen contamination rates.

Exclusioncriteria• Studies involving anti-microbial impregnated catheters

• Children currently receiving antibiotic therapy

• Immunocompromised patients

• Paediatrics under 1 month of age

SearchstrategyThe search strategy was designed to find both published and unpublished studies. A three-step

search strategy was utilized:

1. An initial limited search of MEDLINE and CINAHL was undertaken followed by

2. Analysis of the text words contained in the title and abstract, and of the index terms

used to describe article. A second search using all identified keywords and index terms

was then undertaken across all included databases.

3. Finally, the reference list of all identified reports and articles was searched for

additional studies.

English was the only language considered

DatabasesSearched

The principle databases used to collate healthcare research publications and reports were

searched for this review:

• CINAHL

• MEDLINE

• Embase

UnpublishedstudiesorGreyLiterature

A well appreciated form of bias in healthcare research is what is referred to as publication bias.

Prior to the error of evidence-based healthcare the preference of researches and journals is to

only publish positive outcomes. A systematic review therefore needs to demonstrate the

process for minimizing publication bias. It is therefore important to demonstrate how

unpublished research was accessed.

17

Academic thesis or dissertations are a good point to commence this search for the grey

literature and two excellent databases have been established to collate this research:

• Dissertation Abstracts International

• Mednar

Initialkeywordsused:

Using the acronym PICO helps to establish the core concepts and therefore the key words

used to build the search strategy used for the systematic searching of the subject matter

databases listed above. The key words chosen to focus the search strategy for this review

were:

• Urinary

• Catheter

• Bladder catheterization/catheterisation

• Cleaning solution

• Anti-septic/antiseptic solution

• Children

• Pediatrics / Paediatrics

• Infants

• Urinary tract infection

• Periurethral

• Perineal cleansing

• Midstream clean catch

• Midstream clean collection

• Contamination rates

• Clean void urine

• Urine culture

MethodsoftheReview

Assessmentofmethodologicalquality

Just because it is published does not mean it is valid research! Recommendations that are

based on published research can be of different quality. The credibility of a systematic review is

dependent on the criteria used to assess the internal and external validity of the included

studies. Since poor quality evidence can lead to recommendations that are not in the patients

18

best interest, it is essential to know whether a recommendation is strong (we can be confident

about the recommendation) or weak (we cannot be confident).[94]

The process to critically appraise the methodological quality for this review was threefold:

1. Papers selected for retrieval were assessed by two independent reviewers

2. The use of a standardised critical appraisal instruments comprised of ten questions

from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review

Instrument (JBI- MAStARI) (Appendix 3)

3. According to the results of the critical appraisal each paper was graded accordingly:

i. Low : < 5/10 ii. High: > 5/10

Any disagreements that arose between the reviewers were resolved through discussion, or

with a third reviewer.

DatacollectionThe outcomes for a systematic review are dependent on the raw data derived from published

or unpublished research reports. If the required data is not available every effort is made to

contact the primary authors to determine if they can forward to the review authors the required

data. A structured data extraction tool from JBI-MAStARI (Appendix VI) was used by each

review author to extract the required data for this review. The data extracted included specific

details about the interventions, populations, study methods and outcomes of significance to the

review question and specific objectives.

DatasynthesisThe primary benefit of a systematic review is in its ability to synthesis (combine) the data from

a number of individual studies towards increasing the number of participant data available to

determine the overall estimate of effect. Data synthesis however can only occur if the individual

studies are similar in participant sample, research method and analysis. If the individual studies

are disparate in these criteria then a high degree of heterogeneity is introduced into the review

sample- often likened to trying to compare apples with oranges.

Data synthesis was only possible for 2 of the 3 included studies in this review. [95, 96] (see

Table 1 below which displays Meta Synthesis) To minimize data entry errors, two people

entered the results on separate occasions into the JBI MAStARI database. Given that the data

type for these studies was categorical, relative risk was used to produce a combine estimate of

19

effect for the type of periuretheral cleansing solution used to reduced the rate of contamination

during mid stream urine collection. Heterogeneity was assessed using the standard Chi-square

test. Given that only one RCT was included in this review no pooling of data was possible and

therefore the results are presented in narrative form.

ConflictsofinterestThere was no actual or perceived conflict of interest associated either with the topic selection,

or the methods used to undertake the systematic review.

ConclusionThis chapter presented the JBI-MAStARI method used to conduct this systematic review. JBI

systematic reviews begin with the development of a proposal or protocol that is peer reviewed

and approved by the Institute. A rigorous and extensive search of the international literature

following a three step process is undertaken in the subject matter databases best suited for the

question being asked. Once located the studies are assessed for their applicability to the

protocol criteria and appraised using standardised tools to ensure that only the results of the

highest quality research are included. Clarification of the inclusion and exclusion criteria in

addition to details about data collection and synthesis according to the JBI standards was

provided.

20

Chapter4:Results

IntroductionChapter four reports the results of the systematic review, describing the studies, both included

and excluded, and the conclusions extracted, according to their levels of credibility. The results

of the synthesis are reported by presenting data from the randomized control trial in narrative

form, whilst the two descriptive studies are discussed by interpreting the results of the forest

plot for the meta-analysis depicted in Figure 2.

DescriptionofstudiesTo date, the majority of studies available in the literature that address this question for the

pediatric patient are descriptive in nature. On the hierarchy of evidence for clinical

effectiveness, descriptive studies sit at a level 3 to 5. The type of research design classified as

descriptive are:

• Case controlled studies

• Cohort Studies

• Case Series and Case Reports

Changing clinical practice on level 3-5 is not recommended. The systematic search of suitable

studies to include in this review commenced in May 2010 to April

2011. A research librarian was consulted in the initial stages of planning, and the search

strategy is detailed in Appendix 5. From the search of the literature a total of 414 articles were

identified as potentially relevant to the review. The titles were screened and those that were not

relevant were eliminated. Forty-six papers were duplicates and therefore eliminated.

From 368 articles, 8 were assessed in detail against the protocol eligibility criteria. Of the eight

additional data was needed for three of the studies before they could be included. Attempts to

seek clarification by contacting the author were unsuccessful, resulting in the exclusion of three

studies. The primary reason for exclusion was that efforts to obtain data on the pediatric

participants of their individual studies were unsuccessful. Using the methodological quality

criteria available in MAStARI two studies were considered for exclusion, as they rated low.

