Guidelines to identify abnormalities after childhood urinary tract infections: a prospective audit

Abstract

Objective: To compare the childhood urinary tract infection (UTI) guidelines from the Royal College of Physicians (RCP) in 1991 and from National Institute of Health and Care Excellence (NICE) (CG54) in 2007 by measuring their efficiency at detecting urinary tract abnormalities.

Design: Children with UTIs within the Newcastle Primary Care Trust (population 70,800 children) were referred and imaged according to the RCP guidelines during 2008, and these were compared to the activity that would have been undertaken if we had implemented the CG54 guidelines, including following them through 2011 to identify those with recurrent UTIs.

Main outcome measures: The numbers of children imaged, the imaging burden and efficiency, and urinary tract abnormalities detected by each guideline.

Results: Fewer children would have been imaged by CG54 than RCP (150 vs 427), but its sensitivity was lower, at 44% for detecting scarring, 10% for identifying vesicoureteric reflux and 40% for other abnormalities. Overall, it would have only detected one-quarter of the abnormal cases (8 vs 32) and would have missed five of nine children with scarring, including three with multiple lesions and one with renal impairment. Imposing an age restriction of <8 years to the RCP guidelines would reduce its screening rate by 20% and still detect 90% of the abnormalities.

Interpretation: The CG54 guidelines do not alter the imaging efficiency compared to the RCP guidelines, but they are considerably less sensitive.

Keywords: renal scarring; urinary tract imaging; urinary tract infection; vesicoureteric reflux.

Figure 1

Flow chart showing the imaging that was undertaken on 532 children referred in Newcastle during 2008 with a possible urinary tract infection (UTI) following Royal College of Physicians (RCP)-based guidelines, and the imaging that would have been generated if National Institute of Health and Care Excellence (NICE's) CG54 had been followed. The numbers of imaging tests generated are indicated with shading, and the numbers of abnormal cases identified are shown in brackets.

Figure 2

Dimercaptosuccinic acid (DMSA) scan pictures from five children whose kidney scars were detected by the Royal College of Physicians (RCP) investigation guideline, but were missed by the National Institute of Health and Care Excellence (NICE) guideline.