Quick-Wee versus bladder stimulation to collect midstream urine from precontinent infants under 1 year of age: a study protocol for a randomised controlled trial (ES.Stimquick.U).

INTRODUCTION: Urinary tract infections occur in around 1%-4% of boys and 3%-8% of girls under 2 years old. Diagnosis is difficult because of non-specific symptoms and the risk of urine analysis contamination depending on the sampling method used for precontinent infants. The American Academy of Pediatrics recommend transurethral catheterisation and suprapubic aspiration because of a low contamination rate but these techniques are invasive. On the other hand, while the National Institute for Health and Care Excellence advocate clean catch urine for its minimal invasiveness and acceptable contamination rate, it is difficult to accomplish in precontinent infants. Two recent methods have been described: the Quick-Wee method by Kaufman et al (suprapubic stimulation with cold saline-soaked gauze); and bladder stimulation by Herreros et al then by Tran et al (pubic tapping alternating with lumbar massage). This study aims to compare the effectiveness in collecting midstream urine by bladder stimulation vs the Quick-Wee method in infants under 1 year, before walking. METHODS AND ANALYSIS: This study is a multicentre randomised controlled trial of 230 infants under 1 year and before walking who need urine analysis, conducted in four paediatric emergency departments in France. Patients will be randomised into two groups: bladder stimulation and Quick-Wee method.The primary endpoint will be the success rate of voiding at least 2 mL of urine in less than 5 min.Secondary outcomes are the time to collect at least 2 mL of urine, comfort, quality of urine and the risk factors associated with failure of the two techniques. ETHICS AND DISSEMINATION: The study protocol was approved by the French national ethic committee (consultative committee of the protection of persons). The results of the study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: Clinical Trials Registry - NCT04587999. DATE AND PROTOCOL VERSION IDENTIFIER: October 2020, V.1.

Ecthyma gangrenosum, a skin manifestation of Pseudomonas aeruginosa sepsis in a previously healthy child: A case report.

RATIONALE: Ecthyma gangrenosum (Eg) is a necrotic lesion that is mostly seen in immunocompromised patients. It reflects a severe sepsis, possibly caused by Pseudomonas aeruginosa (Pa). PATIENT CONCERNS: A healthy 3-year-old girl admitted to the Pediatric Emergency Department presented a sepsis-associated purpura with neurological and respiratory distress. INTERVENTIONS: An empiric antibiotherapy (anti-meningococcal) was prescribed. DIAGNOSES: Forty-eight hours after admission, blood and wound cultures were positive for Pa. As a result, the decision was made to change the antibiotic therapy.Unfortunately, on day 3, the patient died. Exhaustive immunologic tests are presently being carried out. OUTCOMES: Eg caused by Pa is uncommon in healthy children, and purpura sepsis is usually caused by Neisseria meningitides infection. LESSONS: Eg should be recognized rapidly so that the appropriate treatment can be prescribed as quickly as possible.

Evaluation of the Bladder Stimulation Technique to Collect Midstream Urine in Infants in a Pediatric Emergency Department.

OBJECTIVE: Midstream clean-catch urine is an accepted method to diagnose urinary tract infection but is impracticable in infants before potty training. We tested the bladder stimulation technique to obtain a clean-catch urine sample in infants. MATERIALS AND METHODS: We included 142 infants under walking age who required a urine sample in a cross-sectional study carried out during a 3-months period, from September to November 2014, in the emergency department of the University Children's Hospital of Nice (France). A technique based on bladder stimulation and lumbar stimulation maneuvers, with at least two attempts, was tested by four trained physicians. The success rate and time to obtain urine sample within 3 minutes were evaluated. Discomfort (EVENDOL score ≥4/15) was measured. We estimated the risk factors in the failure of the technique. Chi-square test or Fisher's exact test were used to compare frequencies. T-test and Wilcoxon test were used to compare quantitative data according to the normality of the distribution. Risk factors for failure of the technique were evaluated using a multivariate logistic regression model. RESULTS: We obtained midstream clean-catch urine in 55.6% of infants with a median time of 52.0 s (10.0; 110.0). The success rate decreased with age from 88.9% (newborn) to 28.6% (>1 y) (p = 0.0001) and with weight, from 85.7% (<4 kg) to 28.6% (>10 kg) (p = 0.0004). The success rate was 60.8% for infants without discomfort (p<0.0001). Heavy weight and discomfort were associated with failure, with adjusted ORs of 1.47 [1.04-2.31] and 6.65 [2.85-15.54], respectively. CONCLUSION: Bladder stimulation seems to be efficient in obtaining midstream urine with a moderate success rate in our study sample. This could be an alternative technique for infants before potty training but further randomized multicenter studies are needed to validate this procedure.