An additional four articles were identified through hand-searching which included the following

steps:

• Identification of leading professional journals/books

21

• Carefully review of the table of contents

• Carefully review of reference list/bibliography of included articles

One of these was a literature review comparing sampling techniques but with no mention of

periurethral cleansing [20]. The other three required additional information:

1. the population studied by Unlu et al [57] was aged 18 -73 years.

2. the population studied by Schlager et al [25] was aged 10 - 19 years; data were

requested between 10 to 18 years.

3. the population studied by Bradbury et al [97] was aged 16 – 75 years; data was

requested from 16 to 18 years.

Additional data was sought from each of the primary authors however all efforts were

unsuccessful, resulting in the final exclusion of these three studies.

The study selection process is illustrated in Figure 1; a total of only 3 studies met the inclusion

criteria: one randomized control trial (RCT) [7] and two descriptive studies.[95, 96] These three

studies were conducted in Canada [7], Costa Rica [96] and the United States of America [95]

and were published (in English) between 1986 and 2009. Details of the excluded studies are

shown in Appendix 4. An additional search was undertaken by reviewing the references cited in

each of the included articles. No articles reviewed at this time were included in the review.

The two descriptive studies used the same inclusion criteria and the same definitions for a

positive culture – i.e. a culture growing one organism with ≤104 CFU / ml urine. Similarly the

collection of clean catch urine was followed in both these studies by meatal cleansing with 2%

Castile soap. Meta-analysis was conducted only on the two descriptive studies.

22

Figure1: Flow diagram of the search results and study selection of the studies

Citations (records) identified through database

searching: Midstream urine collection

n= 255 Urinary catheterization n=

159, Total n= 414 Studies excluded after duplication: Midstream urine collection n= 9

Urinary catheterization n= 37 n=46 Studies excluded after review of title and

abstract, and failure to meet eligibility criteria:

Midstream urine collection n= 239 Urinary catheterization n= 121

Total n= 360Full text retrieved against

eligibility criteria: Midstream urine collection n=

7 Urinary catheterization n= 1

n=8 Studies excluded as did not meet eligibility

criteria: Midstream urine collection n= 5

Urinary catheterization n= 0 n= 5 Studies meeting all eligibility criteria:

Midstream urine collection n= 2 Urinary catheterization n= 1

Additional studies retrieved from hand search: Midstream urine collection n= 4

Urinary catheterization n= 0 Studies included n= 0

Final number of studies retrieved meeting all eligibility criteria and

assessed for methodological quality:

Midstream urine collection n= 2 Urinary catheterization n= 1,

Total n= 3

Studies included: Midstream urine collection n= 2 Urinary catheterization n= 1 Total n=3

23

MethodologicalqualityOf the three studies that fulfilled the protocol inclusion/exclusion criteria, two are classified as

descriptive/case-series according to the appraisal criteria in MAStARI and one a randomized

control trial.[7, 95, 96] Overall the three studies lacked rigor in their design and reporting of

outcomes. Within the randomized control trial, study allocation concealment was undertaken by

means of a computer generated number sealed in an envelope[7]. However, no details are

provided in the published report about how or if blinding of the outcome assessors and

intention to treat analysis were carried out. The data for all enrolled participants were included

in the analyses and final results. Demographic data and clinical presentations were noted to be

similar in both groups. There was no indication that there had been any prior effort to estimate

required sample sizes using power analysis, and reported patient sample sizes were similar

across all three studies. The two descriptive studies failed to demonstrate appropriate use of

statistical analysis.[95, 96] and they lacked clear descriptions of demographics, cultural and

socioeconomic backgrounds. All the included studies had small sample sizes and the sampling

method was not clearly stated. The RCT study received ethics approval from their institutional

review board and participant consent was obtained prior to study enrollment[7]. Both

descriptive studies lacked clear identification of confounding factors and/or strategies

incorporated to deal with them, and only one documented that written consent was

obtained.[96]

All collected urine samples in the RCT were sent immediately to an onsite microbiology

laboratory for processing. When Lohr et al, collected urine samples at a local elementary

school, they were immediately stored on ice and transported to the same facility within one

hour of collection.[95] In addition to urine cultures, two of the included studies [7, 95] completed

a urinalysis as an additional means of determining the presence of infection. All urinalyses by

Lohr et al [95] were negative despite 3 producing positive urine sample cultures. The

breakdown analysis of positive cultures by Al Farsi et al [7] is unclear in its description of what

percentage were negative for leucocytes and nitrates when assessed via urinalysis dipstick.

SamplesizesThe study by Al Farsi et al [7] recruited one hundred & eighty-six consenting pediatric patients.

The two descriptive studies [95, 96] together recruited, two hundred & one pediatric patients.

The number of pediatric patients in each of the three studies ranged from ninety-nine to one

hundred & eighty six, with the total number of three hundred & eighty seven pediatric patients.

24

StudysettingThe randomized control trial comparing periurethral cleansing solutions prior to urinary

catheterization was conducted within an Emergency Department of a tertiary care pediatric

hospital in Toronto, Canada. [7] This department performs approximately 2,000 urinary

catheterisations per year [7]. The two descriptive studies were conducted in the following

settings: Pediatric Clinic in Costa Rica [96], Children’s Medical Centre Clinic and a local

elementary school within the United States.[95]

PediatricpatientsThe question of whether or not circumcision has an effect on the contamination rates in mid-

stream urine collection was raised by the results of the 1986 study by Lohr et al [95], since only

4% of the sample population were circumcised. In 1988, Saez-Llorens et al [96] reported

results from 99 uncircumcised boys with the conclusion that circumcision had no negative

effect on the rate of contamination post-meatal cleansing. Information such as demographics,

ethnicity, socioeconomic and cultural background of study participants was not consistently

provided. The three included studies met the inclusion/exclusion criteria for age and the

condition that the children were not receiving antibiotic therapy. The boys ranged in age from

two to fifteen years in both descriptive studies.[95, 96] Eighty- seven percent of the participants

studied by Al-Farsi et al were under 12 months of age [7]; this indicated that the relevance of

female patients was slightly higher (55%).[7] One study reported reasons for excluding children

who failed to meet the inclusion criteria; the main reason for exclusion was they were

considered very ill and any delay to acquire consent was considered unethical.[7] Of the three

studies reviewed here, the number of different pathogens isolated from the urine cultures

varied from one to seven, with no single pathogen identified across the three study groups;

however Al-Faris et al [7] reported that E. coli was the most common pathogen identified and

seen in both their control and comparison groups. This is comparable to what is reported

elsewhere in the literature.[85]

