NICE: Cheap and easy, but wrong and damaging
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
1. National Institute for Health and Clinical Excellence (NICE).
Urinary tract infection in children. (http://guidance.nice.org.uk/CG054)
Competing interests: No competing interests