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Although urinary tract infection affects at least 3.6% of boys and 11% of girls, establishing the diagnosis is difficult in early childhood owing to the lack of specific urinary symptoms, difficulty in urine collection, and contamination of samples. Most children have a single episode and recover promptly. Current imaging, prophylaxis, and prolonged follow-up strategies place a heavy burden on patients, families, and NHS resources and carry risks without evidence of benefit. This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to provide consistent clinically and cost effective practice for the diagnosis, treatment, and further management of urinary tract infection in childhood.1
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
Despite strongly held views by some clinicians about the role of intensive imaging strategies and prophylactic antibiotic treatment in preventing renal failure after urinary tract infection, current evidence shows no such benefit. The most useful strategy for reducing morbidity from urinary tract infection and preventing subsequent renal parenchymal defects is the prompt diagnosis and treatment of the infection. This is particularly important in infants and young children, in whom the diagnosis can easily be missed.
NICE has developed tools to help organisations implement the guidance (see www.nice.org.uk/page.aspx?o=tools).
The most recent previous guidance on imaging after urinary tract infection in childhood was published by the Royal College of Physicians in 1991.3 In a national audit of the guideline reported in 20014 5 (which included 746 children under 2 years old with a fever in 31 hospitals) testing for possible urinary tract infection was highly variable. Altogether, 38/74 infants with a positive result on urine culture were not given a diagnosis of urinary tract infection and did not receive any treatment, prophylaxis, imaging, or follow-up. There was also no communication with the general practitioner or the patient's carers about the positive culture result. Thus half of the infants and children seen in secondary care with evidence for urinary tract infection did not receive the correct diagnosis or recommended management.
Imaging and follow-up of correctly diagnosed cases were assessed in a second study and showed that 93% of children had at least an ultrasound scan, and only 5% had no imaging test, indicating a high degree of compliance with the imaging strategy.
The new NICE guidance1 proposes that:
The guideline was developed by the National Collaborating Centre for Women and Children's Health. The collaborating centre convened a Guideline Development Group consisting of two paediatric nephrologists, one general paediatrician, one general practitioner, one paediatric urologist, one paediatric radiologist, one paediatric microbiologist, two paediatric nurses, and one patient/carer representative. Technical support was provided by the collaborating centre.
The guideline was developed according to the standard NICE methods (www.nice.org.uk/page.aspx?o=howwework) and checked against a wider stakeholder community of clinicians, methodologists, researchers, patient/carers, and policy makers.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG054).
Future updates of the guideline will be produced as part of the NICE guideline development programme.6
The members of the Guideline Development Group were Kate Verrier Jones, Jay Banerjee, Su-Anna Boddy, David Grier, Lyda Jadresic, James Larcombe, Julie Marriott, Jeni Senior, Kjell Tullus, Sue Vernon, and Craig Williams, with Monica Lakhanpaul, Rintaro Mori, Anita Fitzgerald, Jeff Round, Michael Corkett, Samantha Vahidi, and Rosie Crossley from the National Collaborating Centre for Women's and Children's Health.
Contributors: RM was the project manager and systematic reviewer; he drafted the paper, and all authors contributed to its revision and the final draft. ML is the clinical co-director for the guidelines, was the project director, and convened the Guideline Development Group. KV-J chaired the Guideline Development Group.
Competing interest: None declared.
Funding: The National Collaborating Centre for Women's and Children's Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Provenance and peer review: Commissioned; not externally peer reviewed.