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PRIMARY CARE: Malcolm G Coulthard, Sue J Vernon, Heather J Lambert, and John N S Matthews A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial BMJ 2003; 327: 656 [Abstract] [Full text]

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Priorities in the management of UTI in children

Lyda P Jadresic   (30 September 2003)

But where's the evidence?

Adam Sandell   (1 October 2003)

Preventing rather than documenting renal scars is the priority when managing UTI in children

Malcolm G Coulthard, Sue J Vernon and Heather J Lambert.   (10 October 2003)

Making the most of the evidence there is

Malcolm G Coulthard, Sue J Vernon and Heather J Lambert   (10 October 2003)

Priorities in the management of UTI in children 30 September 2003
Lyda P Jadresic, Consultant Paediatrician Gloucester GL1 3NN Send response to journal: Re: Priorities in the management of UTI in children	Dear Sir/Madam I would like to comment on this carefully performed study by Malcolm Coulthard et al. The study showed how the authors succeeded in increasing compliance among general practitioners with the 1991 RCP Guidelines on UTI management in children. The study put particular emphasis on the imaging investigations and an overwhelming number of children (610) had DMSA scans which yielded only 15 with renal scars (the extent of which is not provided and neither is their potential clinical significance). Another measure of success used was the finding that around 90% or more of the study children under 4 years were put on antibiotic prophylaxis. There has been no study that has shown that children benefit from this practice. I think it is a missed opportunity to devote precious resources to achieve these outcome measures which have not been shown to improve the well being of these children, over and above those such as identifying and managing well established risk factors for UTIs such as constipation and bladder instability and achieving the prompt recognition and treatment of UTIs, an undisputed factor in the limitation or even prevention of potential renal scarring which the study group failed to achieve. The time is ripe for a revision of the imaging guidelines in the RCP recommendations moving away from their blankett approach in a way that their yield of significant abnormalities is increased. Dr Lyda P Jadresic Consultant Paediatrician Gloucestershire Royal Hospital Competing interests:   None declared
But where's the evidence? 1 October 2003
Adam Sandell, GP Principal Adelaide Medical Centre, Newcastle upon Tyne, NE4 8BE Send response to journal: Re: But where's the evidence?	If clinically significant renal damage in children is avoidable, prevention is crucial. But is the well-organised and systematic approach to investigating possible urinary tract infection (UTI) outlined by Malcolm Coulthard and colleagues[1] the way to go? It is peculiarly difficult to find robust direct evidence that clinically significant renal damage is prevented by an aggressive systematic approach to possible UTI in young children. Clinical Evidence finds no randomised controlled trials (RCTs) of routine diagnostic imaging after first UTI in children,[2] and identifies only one systematic review of descriptive studies which itself found no evidence of benefit.[3] Coulthard and colleagues write that 'rigorous hospital based primary care in Sweden has reduced scarring and rates for end stage renal failure in children', a very bold conclusion to draw from small numbers in the epidemiological survey they cite.[4] Another paper cited for evidence of serious sequellae of UTI in children in fact speculates that UTI may not be the problem and its principal conclusion is that 'treatment of children with vesicoureteric reflux has not been accompanied by the hoped-for reduction in the incidence of [end-stage renal disease] attributable to reflux nephropathy'.[5] Clinically significant renal disease is not common, and is very rare in children.[4] Childhood UTI is common. Back-of-an-envelope estimates suggest that, even if the proposed approach to investigation were to prove clinically effective, the number needed to screen to prevent one adverse outcome would be immense. The arguments for aggressive management are largely theoretical; theory is crucial, but has generally proven a dismal basis for screening programmes. General practitioners are often the first port of call for children who might have UTI. Many of us would enthusiastically adopt the proposed approach if the balance of evidence, or even the balance of common sense, weighs in its favour, but this does not yet seem to be clearly so. Investigation has significant costs if adopted universally: worry and inconvenience for parents and children, exposure to radiation, funding, and time no longer available for more evidence-based activities – but then again, it might work. I will be keeping my eyes open for the much-needed RCT with adequate follow-up and relevant outcome measures. [1] Coulthard MG, Vernon SJ, Lambert HJ, Matthews JNS. A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial. BMJ 2003;327: 656. [2] BMJ Publishing Group (UK). Clinical Evidence. London: BMJ Publishing Group; June 2003. [3] Dick PT, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview. J Pediatr 1996;128:15-22. [4] Esbjörner E, Berg U, Hansson S. Epidemiology of chronic renal failure in children: a report from Sweden 1986-1994. Pediatr Nephrol 1997;11: 438-42. [5] Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 2000;105: 1236-41. Competing interests:   None declared
Preventing rather than documenting renal scars is the priority when managing UTI in children 10 October 2003