SolutionsAl Farsi et al [7] studied urinary infection rates in children whose periurethral area was

cleansed prior to urinary catheter insertion with either sterile water or 10% povidone-iodine.[7]

The principle reason for urinary catheterization is this study was to acquire a urine sample for

the analysis and diagnosis of a urinary tract infection. The two descriptive studies undertaken

by Saez-Llorens [96] and Lohr et al [95] were undertaken to ascertain whether or not meatal

cleansing influences the rate of bacterial contamination of midstream urine specimens.[95, 96]

25

Periurethral cleansing was achieved with the use of a 2% Castile soap. The culture media

within the two descriptive studies were identical, using trypticase soy agar with 5% sheep blood

and MacConkey agar 1.[95, 96]

TechniquesofPeriurethralCleansingThe randomized control trial required participants to undergo urethral catheterization.[7]

Standard hospital protocol for urinary catheter insertion was followed in both the sterile water

and Povidone- iodine groups. The patients were place in a dorsal recumbent position with

knees bent and soles of their feet together.[7] The sterile drape was positioned to ensure the

periurethral/urethral meatus area was visible. The catheter tip was lubricated and the non-

lubricated end was positioned to ensure that the urine sample drained into a sterile collection

container. The labia minora were separated during the cleansing process of all female patients.

To expose the urethral opening of those uncircumcised patients gentle tension was applied to

the foreskin. Al-Farsi details that in both groups the perineal area was swabbed from front to

back, center to outward 3 times, and the tip of the penis was cleaned from the urethral opening

backward toward the body 3 times with cotton balls soaked in either 10% Povidone-Iodine or

sterile water.[7] The urine sample was immediately tested within the emergency department

and transported to microbiology for relevant processing.

Saez-Llorens et al [96] replicated the same study method undertaken by Lohr et al [95] for

urine specimen collection obtained with and without metal cleansing; the only difference was

that the patient populations studied by Saez-Llorens et al were uncircumcised. Prior to urine

specimen collection, participants from the study by Lohr et al [95] were individually instructed

by health care personnel on the procedure for midstream urine collection but unlike the patients

studied by Saez-Llorens [96] during the collection process not all participants were supervised.

The first urine sample was without meatal cleansing and designated as a non-clean-catch urine

sample. The specimen was collected in a sterile wide-mouth container with a screw-lid. The

second specimen was collected following meatal cleansing with 2% Castile Soap and

designated as a clean-catch urine sample. Because the patients studied by Saez-Llorens et al

[96] were not circumcised, the foreskin was retracted prior to meatal cleansing and specimen

collection. If the child suffered from Phimosis (the foreskin cannot be fully retracted over the

glans penis exposing the urethral opening), meatal cleansing could not take place [96]. The

procedure was performed using a standard prepackaged urine collection kit. In both studies the

second specimen was collected between 24 and 30 hours after the initial sample.

26

Study one Study two Study three

Primary Author Al-Farsi et al, 2009 Saez-Llorens et al. 1988

Lohr et al. 1986

Research Focus Urinary catheterisation Mid Stream Mid Stream

Study Design RCT Descriptive Descriptive

Study population N=186; Canada Males: 78 Female: 108

N=99, Costa Rica Males: 99 Uncircumcised:99

N= 102: USA Males: 102 Uncircumcised: 4

Circumcised: 98

Intervention Sterile Water: n = 92 No peri urethral cleansing

No peri urethral

cleansing

Comparator 10% Povidone- Iodine: n=94

2% Castile Soap & Water

2% Castile Soap &

Water

Outcome measures Rate of UTI as/ 50 x

106 CFU/ L CFU* > 104/ml urine

CFU* > 104/ml urine

Intervention results 18% 2% 0.01%

Comparator results 16% 2% 0.01%

P Value 0.03 0.2 (Fisher) 0.08 - beta

Table 1: Individual study data and results (*CFU: Colony Forming Units)

A Forest Plot (Figure 2) was used to analyze the data from the two descriptive / case-series

studies. This shows that the Risk Ratios and the associated 95% confidence intervals the two

individual studies are 1.00 (0.14, 6.96) [95] and 1.15 (0.07, 18.06) [94]. According to these

analyses, neither study was able to demonstrate a significant clinical effect. Judging from the

large confidence intervals associated with these studies, both studies would appear to be

significantly underpowered, so that their results are inconclusive. The results from a meta

analysis shown in the same figure support the findings of the individual studies. The overall

Risk Ratio is 1.05 (0.21, 5.11), and although the p-value is extremely non-significant

(p=0.9602), nonetheless the wide confidence limits indicate that no firm conclusions should be

derived from these results.

27

Figure 2: Results of meta-synthesis of quantitative research findings

ConclusionThis chapter provided a detailed discussion of the methodological quality and synthesis of the

included studies. Overall the methodological quality of the included studies is rated as poor,

primarily because of the paucity of raw data from published research reports. This chapter

highlights the lack of methodologically sound research available to direct the decision-making

efforts of healthcare professionals related to the most effective method for periutheral cleansing in

the pediatric patient.

28

Chapter5:DiscussionandConclusions

IntroductionThis review has focused on the study of the best available evidence for determining the

optimum method and solution for (i) periurethral and (ii) periurethral cleansing in the

management of midstream urine sample contamination and the prevention of catheter-

associated urinary tract infection respectively, in pediatric patients.

The paediatric patients included in the three reviewed studies were aged between a few weeks

and 15 years, with most being under 12 months of age in the study conducted by Al Farsi et

al.[7] Two included studies evaluated or investigated the effects of periurethral cleansing on

contamination rates midstream urine collection and one study compared two different cleansing

solution.

