SN Wong, wky Chan, S Chim, WM Lai, LCK Leung, NKC Tse

Abstract

The concept and management of urinary tract infection in children has been evolving over the past decades. While previous guidelines advocated universal imaging and antibiotic prophylaxis for young children with first time urinary tract infection (UTI), the recent guideline issued by the National Institute for Health and Clinical Excellence in the United Kingdom in August 2007 recommended a more selective strategy. This article presents a summary of the NICE Guideline with comments and recommendations by the authors. The Guideline was stringently developed and has incorporated recent scientific findings. Compared to previous guidelines, the major changes include the following: Firstly, it presents a complex algorithm for the diagnosis of UTI by rapid bedside tests. Diagnosis does not require urine culture in children above 3 years old who show positive dipstix results. Secondly it adopts a selective imaging strategy after first UTI. Ultrasound was recommended for infants below 6 months, or children of any age with atypical or recurrent UTI. Dimercapto-succinic acid scan was recommended for infants below 3 years with atypical or recurrent UTI, and those above 3 years with recurrent UTI. Micturiting cystourethrogram was recommended only for infants below 6 months with atypical or recurrent UTI or with abnormal ultrasound, and for infants above 6 months with atypical or recurrent UTI AND a family history of vesicoureteral reflux (VUR), poor urine stream, non-E.coli infection, or dilated renal pelves. Thirdly, antibiotic prophylaxis or surgery was not recommended routinely for VUR treatment. The authors discuss several concerns and suggest the following modifications for local practice: that a pre-treatment urine culture is useful in treatment by identifying the pathogen and its antibiotic sensitivity; that an ultrasound scan is reasonable, if a patient has not had a reliable antenatal or postnatal ultrasound, to exclude obstructive uropathies. For imaging strategy after a first UTI, the NICE Guideline is a reasonable approach if parents accept the small possibility of missing severe VUR for which the optimal treatment is still undecided. Until further evidence is available, a prudent option is to continue full imaging for infants below 12 months old and recommend antibiotics prophylaxis for Grade IV-V VUR. Further research is needed to better define the best treatment for severe VUR and to devise an investigation strategy that can identify those patients who may benefit from early detection of VUR and its treatment, and at the same time avoid over-investigating and over-treating the remaining patients.