Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Nasty guidelines: perspectives from the developing world
- Peter J Campbell (7 September 2007)
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Nuclear response to UTI in children
- Stephen Ware, CM11 1AT (7 September 2007)
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Why doesn't NICE seek genuine consensus?
- Heather J Lambert (11 September 2007)
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uti needs more evidence base
- ignatius e losa (13 September 2007)
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The Most Controversial Guideline Ever Produced
- Kishor Tewary (14 September 2007)
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NICE Guidlines for UTI
- Ian E Willetts (14 September 2007)
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Peter J Campbell, Regional Director, Quality Improvement in Health USAID-ZdravPlus project, Bozbozor 16, Tashkent 100077, Uzbekistan
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In response to the forthright article by Malcolm G Coulthard on the allegedly not-so-NICE UTI guideline, I would like to broaden the discussion to the use of EBM in general, which is now a hot topic throughout the world, and increasingly so in developing countries. It is astonishing that in the so-called developed world we can have such a "secretive" system of guideline development that leaves leading consultants in such disagreement. In the developing world, the problems are worse, compounded in particular by a lack of knowledge of EBM among leading experts and authorities, leaving the expertise in the hands of a few who may be able to push their own versions (or the version wished for by their sponsors) without any such open discussion/critique as exemplified by this BMJ forum. Other difficulties in developing countries include the lack of awareness of those trained in EBM of their own limitations. For example, the WHO have produced a number of excellent guidelines (Integrated Management of Childhood Illness (IMCI), Making Pregnancy Safer etc) which are designed with a particular strata of healthcare providers/ consumers in mind (ie maximum effectiveness for minimum cost). However, the newly trained "EBM experts" now develop new guidelines which are often framed in terms of enhancing the WHO ones, but which in the end lead to conclusions that advocate far more expensive investigations/ treatments than are affordable by the target group, and which may be only marginally more beneficial in terms of treatment outcome. The other great danger is the development of algorithms, the only part of a guideline often read by the practitioners. Qualifications in EBM research are not qualifications for algorithm development, especially if the new ones contradict WHO ones. WHO has clear criteria for development of algorithms, including extensive testing to ensure accuracy and comprehensibility, skills not usually taught to EBM guideline researchers. In the context of countries where EBM is being promoted to challenge outdated and non-evidenced based theories of medical practice, the nasty development of EBM guidelines is in danger of causing confusion and controversy, and worse, unquestioned implementation leading to patient harm (especially if new algorithms are unclear or inaccurate). Long live the open debate on guideline development, and long live improvements to the development of guidelines for the benefit of the population, not the benefit of the developers. Competing interests: None declared |
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Stephen Ware, Retired Paediatrician Billericay, CM11 1AT
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I share Dr Coulthard's concerns about NICE's ultra-conservative approach to management of urinary tract infection (UTI) in children. The reason why this problem is hardly amenable to Evidenced Based Medicine or even consensus is that though it is extremely common, like a nuclear accident the risk of seriously adverse outcome is very small, but when it does happen it is catastrophic. In nearly 40 years of practice I can remember only a handful of such cases. I recall a case of a toddler with a respiratory illness and no urinary symptoms who was overflowed into a paediatric surgical ward where a urine culture was sent to the lab for no good reason. The abnormal result was overlooked but the infection was perchance treated with respiratory antibiotic to which the organism was sensitive. Two years later however, after a period of chronic illness, a kidney abscess led to nephrectomy. In my view every pre-school child with a proven UTI deserves at least ultrasound (cheap, non-invasive) and skilful counselling. These 2 are equally important. Clearly counsellors need to be au fait with the limitations of ultrasound and in particular of their ultrasonographer. I hope Dr Coulthard will not mind me pointing out that though the overall radiation penalty of DMSA is comparable to that of an abdominal X- ray, a very substantial dose is delivered locally to the kidneys, where it remains concentrated for some hours. I am glad this investigation, though important, is becoming less frequently used. Competing interests: None declared |
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Heather J Lambert, consultant paediatric nephrologist Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP
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The NICE childhood urinary tract infection (UTI) guideline[1] recommends some radical changes from current practice without convincing evidence. Much of the guideline is identified as being derived from “consensus techniques”[2], but who was able to contribute to that consensus opinion? Watson[3] fails to answer Coulthard’s criticisms[4] regarding the flawed NICE process, while the authors have not responded at all. Watson argues in favour of evidence-based medicine, but is uncritical of recommendations in two highly controversial areas; location of UTI and imaging. Despite NICE’s own statements regarding the unreliability of distinguishing upper and lower UTI by clinical features or laboratory investigations, their main recommendations are underpinned by assuming that the “high risk” children, with upper UTI, can be identified. Less imaging would be widely welcomed if children at risk of developing or progressing renal damage could still be identified. The guideline development group (GDG) took the controversial view that vesicoureteric reflux is unimportant, and based their imaging strategy on this. A major criticism of current practice is that many children already have scarring at the time of first investigation, offering little opportunity for prevention. The NICE guideline emphasises early diagnosis and rapid treatment to prevent scars, especially in the most vulnerable, youngest children. However, to recommend that even they are only fully investigated if their UTI is “atypical” or “recurrent” is illogical. If they are at risk of scarring, why wait until they have recurrent infections, further closing any window of opportunity to prevent damage. If they really believe that most “scarring” is congenital (so, unpreventable), why investigate later? There is a broad range