The NICE childhood UTI guideline: NASTY processes produce NASTY guidelines
NICE’s childhood UTI guideline was welcomed by the BMJ. 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. 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 firstname.lastname@example.org) 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 and Watson 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
NICE guidelines result in uniformity of practice; clinicians “are
expected to follow them”. 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,
which appears to be reducing renal scarring rates (despite Watson’s
assertion that most scars are congenital). 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)
2. Watson AR. Management of urinary tract infection in children.
British Medical Journal 2007;335:356-7.
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
Competing interests: No competing interests