Three articles met the required inclusion criteria. In two of the studies, midstream urine

specimens were collected from healthy male children. Each study provided clear criteria to

specify a urine specimen as being positive, contaminated or sterile [7, 95, 96] although the

analyses undertaken in this review only focused on positive results. One study within the

review compared urinary infection rates and periurethral cleansing with sterile water versus an

antiseptic solution. Within the two other (descriptive) studies, intervention and comparator and

therefore allowing a meta-analysis to be conducted to determine the affects of meatal

cleansing and the rate of contamination in midstream urine specimens.

The primary outcome measured was the incidence of urinary tract infection, as determined by

the colony forming units in the urine culture. The results of the two studies included in the

meta-analysis are represented in the Forest Plot of Figure 2. Of note is the fact that both

studies used the same research protocol and analysis but in two different population [96] is a

replication of the other.[95] The combined relative risk (RR) calculated for the two studies is

1.05, however the p –value is non-significant and therefore there is no evidence of a genuine

effect. Neither of these studies included female patients which raises the question if there is a

gender difference in the presentation and management of this condition. The only available

RCT concludes with the statement that sterile water is not inferior to 10% Povidone-Iodine for

cleansing in the periurethral area prior to bladder catheterisation in infants and children.[7]p659

However, this recommendation is based on a single study, which was substantially

underpowered. As only 3 studies were included in the review this clearly demonstrates there is

an urgent need for further research in the pediatric population on the use of appropriate

periurethral cleansing prior to urinary catheterization and midstream urine collection.

29

ImplicationsforPracticeGiven the findings from this review there is some evidence to suggest that implementing the

following interventions would not negatively impact the quality of patient outcomes.

PeriurethralCleansingPriortoUrinaryCatheterisationThe rates of UTI when using sterile water versus 10% povidone-iodine as the cleansing

solution prior to urinary catheterization are comparable. The same outcomes have been found

in the adult based research for example three different studies conducted by Cheung et al.;

Webster et al. and Nasiriana et al [4, 6, 67] demonstrated that there was no increase risk of

acquiring a urinary tract infection if periurethral cleansing was undertaken with potable water.

Consequently, if there is no associated risk of developing a urinary tract infection when

cleansing with sterile water, the cost benefit in the form of both fiscal (cost of antiseptic

solutions) and quality of life (non irritant of periurethral mucosa) is worthy of consideration. In

addition, in countries where the accessibility to antiseptic solutions is limited, this evidence is

worthy of further investigation through a large well-designed RCT.

BacterialcontaminationofmidstreamurinecollectionThe available research in this area considered suitable to include in this review was conducted

in pediatric males either circumcised or not with a meta-analysis demonstrating a non-

significant trend in favor for no cleansing solution required. These studies are descriptive in

design and therefore sit at a level of evidence 3-5. A change in clinical practice is therefore not

recommended.

ImplicationsforresearchDespite the fact that the results favour periurethral cleansing with sterile water as opposed to

an antiseptic based solution when performing urinary catheterisation and that meatal cleansing

does not significantly decrease the rate of bacterial contamination of midstream urine samples

in boys, this review clearly demonstrates the need for more research within the pediatric

population.

Comprehensive work has been undertaken to guide multi-disciplinary care for adult populations

and urinary catheter insertion and ongoing management. The Joint Commission’s recent

recommendation identifies that during 2012, JACHO and JCIA accredited healthcare

organizations must plan for the full implementation of the National Patient Safety Goals

(NPSG) #07.06.01 by January 1, 2013.[5] This NPSG calls for the implementation of evidence-

based practices to prevent indwelling catheter- associated urinary tract infections (CAUTI). Of

concern is there concluding statement that these guidelines are not applicable to pediatric

30

populations as the research needed to support and change in practice in the form of evidence

bundles is not available for the pediatric population. It is therefore of critical importance that a

well designed RCT is undertaken to demonstration the effectiveness of periurethral cleansing

solution(s) on reducing either the rate of nosocomial infection during urinary catherterisation in

the pediatrics patients and/or the contamination of mid-stream urine samples. The results of

this review suggest that the comparators for this RCT need to be sterile water; soap and water

and an antiseptic solution.

ConclusionsThe only available RCT evidence suggests that sterile water is sufficient for periurethral

cleansing prior to urinary catheterization. However, this recommendation is based on a single

study, which was substantially underpowered and therefore is not worthy to effect and change

in practice. The available research regarding effective solutions to minimize the contamination

of mid-stream urine samples is of a descriptive nature and therefore not worthy of

recommending a change in practice. Given the rising awareness of recipients of healthcare and

the subsequent zero tolerance of nosocomial infections, there is an urgent need for further

research in the pediatric population on the use of appropriate periurethral cleansing prior to

urinary catheterization and/or midstream urine collection.

31

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123(1): p. 17-23. 2. Kass, E.H., Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians, 1956. 69:

p. 56-64. 3. Kass, E.H., Bacteriuria and the diagnosis of infections of the urinary tract Arch Int Med, 1956.

100: p. 709-714. 4. Cheung K Fau - Leung, P., et al., Water versus antiseptic periurethral cleansing before

catheterization among home care patients: a randomized controlled trial. (1527-3296 (Electronic)).

5. Commission, T.J. New 2012 National Patient Safety Goal - Catheter - Associated Urinary Tract Infection (CAUTI) (NPSG.07.06.01). May 2011 [cited 2011 September]; Available from: http://www.jointcomission.org/assets/1/6/Pre_Pubs_NPSGs_CAUTI_HAI_20110509.pdf.

6. Webster, J., et al., Water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled trial. Am J Infect Control, 2001. 29(6): p. 389-94.

7. Al-Farsi, S., et al., Periurethral cleaning prior to urinary catheterization in children: sterile water versus 10% povidone-iodine. Clin Pediatr (Phila), 2009. 48(6): p. 656-60.

8. Wong, E.S., Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control, 1983. 11(1): p. 28-36.

9. Langley, J.M., M. Hanakowski, and J.C. Leblanc, Unique epidemiology of nosocomial urinary tract infection in children. Am J Infect Control, 2001. 29(2): p. 94-8.

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11. Karacan, C., et al., Evaluation of urine collection methods for the diagnosis of urinary tract infection in children. Med Princ Pract, 2010. 19(3): p. 188-91.

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15. Bollgren, I. and J. Winberg, The periurethral aerobic flora in girls highly susceptible to urinary infections. Acta Paediatr Scand, 1976. 65(1): p. 81-7.

