BMJ  2003;327:1346 (6 December), doi:10.1136/bmj.327.7427.1346-a

Letter

Management of urinary tract infections in children

No evidence exists

EDITOR—Renal disease is serious, but it is peculiarly difficult to find direct evidence that it can be prevented by the systematic approach to possible urinary tract infection in young children advocated by Coulthard et al¹.

Clinical Evidence identifies no relevant randomised controlled trials² and one systematic review of descriptive studies that itself found no evidence of benefit³. The claim by Coulthard et al that Sweden's aggressive approach has reduced end stage renal failure is a bold conclusion to draw from small numbers in the epidemiological survey they cite⁴.

Another paper they offer as evidence of serious sequelae of urinary tract infection in children implies that such infections may not be the problem⁵.

Serious renal disease is comparatively rare⁴, whereas urinary tract infection in childhood is common. Even if effective, the number needed to screen to prevent one adverse outcome is likely to be huge. Arguments for an aggressive approach are largely theoretical: theory is crucial but has generally proved a dismal basis for screening programmes.

General practitioners are often the first port of call for children who might have urinary tract infections. Many would enthusiastically adopt the proposed approach if the balance of evidence, or even of common sense, weighed in its favour, but this does not yet seem to be clearly so. Investigation has costs: worry and inconvenience for families, exposure to radiation, funding, and time no longer available for more evidence based activities—but then again, it might work. I will be keeping my eyes open for the much needed prospective trial with adequate follow up and meaningful outcome measures.

Adelaide Medical Centre, Adelaide Terrace, Newcastle upon Tyne NE4 8BE adam.sandell{at}nhs.net

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Competing interests: None declared.

References

1. Coulthard MG, Vernon SJ, Lambert HJ, Matthews JNS. A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial. BMJ 2003;327: 656-9. (20 September.)[Abstract/Free Full Text]
2. BMJ Publishing Group (UK). Clinical evidence. Issue 9 (June). London: BMJ Publishing Group, 2003: 453-4.
3. Dick PT, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview. J Pediatr 1996;128: 15-22.[CrossRef][ISI][Medline]
4. Esbjörner E, Berg U, Hansson S. Epidemiology of chronic renal failure in children: a report from Sweden 1986-1994. Pediatr Nephrol 1997;11: 438-42.[CrossRef][ISI][Medline]
5. Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 2000;105: 1236-41.[Abstract/Free Full Text]

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Related Article

A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial

Malcolm G Coulthard, Sue J Vernon, Heather J Lambert, and John N S Matthews
BMJ 2003 327: 656. [Abstract] [Full Text] [PDF]