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The guideline on urinary tract infection (UTI) in children from the National Institute for Health and Clinical Excellence (NICE) will precipitate debate, but hopefully cause less consternation than that expressed by Coulthard (previous letter). 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, recognition has been increasing that a lot of what we called reflux nephropathy is 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 episode and recover there has been legitimate concern about over-investigation. The NICE guideline does help us focus on important groups—young people and patients with unexplained fever, atypical UTI, or recurrent UTI. Prompt diagnosis and treatment are emphasised, but debate will continue about the relative merits of microscopy and dipsticks. One point to bear in mind is that UTI is a combination of symptoms and growth of organisms from an appropriately taken urine sample. Clinical decision making can be difficult, 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 two 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 and carers express concern about long term usage. However, children are our priority and we must justify to them the taking of the nasty medicine and the need for potentially nasty invasive tests.
Competing interests: None declared.