16. Insitutite, J.B., Management of Short Term Indwelling Urethral Catheters to Prevent Urinary Tract Infections. Best Practice: Evidence Based Practice Information Sheets for Health Professionals, 2002. 4(1): p. 1 - 6.

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19. Roberts, A.P., R.E. Robinson, and R.W. Beard, Some factors affecting bacterial colony counts in urinary infection. Br Med J, 1967. 1(5537): p. 400-3.

20. Loane, V., Obtaining urine for culture from non-potty-trained children. Paediatr Nurs, 2005. 17(9): p. 39-42.

21. Macfarlane, P.I., Pad Urinary Collection for Early Childhood Urinary Tract Infection. Lancet, 1999. 354(9178): p. 571-72.

22. Vaillancourt, S., et al., To clean or not to clean: effect on contamination rates in midstream urine collections in toilet-trained children. Pediatrics, 2007. 119(6): p. e1288-93.

23. Leisure, M.K., S.M. Dudley, and L.G. Donowitz, Does a clean-catch urine sample reduce bacterial contamination? N Engl J Med, 1993. 328(4): p. 289-90.

24. Lifshitz, E. and L. Kramer, Outpatient urine culture: does collection technique matter? Arch Intern Med, 2000. 160(16): p. 2537-40.

25. Schlager, T.A., D.E. Smith, and L.G. Donowitz, Perineal cleansing does not reduce contamination of urine samples from pregnant adolescents. Pediatr Infect Dis J,

32

1995. 14(10): p. 909-11. 26. Campbell S, G.E., Whaley and Wong's Children's Nursing. 1995, London: Mosby. 27. Hardy, J.D., P.M. Furnell, and W. Brumfitt, Comparison of sterile bag, clean catch and

suprapubic aspiration in the diagnosis of urinary infection in early childhood. Br J Urol, 1976. 48(4): p. 279-83.

28. Matlow, A.G., R.D. Wray, and P.N. Cox, Nosocomial urinary tract infections in children in a pediatric intensive care unit: a follow-up after 10 years. Pediatr Crit Care Med, 2003. 4(1): p. 74-7.

29. (NHSN), N.H.S.N., Catheter-Associated Urinary tract Infections (CAUTI) Event, in NHSN Patient Safety Component Manual. 2009, Centers for Disease Control and Prevention p. 7-17-3.

30. Freedman, A.L., Urologic diseases in North America Project: trends in resource utilization for urinary tract infections in children. J Urol, 2005. 173(3): p. 949-54.

31. Harmsen, M., et al., Management of childhood urinary tract infections: an economic modeling study. Value Health, 2009. 12(4): p. 466-72.

32. Health, N.C.C.f.W.s.a.C.s., Urinary tract infection in children: diagnosis, treatment and long tern management. 2007: p. 1-178.

33. Saint, S., Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control, 2000. 28(1): p. 68-75.

34. Gould, C.V., et al., Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol, 2010. 31(4): p. 319-26.

35. The management of urinary tract infection in children. Drug Ther Bull, 1997. 35(9): p. 65-9. 36. Hoberman, A., et al., Oral versus initial intravenous therapy for urinary tract infections in

young febrile children. Pediatrics, 1999. 104(1 Pt 1): p. 79-86. 37. Mackenzie, J.R., et al., Guidelines for the management of acute urinary tract infection in

childhood. J R Coll Physicians Lond, 1991. 25(3): p. 263. 38. Shaikh, N., et al., Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr

Infect Dis J, 2008. 27(4): p. 302-8. 39. Larcombe, J., Urinary tract infection. Clin Evid, 2002(8): p. 406-20. 40. Ditchfield, M.R., et al., Risk factors in the development of early renal cortical defects in

children with urinary tract infection. AJR Am J Roentgenol, 1994. 162(6): p. 1393-7. 41. Jacobson, S.H., et al., Development of hypertension and uraemia after pyelonephritis in

childhood: 27 year follow up. BMJ, 1989. 299(6701): p. 703-6. 42. Nagler, E.V., et al., Interventions for primary vesicoureteric reflux. Cochrane Database Syst

Rev, 2011(6): p. CD001532. 43. Spencer, J.D., et al., Pediatric urinary tract infections: an analysis of hospitalizations, charges,

and costs in the USA. Pediatr Nephrol, 2010. 25(12): p. 2469-75. 44. Gorelick, M.H. and K.N. Shaw, Clinical decision rule to identify febrile young girls at risk for

urinary tract infection. Arch Pediatr Adolesc Med, 2000. 154(4): p. 386-90. 45. Blake, D.R. and L.F. Doherty, Effect of perineal cleansing on contamination rate of mid-

stream urine culture. J Pediatr Adolesc Gynecol, 2006. 19(1): p. 31-4. 46. Lau, A.Y., et al., A comparative study on bacterial cultures of urine samples obtained by

clean-void technique versus urethral catheterization. Acta Paediatr, 2007. 96(3): p. 432-6. 47. Pryles, C.V. and N.L. Steg, Specimens of urine obtained from young girls by catheter versus

voiding; a comparative study of bacterial cultures, gram stains and bacterial counts in paired specimens. Pediatrics, 1959. 23(3): p. 441-52.

48. Al-Orifi, F., et al., Urine culture from bag specimens in young children: are the risks too high? J Pediatr, 2000. 137(2): p. 221-6.

49. Downs, S.M., Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics, 1999. 103(4): p. e54.

50. Shaw, K.N., et al., Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics, 1998. 102(2): p. e16.

51. Winberg, J., et al., Epidemiology of symptomatic urinary tract infection in childhood. Acta

33

Paediatr Scand Suppl, 1974(252): p. 1-20. 52. Wiswell, T.E. and W.E. Hachey, Urinary tract infections and the uncircumcised state: an

update. Clin Pediatr (Phila), 1993. 32(3): p. 130-4. 53. Quigley, R., Diagnosis of urinary tract infections in children. Curr Opin Pediatr, 2009. 21(2): p.

