A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7416.656 (Published 18 September 2003) Cite this as: BMJ 2003;327:656
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests