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Rapid Responses: Rapid Responses published:
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The NICE childhood UTI guideline: NASTY processes produce NASTY guidelines
- Malcolm G Coulthard (28 August 2007)
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The NICE childhood UTI guideline: response to NASTY processes produce NASTY guidelines
- Alan R Watson (30 August 2007)
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A positive document
- Ashok Beckaya (31 August 2007)
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NICE: Cheap and easy, but wrong and damaging
- Nadeem E Moghal (9 September 2007)
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Malcolm G Coulthard, consultant paediatric nephrologist Royal Victoria Infirmary, Newcatle, NE1 4LP
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NICE’s childhood UTI guideline[1] was welcomed by the BMJ.[2] Most readers will assume it was based on evidence correctly analysed by appropriate medical statisticians, robustly peer-reviewed, and openly debated. Being a controversial subject, dependent more on small studies than RCTs, many will imagine it represented consensus following wide consultation, as they state.[1] Sadly, all these assumptions are wrong. The NICE guideline committee signed highly restrictive secrecy agreements, and its two paediatric nephrologists did not consult with the British Association for Paediatric Nephrology (BAPN), whose members hold diverse views. I was a peer-reviewer, but was not treated as one. My first -draft review (available from malcolm.coulthard@nuth.nhs.uk) identified major flaws, was supported by the BAPN, and delayed publication by six months. However, I was only allowed to see their adjustments after strong insistence, signing a secrecy document, and accepting that they would ignore my responses to them. The errors persist. The guidelines were derived from an inadequate review of the literature. The authors misused statistics and reached beyond the evidence to make erroneous conclusions based on flawed logic. Thus, some appeared to reflect opinion rather than fact. Their own figures showed that nitrite -screening has a mean sensitivity of about 50%, so will miss half the cases, yet they[1] and Watson[2] advise its use unreservedly. Similarly, both promote the use of ultrasound rather than dimercaptosuccinic acid (DMSA) scans, despite their own data showing DMSAs to be much more sensitive; on average ultrasound misses half the scars. They also view DMSA as invasive even though it requires only a single venepuncture and has the radiation burden of one abdominal x-ray. Both advise a temperature cut-off of 38°C for investigating infants’ urines without clear evidence, and both assume that a lack of evidence for prophylactic antibiotics equates to evidence against their benefit, which many paediatricians dispute. NICE guidelines result in uniformity of practice; clinicians “are expected to follow them”.[3] Unifying practice before a consensus emerges is absurd. Scientific debates are not resolved by secrecy and decree, but by patient research and genuinely open discussion. The premature imposition of inappropriate guidelines will stifle new clinical developments. For example, our own unit runs a direct access service,[4] which appears to be reducing renal scarring rates (despite Watson’s assertion that most scars are congenital[2]). If we are all forced into one mould based on poor analysis of evidence, we will miss the opportunity to make important advances. 1. National Institute for Health and Clinical Excellence (NICE). Urinary tract infection in children. (http://guidance.nice.org.uk/CG054) 2007. 2. Watson AR. Management of urinary tract infection in children. British Medical Journal 2007;335:356-7. 3. http://www.nice.org.uk/page.aspx?o=AboutGuidance. 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 |
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Alan R Watson, Consultant Paediatric Nephrologist Nottingham University Hospitals, City Hospital Campus NG5 1PB
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The NICE guideline on urinary tract infection in children will precipitate debate, but hopefully cause less consternation than that expressed by Coulthard. The published clinical guideline runs to 150 pages and 271 references with many systematic reviews. [1] We can all quote observational studies that don’t pass the scrutiny of evidence-based medicine but perhaps we should remember that the 1991 Royal College of Physicians guidelines were produced by 18 “experts” at a one-day consensus meeting with medical audit in mind. Achieving a further consensus has been difficult with imaging modalities changing from intravenous urogram and micturating cystogram for all to ultrasound, radionuclide imaging and more selective cystograms. At the same time, there has been increasing recognition that a lot of what we called “reflux nephropathy” is actually “reflux-associated damage” in association with congenital dysplastic and obstructive kidneys. The UTI algorithms that were devised didn’t really distinguish between upper tract and lower tract infection. As most children only have a single UTI episode and recover there has been legitimate concern about over-investigation. The NICE guideline does help us focus on important groups, ie the young, those with unexplained fever, atypical or recurrent UTI. Prompt diagnosis and treatment is emphasised but debate will continue about the relative merits of microscopy and dipsticks. One point to bear in mind is that urinary tract infection is a combination of symptoms and growth of organisms from an appropriately taken urine sample. Clinical decision-making can be difficult in this area but it is clearly stated in the NICE guidelines that “the guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.!” This may certainly be appropriate in the debated area of antibiotic prophylaxis. A recently published Cochrane review quoted only 2 small studies where no significant differences in risk for UTI were found between antibiotic prophylaxis and no treatment.[2] We urgently need a controlled trial in this area, especially as compliance with long-term prophylaxis is probably worse than we think and some parents/carers express concern about long- term usage. However as children are our priority and we must justify to them the taking of the nasty medicine and the need for potentially nasty invasive tests. References 1. Verrier Jones K, Bannerjee J, Boddy S-A et al. NICE guideline - Urinary tract infection in children: diagnosis, treatment and long-term management. Welsh A (ed) RCOG Press, London 2007. www.nice.org.uk 2. Hodson EM, Wheeler DM, Vimalchandra D et al. Interventions for primary vesicoureteric reflux. Cochrane Database of Systematic Reviews 2007. Issue 3. Art.No: CD001532. DOI: 10.1002/14651858.CD001532.pub3. Competing interests: None declared |
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Ashok Beckaya, Associate Specialist Paediatrician Epsom & St. Helier Univ. Hosps
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The recent UTI guildlines are to be welcomed by general paediatricians and general practice. It may not be perfect but certainly a significant improvement on previous guidelines, clearer and more objective. Advantages are: 1. Reduced burden on NHS and decrease expenditure in managing UTIs.
I feel this is an important document for the management of UTI in children, good for the patients, good for doctors and good for the health service. In current times of financial contraints, it is responsibility of medical profession not to ignore the cost implications while propagating evidenced based medicine. There needs to be an acceptable balance in our approach in the future. 1. National Institute for Health and Clinical Excellence (NICE). Urinary tract infection in children. (http://guidance.nice.org.uk/CG054) 2007. 2. Watson AR. Management of urinary tract infection in children. British Medical Journal 2007;335:356-7. Competing interests: None declared |
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Nadeem E Moghal, Consultant Paediatric Nephrologist & Head of Department Royal Victoria Infirmary, Newcastle NE1 4LP
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I share Coulthard’s concerns about the NICE childhood urinary tract infection (UTI) guidelines, as did the parents of a 3¼ year-old boy we identified as having extensive bilateral renal scarring following a UTI. They pointed out to us that if they had been managed according to the (then provisional) NICE guidelines,1 neither the diagnosis of a UTI, nor of scarring, would have been made. The lad had merely been ‘a bit under the weather’, without specific symptoms, and did not develop a temperature of 38°C. According to the NICE guideline, he would not have required a urine check, but his general practitioner disagreed. He also performed a urine culture rather than relying on stick-testing, being aware that that misses approximately 50% of positive cases. The culture revealed >105 E coli per ml, and treatment was then started. Though the NICE guideline indicates he would not require imaging after an uncomplicated UTI at 3 years, he had a renal tract ultrasound. This was normal, which the NICE guideline suggests excludes renal tract scarring, even though the evidence from which the guideline was derived indicates that an ultrasound scan alone will miss about half the cases of scarring. Being aware of this limitation, our department routinely performs an interval dimercaptosuccinic acid (DMSA) scan after the first UTI since this is highly sensitive, requiring just one venepuncture, and only has the same radiation dose as an abdominal radiograph. In his case it showed extensive bilateral irregular scars. A micturating cystogram subsequently confirmed bilateral vesicoureteric reflux. We regret that the time to treatment in this case was not shorter than it was, which may have prevented his scarring. However, we are pleased that we have identified it. He is now maintained on prophylactic trimethoprim, even though its benefit has neither been proved nor disproved by a randomised trial. As importantly, we know to screen his urine very quickly if he has another febrile illness, of any degree, in the future. We will monitor his blood pressure very occasionally in the future even though his individual risk of hypertension is relatively small, and will thereby ensure he does not present with the complications of unexpected severe hypertension. It is easy to see how it would have been cheaper and easier to follow the NICE guidelines, but hard to see how it would have improved this lad’s care. 1. National Institute for Health and Clinical Excellence (NICE). Urinary tract infection in children. (http://guidance.nice.org.uk/CG054) 2007. Competing interests: None declared |
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