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Re: NICE guidelines on childhood UTI
- J Valmai Cook (1 October 2007)
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J Valmai Cook, Consultant Radiologist Queen Mary’s Hospital for Children, Epsom and St Helier University NHS Trust, Carshalton SM5 1AA
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The production of national guidelines, in a controversial subject such as the management of urinary tract infection in childhood, was always going to be difficult. The NICE guideline committee are to be congratulated on their attempt to base the guidelines on publications which stand up to the scrutiny of evidence based medicine and include new understanding of the pathogenesis of the interrelationship of voiding dysfunction, renal scarring, dysplasia and vesicoureteric reflux ( VUR). However, the new NICE guidelines (1) do represent a fairly major shift in the diagnostic paradigm since the Royal College of Physicians’ guidelines in 1991. Most involved in the management and imaging of children with urinary tract infection have seen a decline in the number of children with renal scarring over the years . This can be considered to be due to the greater awareness of the importance of detecting and investigating urinary tract infections in childhood, the improvements in antenatal scanning and a clearer understanding of the importance of bladder dysfunction as an important contributory factor. There is concern , by many , that the new NICE guidelines could result in a reversal of this position. There is also controversy regarding the value of prophylactic antibiotics in young children with either reflux or previous renal damage. If it is believed that prophylaxis does not alter the natural history, then it is difficult to advocate investigation to identify patients that need treatment. This is a fundamental premise before one begins to address the controversies that exist in selecting the most appropriate imaging technique (3) which may be of a variable standard. I completely agree that a randomised placebo controlled trial of prophylactic urinary antibiotics should be undertaken and before the NICE guidelines are universally adopted as it may then be difficult to mount such a treatment trial when fewer children will be identified as potential candidates. When the draft NICE guidelines were first published, I , with members of my department, retrospectively applied the proposed NICE protocol of investigation to a cohort of 79 infants under the age of 1 year who were fully investigated (ultrasound, micturating contrast cystography and delayed DMSA) over the last 3 years.(2) This under 1 year group of children represented those whose management would be most altered by adopting the NICE guidelines. A brief summary of the results is tabulated below. Results of Imaging Infants 0-6months with an urinary tract infection Good response (55) 30 normal Ultrasound ( US) 8 VUR No DMSA scars Poor response /complex (14) 4 normal US 4 VUR 1 DMSA scar Good response (55) 25 abnormal US 11 VUR, 2 duplex and 1 single kidney 3 Vesico ureteric junction obstruction Poor response /complex (14) 10 abnormal US 6 VUR 2 DMSA scars Results of Imaging Infants 6m-1 year with an urinary tract infection Good response(7) 5 normal US 3 VUR No DMSA scar Poor response /complex (3) 1 normal US I VUR No DMSA scar Good response(7) 2 abnormal US 2 VUR 2 DMSA scans Poor response /complex (3) 2 abnormal US 2 VUR 1 DMSA scar Comparison of Local and NICE guidelines , MCUG results 0-6 months good response 0-6 months complex 6m-1y good response 6m-1 year complex Total 55 14 7 3 Local invx. 55 14 7 3 Local abnormality 22 10 3 2 NICE invx. 25 14 0 3 NICE abnormality 13 10 0 2 NICE MISSED 8 0 3 0 Comparison of Local and NICE guidelines, DMSA results 0-6 months good response 0-6 months complex 6m-1y good response 6m-1y complex Total 55 14 7 3 Local invx 55 14 7 3 Local abnormal 1 3 2 1 NICE invx 0 14 0 3 NICE abnormal 0 3 0 1 NICE MISSED 1 0 2 0 Ultrasound abnormalities also included subtle findings such as dilatation of the distal ureters beyond 4 mm and presence of any urothelial thickening. The results of this small study suggest that most children in a paediatric centre will be detected by the NICE guidelines but a small number will be missed and the significance of this is uncertain . Most children were found to be in the 0-6 months age group including cases from the neonatal unit. In this study, all children with renal scarring had been demonstrated to have VUR except for one patient who had unilateral VUR and a scar in the contralateral kidney. There were very few with obstructed renal tracts as the vast majority of these had been detected by a careful antenatal hydronephrosis screening programme. There are many very useful clinical recommendations proposed by NICE . However, in view of the controversies that range it might be a little premature to adopt such a minimalist protocol of imaging as yet. It may be possible for other larger centres to also retrospectively apply the NICE guidelines or alternatively a national prospective trial of centres prepared to follow the previous Royal College of Physicians guidelines or the new NICE protocols could be considered. J. Valmai Cook
Competing interests: None declared |
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