Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Diagnosis and management of urinary tract infection in children: summary of NICE guidance

BMJ 2007; 335 doi: (Published 23 August 2007) Cite this as: BMJ 2007;335:395

Rapid Response:

The NICE childhood UTI guideline: response to NASTY processes produce NASTY guidelines

The NICE guideline on urinary tract infection in children will
precipitate debate, but hopefully cause less consternation than that
expressed by Coulthard. The published clinical guideline runs to 150
pages and 271 references with many systematic reviews. [1] We can all
quote observational studies that don’t pass the scrutiny of evidence-based
medicine but perhaps we should remember that the 1991 Royal College of
Physicians guidelines were produced by 18 “experts” at a one-day consensus
meeting with medical audit in mind. Achieving a further consensus has
been difficult with imaging modalities changing from intravenous urogram
and micturating cystogram for all to ultrasound, radionuclide imaging and
more selective cystograms. At the same time, there has been increasing
recognition that a lot of what we called “reflux nephropathy” is actually
“reflux-associated damage” in association with congenital dysplastic and
obstructive kidneys.

The UTI algorithms that were devised didn’t really distinguish
between upper tract and lower tract infection. As most children only have
a single UTI episode and recover there has been legitimate concern about
over-investigation. The NICE guideline does help us focus on important
groups, ie the young, those with unexplained fever, atypical or recurrent
UTI. Prompt diagnosis and treatment is emphasised but debate will
continue about the relative merits of microscopy and dipsticks. One point
to bear in mind is that urinary tract infection is a combination of
symptoms and growth of organisms from an appropriately taken urine sample.
Clinical decision-making can be difficult in this area but it is clearly
stated in the NICE guidelines that “the guidance does not, however,
override the individual responsibility of healthcare professionals to make
decisions appropriate to the circumstances of the individual patient, in
consultation with the patient and/or guardian or carer.!” This may
certainly be appropriate in the debated area of antibiotic prophylaxis. A
recently published Cochrane review quoted only 2 small studies where no
significant differences in risk for UTI were found between antibiotic
prophylaxis and no treatment.[2] We urgently need a controlled trial in
this area, especially as compliance with long-term prophylaxis is probably
worse than we think and some parents/carers express concern about long-
term usage. However as children are our priority and we must justify to
them the taking of the nasty medicine and the need for potentially nasty
invasive tests.


1. Verrier Jones K, Bannerjee J, Boddy S-A et al. NICE guideline -
Urinary tract infection in children: diagnosis, treatment and long-term
management. Welsh A (ed) RCOG Press, London 2007.

2. Hodson EM, Wheeler DM, Vimalchandra D et al. Interventions for primary
vesicoureteric reflux. Cochrane Database of Systematic Reviews 2007.
Issue 3. Art.No: CD001532. DOI: 10.1002/14651858.CD001532.pub3.

Competing interests:
None declared

Competing interests: No competing interests

30 August 2007
Alan R Watson
Consultant Paediatric Nephrologist
Nottingham University Hospitals, City Hospital Campus NG5 1PB