of views amongst paediatric nephrologists about how intensively to investigate. When NICE proposed their extremely limited imaging strategy, they only took the views of a handful of people, and made no attempt to widely consult academics, practising paediatric nephrologists, or other UK experts. Yet, professionals and the public probably assume that NICE guidelines do represent expert consensus. Stakeholder groups were permitted to comment once, after the draft publication, but there was no meaningful dialogue. The British Association for Paediatric Nephrology was allowed a limited meeting with NICE immediately pre-publication, but there was no opportunity to make significant changes. NICE have missed the chance to formulate a genuine consensus statement, or even to raise valuable clinical questions about these controversial areas. Their ‘Quick reference guide’ doesn’t even identify those areas which are not evidence based, which is misleading and intellectually dishonest. The publication of such restrictive and poorly qualified guidelines will limit opportunities to look critically at these issues. References 1. National Institute for Health and Clinical Excellence (NICE). Urinary tract infection in children. (http://guidance.nice.org.uk/CG054) 2007. 2. Mori R, Lakenpaul M, Verrier-Jones K. Diagnosis and management of urinary tract infection in children: summary of NICE guidance. British Medical Journal 2007;335:395-7. 3. Watson AR. NASTY processes produce NASTY guidelines: Author's reply. British Medical Journal 2007;335:463-464. 4. Coulthard MG. NASTY processes produce NASTY guidelines. British Medical Journal 2007;335:463. Competing interests: None declared |
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ignatius e losa, consultant paediatrician macclesfield district hospital, sk10 3bl
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I agree with the response by Malcolm Coulthard re: NICE ON UTI in the BMJ 8th September, about the inadequacy of the literature review.I note that the "grey" literature was purposely omitted, and wondered if these have been included in the search, that perhaps, some useful evidence or papers of "good quality" may have been highlighted, and these could have, in part, led to different recommendations being made.
As the under 2's are the patients in whom the" classsic" features of UTI's are usually absent, and are also the group in whom it is difficult to obtain clean voided samples, even if the risk is presumed to be low,every effort should be made to exclude a urine infection, and the reliance on a screening test,that is,dipstix, can therefore be very misleading. The test for nitrite has higher specificity and lower sensitivity, and may be useful for "ruling in" UTI when positive, but has little value in ruling out UTI.
The odd patient with low risk that has been commenced on antibiotic, and who does not get better, will only complicate issues, as patients do not always present classically as in textbooks, and neither do they fit into boxes, and this approach may mask other serious infections. The other point is that two pathologies may co-exist.
The use of just ultrasound scan in some of the cases, as proposed, is not a useful tool if the purpose is to identify or document reflux.
However, the approach set out by NICE will certainly reduce the cost for the NHS in terms of less investigations being performed,especially the reduction in numbers of micturating cystograms,which will be of delight to some professionals, and of course,patients and their carers.
Competing interests: None declared |
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Kishor Tewary, Consultant Paediatrician, Special Interest in Renal Paediatrics Stafford General Hospital
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Dear Editor With the publication of latest NICE guideline on UTI management in children,a stream of varied opinions have surfaced.This is extremely sad that even after years of consultation and experience NICE has failed to produce a consensus guideline on this subject.I have been running a UTI clinic myself for last few years and find some aspects of this guideline very controversial.Historically a large number of patients have been inadvertantly being treated for UTI just for a postive culture but no real symptoms.NICE has failed to highlight the issue of relevent sympomtoms and likelihhod of diagnosis at all and the chart showing 'Suspecting UTI' is very confusing.There are some good inclusions such as issue of not treating an asymptomatic child unless high risk,no urine c/s needed if alternate site of infection found and stressing need of urine culture as a gold standard for making the diagnosis compared to the dipstix.However, the issue of imaging is very debatable. The consensus statement on this issue seems to come from a group who are working in a very specialised areas, with back up of paediatric radiology experts.I find it extremely uncomfortable to adopt a similar practice in a district general hospital where a child may be scanned by a radiographer with a far less experience than a pediatric radilogist. It would be prudent to discharge a young child especially someone less than a year old, just after getting a normal report for ultrasound as the report may be baised by the expertise of the person doing the scan. Hence if a child has been ill with UTI, I recommend to do a full imaging in less than 6-12 months old,unless the ultrasound has been reported normal by a paediatric radiologist or sopmebody of equal expertise.Similarly the issue of prophylaxis has been raised with a good approach. But majority of articles published on this topic are from children who had recurrent UTI, who almost always have some other risk factors for recurrence such as a poor hyegine, poor bladder habit or others.In this circumstance, the prophylaxis alone may not work and invariable these children will get a reccurrence with a resistant organism.In my practice, I have found prophylaxis more helpful than a problem though it can be ever debated.We all had high hopes from NICE,. Sadly it has proven itself disappointing. Competing interests: None declared |
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Ian E Willetts, Consultant Paediatric Urologist Newcastle Teaching Hospitals NHS Trust
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On points of interest in response to Watsons editorial on the NICE UTI guidelines in children, the published document seems to be at odds with his statement that clinical staff will use their clinical accumen to treat children and that these guidelines are not 'set in stone' - the document states that NHS staff will be expected to institute these guidelines (ie PCTs attempting to cut cost will use this document to decide on the management of childhood UTI). How much money was spent in formulating these inadequate guidelines? The NICE process does not appear to be very transparent or accountable. This is a serious issue of national importance - if all NICE committees operate in this way this requires investigation at the highest level if patient care is not to be compromised in the future. Competing interests: None declared |
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