194-8. 54. Wettergren, B., U. Jodal, and G. Jonasson, Epidemiology of bacteriuria during the first year of

life. Acta Paediatr Scand, 1985. 74(6): p. 925-33. 55. Aronson, A.S., B. Gustafson, and N.W. Svenningsen, Combined suprapubic aspiration and

clean-voided urine examination in infants and children. Acta Paediatr Scand, 1973. 62(4): p. 396-400.

56. Crain, E.F. and J.C. Gershel, Urinary tract infections in febrile infants younger than 8 weeks of age. Pediatrics, 1990. 86(3): p. 363-7.

57. Unlu, H., Y.C. Sardan, and S. Ulker, Comparison of sampling methods for urine cultures. J Nurs Scholarsh, 2007. 39(4): p. 325-9.

58. Chang, S.L. and L.D. Shortliffe, Pediatric urinary tract infections. Pediatr Clin North Am, 2006. 53(3): p. 379-400, vi.

59. Alam, M.T., 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(1): p. 29-34.

60. Amir, J., et al., The reliability of midstream urine culture from circumcised male infants. Am J Dis Child, 1993. 147(9): p. 969-70.

61. Lohr, J.A., L.G. Donowitz, and S.M. Dudley, Bacterial contamination rates in voided urine collections in girls. J Pediatr, 1989. 114(1): p. 91-3.

62. Pollack, C.V., Jr., E.S. Pollack, and M.E. Andrew, Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Ann Emerg Med, 1994. 23(2): p. 225-30.

63. Rachmiel, M., et al., Symptomatic urinary tract infections following voiding cystourethrography. Pediatr Nephrol, 2005. 20(10): p. 1449-52.

64. Lindehall, B., et al., Complications of clean intermittent catheterization in boys and young males with neurogenic bladder dysfunction. J Urol, 2004. 172(4 Pt 2): p. 1686-8.

65. Turner, T.W., Intravesical catheter knotting: an uncommon complication of urinary catheterization. Pediatr Emerg Care, 2004. 20(2): p. 115-7.

66. Schiotz, H.A., Antiseptic catheter gel and urinary tract infection after short-term postoperative catheterization in women. Arch Gynecol Obstet, 1996. 258(2): p. 97-100.

67. Nasiriani, K., et al., Comparison of the effect of water vs. povidone-iodine solution for periurethral cleaning in women requiring an indwelling catheter prior to gynecologic surgery. Urol Nurs, 2009. 29(2): p. 118-21, 131.

68. Beeson, P.B. and L.B. Guze, Observations on the reliability and safety of bladder catheterization for bacteriologic study of the urine. N Engl J Med, 1956. 255(10): p. 474-5.

69. Long, E. and J. Vince, Evidence behind the WHO guidelines: Hospital Care for Children: what are appropriate methods of urine collection in UTI? J Trop Pediatr, 2007. 53(4): p. 221-4.

70. Werman, H.A. and C.G. Brown, Utility of urine cultures in the emergency department. Ann Emerg Med, 1986. 15(3): p. 302-7.

71. O'Callaghan, C. and P.N. McDougall, Successful suprapubic aspiration of urine. Arch Dis Child, 1987. 62(10): p. 1072-3.

72. Rockoff, A.L., Letter: Hemorrhage after suprapubic bladder aspiration. J Pediatr, 1976. 89(2): p. 327. 73. Mandell, J. and P.S. Stevens, Supravesical hematoma following suprapubic urine aspiration. J

Urol, 1978. 119(2): p. 286. 74. Morrell, R.E., G. Duritz, and C. Oltorf, Suprapubic aspiration associated with hematoma.

Pediatrics, 1982. 69(4): p. 455-7. 75. Polnay, L., A.M. Fraser, and J.M. Lewis, Complication of suprapubic bladder aspiration. Arch Dis Child, 1975. 50(1): p. 80-81. 76. Schreiner, R.L. and P. Skafish, Complications of subrapubic bladder aspiration. Am J Dis Child,

34

1978. 132(1): p. 98-9. 77. Uhari, M., M. Remes, and A. Mustonen, Suprapubic abscess--a complication of suprapubic

bladder aspiration. Arch Dis Child, 1977. 52(12): p. 985. 78. Coulthard, M.G., et al., Redefining urinary tract infections by bacterial colony counts.

Pediatrics, 2010. 125(2): p. 335-41. 79. Klevens, R.M., et al., Estimating health care-associated infections and deaths in U.S.

hospitals, 2002. Public Health Rep, 2007. 122(2): p. 160-6. 80. Trautner, B.W., Management of catheter-associated urinary tract infection. Curr Opin Infect Dis,

2010. 23(1): p. 76-82. 81. Edwards, J.R., et al., National Healthcare Safety Network (NHSN) Report, data summary for

2006, issued June 2007. Am J Infect Control, 2007. 35(5): p. 290-301. 82. Saint, S. and B.A. Lipsky, Preventing catheter-related bacteriuria: should we? Can we? How?

Arch Intern Med, 1999. 159(8): p. 800-8. 83. Davies, H.D., et al., Nosocomial urinary tract infections at a pediatric hospital. Pediatr Infect Dis

J, 1992. 11(5): p. 349-54. 84. Lohr, J.A., Donowitz, L.G, adler, J.E, Hospital acquired urinary tract infections. Pediatrics,

1988. 83: p. 193-199. 85. Hidron, A.I., et al., NHSN annual update: antimicrobial-resistant pathogens associated with

healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol, 2008. 29(11): p. 996-1011.

86. Todd, J., Prevention of urinary tract infections in children. 1997. 87. Pratt, R.J., et al., epic2: National evidence-based guidelines for preventing healthcare-

associated infections in NHS hospitals in England. J Hosp Infect, 2007. 65 Suppl 1: p. S1-64. 88. Malt, G. and S. Robertson-Malt, A Rapid Quality Control Initiative to reduce the incidence of

urinary tract infection in the paediatric intensive care patient--Part one. Int J Nurs Pract, 2007. 13(6): p. 348-53.

89. Umscheid, C.A., Mitchell, M.D., et al, Mortality from reasonably preventable hospital aquired infections, Penn Center for Evidence based practice advisory: Philadelphia. p. 1 - 11.

90. Saint, S., et al., The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med, 1998. 105(3): p. 236-41.

91. Schultz, T., Florence,Z., MAStARI: The Joanna Briggs Institute meta analysis of statistics assessment and review instrument, in SUMARI:The Joanna Briggs Institute system for the unified management, assessment and review of information, A. Pearson, Editor. 2007, The Joanna Briggs Institute: Adelaide. p. 73-96.

