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Beyond the white coat: catheter or bag?

It is such a common situation that you would think it would be a cut-and-dried decision. But in some ways it reflects at the core of medical professionalism. A 2-month-old infant presents to the emergency department with a 101.6[degrees]F fever.

The history provides no hint at a specific diagnosis and the physical exam is unremarkable with a well-appearing baby. I've been using the Rochester criteria in this situation for nigh on 20 years. I need a CBC and urinalysis. Then I can decide on whether to do a lumbar puncture. The mother, however, resists the idea of doing a catheter for a urine sample. Now what?

The merits of bagged vs. catheter urine specimens have been debated for decades. In the United States, the experts have been in agreement for many years that catheter specimens are recommended.

My cause for skepticism has been that experts elsewhere have made contrary recommendations.

For many illnesses, I find the online resources of the Royal Children's Hospital in Melbourne to be very helpful because they are so specific yet thorough, including those for urinary tract infections (UTIs).

Those guidelines were last updated in 2011. These are only two pages of bulleted items, so I strongly recommend reading them. You may find them eye-opening. Those guidelines believe suprapubic aspiration remains the preferred method, at least in sick children. They also state that there is no indication for culture of urine from a bag specimen.

In Britain, the National Institute for Health and Care Excellence (NICE) guidelines have taken another approach. For them, "Noninvasive methods such as pads or bags should be used before trying to gain a sample by invasive methods," such as catheter or suprapubic aspiration. Those were 2007 NICE guidelines, referenced and reaffirmed in a 2013 guideline at the Royal Cornwall Hospitals Trust.

The British also have a protocol in which the baby is left undiapered and a parent waits to catch the urine in a sterile cup with the next void.

Furthermore, at least in the recent past, decisions in Britain about treating UTIs often were made based on dipstick alone if the child was well appearing. This made sterile collection less stringent. The costs of culture were thought excessive, compared with the improvement in accuracy of the diagnosis. This was analogous to the ongoing debate over whether to always test for strep throats before treating vs. treating empirically. The United States has moved strongly in the other direction. The 2011 American Academy of Pediatrics guidelines now require both a positive culture and a positive urinalysis to diagnose a UTI (Pediatrics 2011;128:595-610).

Why this difference? Because the diagnosis of a UTI in a young child in the United States under the now--discredited 1999 guidelines led to unnecessary admissions, intravenous therapy, renal ultrasounds, repeated voiding cystourethrograms, and long term antibiotic prophylaxis. Invasive overtreatment certainly can be used to justify overly invasive diagnostic tests. The wiser course would be to stop the overtreatment.

All this knowledge and perspective didn't help me in the ED with this mother. I suggested that, to a control-freak toddler, wearing a urine bag can be perceived as at least as invasive as the quick catheterization. I was not persuasive. Fortunately, the ED was empty at 3 a.m. So, if mom wanted to spend those extra 3 hours waiting for the child to pee into a bag, I could accommodate her autonomy.

My colleagues have differing opinions on what to do in this situation. One is a strong advocate for evidence-based medicine (EBM). Because the guidelines state that catheterization is the recommended method, he would argue that that is the only option that should be

presented to the parent. That emphasis on EBM becomes his definition of professionalism. Other colleagues are less dogmatic. They will point out that at 10 p.m. with all the ED rooms full and the waiting room overflowing, accommodating this situation would be more problematic.

I think my experiences working in so many different parts of the country have shaped me to value flexibility and accommodation. I've seen many situations where differing locations are dogmatic in differing directions in how the local doctors believe care should be delivered. I've also anxiously received minor medical treatment while overseas when I did not speak the local language, so the phrase "delivering care" is a particularly meaningful concept.

I think I could have used my knowledge and status to bully this mother into permitting her infant to be catheterized. Perhaps that is the scientifically ideal approach. I worry, though, that it would not be the most compassionate approach. The risk to the infant in both scenarios is very small. So to me, it wasn't a choice of catheter vs. bag. It was a choice of expressing compassion rather than expertise.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. E-mail him at Scan this QR code or go to to view similar articles.
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Title Annotation:OPINION
Author:Powell, Kevin T.
Publication:Pediatric News
Date:Sep 1, 2014
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