Malcolm G Coulthard, Consultant paediatric nephrologist Royal Victoria Infirmary, Newcastle, NE1 4LP, Sue J Vernon and Heather J Lambert. Send response to journal: Re: Preventing rather than documenting renal scars is the priority when managing UTI in children	We thank Lyda Jadresic for her thoughtful comments[1] on our study of the primary care management of UTI in children.[2] She is concerned that our intervention resulted in us imaging a large number of children but finding very few kidney scars, and concludes that the 1991 RCP Guidelines[3] should be revised to avoid the present ‘blanket approach’ to investigation, and to increase the yield of abnormalities. The main benefit from introducing a nurse led, education and direct access service to general practitioners for managing children with UTI was to try to prevent scars occurring rather than identifying them when they had. Among the study children, it is true that we only identified 10 who had scars after imaging 537. Of these 10, half were over the age of four and therefore were very likely to have sustained their scars previously, so we only actually identified 5 children who may have sustained scarring from a UTI that they suffered during the study period. Much more importantly we identified 12 infants who did not sustain scars despite having a proven urine infection in the presence of vesicoureteric reflux. There are good reasons to suggest that most of these 12 children were at high risk of scarring,[4] and it is reasonable to assume that the increased awareness among the study general practitioners of rapidly diagnosing and treating UTIs may have prevented this from happening. An ideal management outcome would be that scars would be found in no children. Dr Jadresic doubts that the increased use of low dose antibiotic prophylaxis is important. Our data do not allow us to determine which individual component of the management package we used contributed to the improved outcome. We will therefore continue to use prophylaxis until there is evidence that it is unimportant. A randomised controlled trial of antibiotic prophylaxis is needed but is difficult to achieve (as we have found in previous studies) because of parents having underlying beliefs about antibiotic usage. 1. Jadresic LP. Priorities in the management of UTI in children. British Medical Journal 2003;327(30 September):eletters. 2. Coulthard MG, Vernon SJ, Lambert HJ, Matthews JNS. A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial. British Medical Journal 2003;327:656-659. 3. Royal College of Physicians Research Unit Working Group. Guidelines for the management of acute urinary tract infection in childhood. Journal of the Royal College of Physicians of London 1991;25:36 -42. 4. Coulthard MG. Do kidneys outgrow the risk of reflux nephropathy? Pediatric Nephrology 2002;17:477-480. Competing interests:   None declared
Making the most of the evidence there is 10 October 2003
Malcolm G Coulthard, Consultant paediatric nephrologist Royal Victoria Infirmary, Newcastle, NE1 4LP, Sue J Vernon and Heather J Lambert Send response to journal: Re: Making the most of the evidence there is	Adam Sandell states that clinically significant renal disease is very rare in children, and uses this assertion to argue a “back of the envelope” case against investigating all children after urinary tract infection.[1] Unfortunately his statement is misleading because he excludes from his calculations the large majority of young children whose scarring-related hypertension or renal failure does not present until adult life. The approximately 20 adults transplanted in the Northern Deanery in the UK each year because of pyelonephritis will have almost certainly initiated their renal scarring under the age of four, and probably as babies.[2] The question remains, can these or the dozens of cases of hypertension be prevented? Like him, we would like to base management on evidence from randomised controlled trials (RCTs). However, in many areas none exist to guide practice. We agree that current investigation protocols need questioning. However that was not the object of this particular study which employed an investigation protocol similar to that in common use in much of the UK.[3] We have to be pragmatic, formulating clinical plans from the evidence that does exist, observational data and theoretical speculation. In combination these suggest that factors associated with renal scarring include young age, delay in diagnosis, repeated infections and vesicoureteric reflux (VUR). Currently it is clear that the first recognised UTI is often not the first. Unless the underlying diagnosis of UTI is correct it is pointless to try to compare investigation protocols, with or without RCTs. That is the next stage. Previous studies comparing treatments of VUR have focused specifically on a different population, namely those children who already have scars. Our study is an RCT which demonstrates that general practitioners who use conventional management protocols for children with urinary tract infections are likely to miss approximately three-quarters of infant cases.[4] It is true that we have not shown that using a nurse-led education-based direct-access service will alter the outcome for children managed by that system, though the identification of 12 infants with VUR but without scarring suggests that some scarring may be preventable. We now provide direct-access as a clinical service to our local population. In future years we will be able to report the scarring rates among children born in Newcastle since this initiative began. Though this will not constitute an RCT we hope it will provide useful evidence. As a general practitioner in Newcastle, Adam Sandell will of course contribute to that. [1]. Sandell A. But where's the evidence? British Medical Journal 2003;327(1st October):eletters. [2]. Vernon SJ, Coulthard MG, Lambert HJ, Keir MJ, Matthews JNS. New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid: follow up study. British Medical Journal 1997;315:905-908. [3]. Royal College of Physicians Research Unit Working Group. Guidelines for the management of acute urinary tract infection in childhood. Journal of the Royal College of Physicians of London 1991;25:36 -42. [4]. Coulthard MG, Vernon SJ, Lambert HJ, Matthews JNS. A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial. British Medical Journal 2003;327:656-659. Competing interests:   None declared