92. Jennison, M.H., Coleman, A.B, et al, Age limits of pediatrics. Pediatrics, 1972. 49(3): p. 463. 93. Lockwood, C., Page, T,. et al, Management of short term indwelling urethral catheters to

prevent urinary tract infections. The JBI Library of Systematic Reviews., 2004: p. 1 - 36. 94. Guyatt, G.O., A. Schunemann H. Tugwell, P. Knottnerus, A, GRADE guidelines: A new series of

articles in the journal of clinical epidemiology. Journal of Clinical Epidemiology, 2010. 64(4): p. 380-82.

95. Lohr, J.A., L.G. Donowitz, and S.M. Dudley, Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in boys. J Pediatr, 1986. 109(4): p. 659-60.

96. Saez-Llorens, X., et al., Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in uncircumcised boys. J Pediatr, 1989. 114(1): p. 93-5.

97. Bradbury, S.M., Collection of urine specimens in general practice: to clean or not to clean? J R Coll Gen Pract, 1988. 38(313): p. 363-5.

� 35

����������� ������������������������������

�

NOTE: This appendix is included on pages 35-37 of the print copy of the thesis held in the University of Adelaide Library.

38

AppendixII:Finalassessmentofincludedstudies

Citation

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Al-Farsi, S., Oliva, M.,

Davidson, R.,

Richardson, S. E.,

Ratnapalan, S., 2009

Y

Y

U

N/A

U

Y

Y

Y

Y

U

%

100.

0

100.

0

0.0

N/A

0.0

100.

0

100.

0

100.

0

100.

0

0.0

Citation

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Lohr, J. A., Donowitz,

L. G., Dudley, S. M.,

1986

N

Y

N

Y

Y

N/A

N/A

Y

Y

Saez-Llorens, X.,

Umana, M. A., Odio,

C. M., Lohr, J. A.,

1989

U

Y

N

Y

Y

N/A

N/A

Y

U

%

0.0

100.0

0.0

100.0

100.0

N/A

N/A

100.0

50.0

� 39

����������� ����������������������������

NOTE: This appendix is included on pages 39-40 of the print copy of the thesis held in the University of Adelaide Library.

41

AppendixIV:ListofexcludedstudiesBlake, D. R. and L. F. Doherty (2006). "Effect of perineal cleansing on contamination rate of

mid-stream urine culture." J Pediatr Adolesc Gynecol 19(1): 31-34.

Reason for Exclusion: Unable to contact author for further information

Bradbury, S. M. (1988). "Collection of urine specimens in general practice: to clean or not to

clean?" J R Coll Gen Pract 38(313): 363-365.

Reason for Exclusion: Unable to contact author for further information

Lifshitz, E. and L. Kramer (2000). "Outpatient urine culture: does collection technique matter?"

Arch Intern Med 160(16): 2537-2540.

Reason for Exclusion: Unable to contact author for further information

Loane, V. (2005). "Obtaining urine for culture from non-potty-trained children." Paediatr Nurs

17(9): 39-42.

Reason for Exclusion: Literature review

Lohr, J. A., L. G. Donowitz, et al. (1989). "Bacterial contamination rates in voided urine

collections in girls." J Pediatr 114(1): 91-93.

Reason for Exclusion: Undertaking the quality assessment study rate low

Prandoni, D., M. H. Boone, et al. (1996). "Assessment of urine collection technique for

microbial culture." Am J Infect Control 24(3): 219-221.

Reason for Exclusion: Unable to contact author for further information

Schlager, T. A., D. E. Smith, et al. (1995). "Perineal cleansing does not reduce contamination

of urine samples from pregnant adolescents." Pediatr Infect Dis J 14(10): 909-911.

Reason for Exclusion: Unable to contact author for further information

Unlu, H., Y. C. Sardan, et al. (2007). "Comparison of sampling methods for urine cultures." J

Nurs Scholarsh 39(4): 325-329.

Reason for Exclusion: Unable to contact author for further information

Vaillancourt, S., D. McGillivray, et al. (2007). "To clean or not to clean: effect on contamination

rates in midstream urine collections in toilet-trained children." Pediatrics 119(6): e1288-1293.

Reason for Exclusion: Undertaking the quality assessment study rate low

42

AppendixV:Comprehensivesearchstrategies

Core Concepts to identify Keywords for Urinary Catheterization

Urinary catheterization

Urinary catheterization

Urinary catheter Urethral catheter

Urinary tract infections

Urinary tract infection

Bacteriuria

Catheter-related infections

Catheter-related infection

Children

child

infant

infancy

adolesc*

teenage*

pediatric*

paediatric

pediatric nursing paediatrics

Disinfectants

43

Povidone-iodine

Chlorhexidine

Gluconate

Anti-infective agents

Anti-infective

Disinfection

Saline

Isotonic solutions

Saline solution, hypertonic

Saline solution

Sterile water

Water

Antiseptic

Antisepsis

Asepsis

Periurethral

Periuthra*

Perineum

Perineal

Meatus

Meatal

44

Core Concepts to identify Keywords Midstream Urine Collection Midstream urine

Mid stream

Midstream

Disinfectants

Povidone-iodine

Chlorhexidine Gluconate

Anti-infective agents

Anti-infective

Disinfection

Saline

Isotonic solutions

Saline solution, hypertonic

Saline solution

Sterile water

Water

Antiseptic

Antisepsis

Asepsis

Periurethral Periuthra*

Perineum

Perineal

45

Meatus

Meatal

Infection

Urinary tract infection

Bacteriuria

Anti-Infective Agents, Urinary

Sources and search strategy used to locate Studies Urinary Catheterization

PubMed Urinary catheterization [mh] OR Urinary catheter*[tiab] OR Urinary catheter*[tiab] OR Urethral

catheter*[tiab] OR Urethral catheter*[tiab] OR Urinary tract infections[mh] OR

Urinary tract infection*[tiab] OR Bacteriuria[tiab] OR Catheter-related infections[mh] OR

Catheter-related infection*[tiab]

Povidone-iodine[nm] OR Providone-iodine[tiab] OR Chlorhexidine Gluconate[nm] OR

Chlorhexidine Gluconate[tiab] OR Anti-infective agents[mh] OR Anti-infective[tiab] OR

Disinfection[mh] OR Disinfection[tiab] OR Saline[tiab] OR Isotonic solutions[mh] OR

Isotonic solution*[tiab] OR Saline solution, hypertonic[mh] OR Saline solution*[tiab] OR

Sterile water[tiab] OR Water[mh] OR Antiseptic[tiab]

Periuthra*[tiab] OR Perineum[mh] OR Perineum[tiab] OR Perineal[tiab] OR

Meatus[tiab] OR Meatal[tiab]

child*[tiab] OR infant*[tiab] OR infancy[tiab] OR adolesc*[tiab] OR teenage*[tiab] OR

pediatric*[tiab] OR paediatric[tiab] OR pediatric nursing[mh] OR paediatrics[mh]

46

Sources and search strategy used to locate Studies Midstream Urine Collection

PubMed Urinary tract infections [mh] OR Urinary tract infection*[tiab] OR Bacteriuria[tiab] OR Anti-

Infective

Agents, Urinary [mh] OR Anti-Infective Agents, Urinary [tiab]

Povidone-iodine[nm] OR Providone-iodine[tiab] OR Chlorhexidine Gluconate[nm] OR

Chlorhexidine Gluconate[tiab] OR Anti-infective agents[mh] OR Anti-infective[tiab] OR

Disinfection[mh] OR Disinfection[tiab] OR Saline[tiab] OR Isotonic solutions[mh] OR Isotonic

solution*[tiab] OR Saline solution, hypertonic[mh] OR Saline solution*[tiab] OR Sterile

water[tiab] OR Water[mh] OR Antiseptic[tiab]

midstream[tiab] OR mid stream[tiab]

child*[tiab] OR infant*[tiab] OR infancy[tiab] OR adolesc*[tiab] OR teenage*[tiab] OR

pediatric*[tiab] OR paediatric[tiab] OR pediatric nursing[mh] OR paediatrics[mh]

Periuthra*[tiab] OR Perineum[mh] OR Perineum[tiab] OR Perineal[tiab] OR

Meatus[tiab] OR Meatal[tiab]

47

To obtain relevant Urinary Catheterization articles search included only periurethral cleansing

PubMed

6 Search periurethral cleansing 8

5 Search #4 Limits: All Child: 0-18 years

15 4 Search #1 AND #2 AND #3

70 3 Search Periuthra*[tiab] OR Perineum[mh] OR Perineum[tiab] OR Perineal[tiab]

OR Meatus[tiab] OR Meatal[tiab]

18799

2 Search Povidone-iodine[nm] OR Providone-iodine[tiab] OR Chlorhexidine Gluconate[nm] OR Chlorhexidine Gluconate[tiab] OR Anti-infective agents[mh] OR Anti-infective[tiab] OR Disinfection[mh] OR Disinfection[tiab] OR Saline[tiab] OR Isotonic solutions[mh] OR Isotonic solution*[tiab] OR Saline solution, hypertonic[mh] OR Saline solution*[tiab] OR Sterile water[tiab] OR Water[mh] OR Antiseptic[tiab]

665364

1 Search Urinary catheterization [mh] OR Urinary catheter*[tiab] OR Urinary catheter*[tiab] OR Urethral catheter*[tiab] OR Urethral catheter*[tiab] OR Urinary tract infections [mh] OR Urinary tract infection*[tiab] OR Bacteriuria[tiab] OR Catheter-related infections[mh] OR Catheter-related infection*[tiab] 57455

57455

48

Meatus[tiab]OR Meatal[tiab]

2 Search Povidone-iodine[nm] OR Providone-iodine[tiab] OR Chlorhexidine

Gluconate[nm] OR Chlorhexidine Gluconate[tiab] OR Anti-infective agents[mh]

OR Anti-infective[tiab] OR Disinfection[mh] OR Disinfection[tiab] OR Saline[tiab]

OR Isotonic solutions[mh] OR Isotonic solution*[tiab] OR Saline solution,

hypertonic[mh] OR Saline solution*[tiab] OR Sterile water[tiab] OR Water[mh]

OR Antiseptic[tiab]

66536

1 Search Urinary catheterization [mh] OR Urinary catheter*[tiab] OR Urinary

catheter*[tiab] OR Urethral catheter*[tiab] OR Urethral catheter*[tiab] OR

Urinary tract infections [mh] OR Urinary tract infection*[tiab] OR Bacteriuria[tiab]

OR Catheter-related infections[mh] OR Catheter-related infection*[tiab]

57455

PubMed To obtain relevant Midstream Urine Collection articles search included only Mid stream[tiab]

OR Midstream[tiab] AND Limits: All Child: 0-18 years

#7 Search #5 Limits: All Child: 0-18 years 211

#6 Search child*[tiab] OR infant*[tiab] OR infancy[tiab] OR adolesc*[tiab] OR

teenage*[tiab] OR pediatric*[tiab] OR paediatric[tiab] OR pediatric

nursing[mh] OR paediatrics[mh]

1238110

#5 Search Mid stream[tiab] OR Midstream[tiab] 728

#4 Search #1 AND #2 AND #3 65

#3 Search Periuthra*[tiab] OR Perineum[mh] OR Perineum[tiab] OR

Perineal[tiab] OR Meatus[tiab] OR Meatal[tiab]

18798

#2 Search Povidone-iodine[nm] OR Providone-iodine[tiab] OR Chlorhexidine

Gluconate[nm] OR Chlorhexidine Gluconate[tiab] OR Anti-infective

agents[mh] OR Anti-infective[tiab] OR Disinfection[mh] OR Disinfection[tiab]

OR Saline[tiab] OR Isotonic solutions[mh] OR Isotonic solution*[tiab] OR

Saline solution, hypertonic[mh] OR Saline solution*[tiab] OR Sterile

water[tiab] OR Water[mh] OR Antiseptic[tiab]

665168

49

#1 Search Urinary tract infections [mh] OR Urinary tract infection*[tiab] OR

Bacteriuria[tiab] OR Anti-Infective Agents, Urinary [mh] OR Anti-Infective

Agents, Urinary [tiab]

46511