MCUGs for the detection of vesicoureteric reflux in children with UTI – are we missing disease due to nice?

Abstract

Aim Urinary tract infection (UTI) is a common bacterial infection in children. Much controversy exists over the level of investigation required for UTI, looking for evidence of scarring and vesicoureteric reflux (VUR). In the Northern Region we follow local guidelines which involve imaging, prophylaxis and prolonged follow-up for all those with first UTI under 1 year of age. This places a heavy burden on NHS resources. NICE produced new guidelines in 2007 which results in fewer investigations being recommended in a more targeted fashion. Our aim is to identify how many episodes of VUR we would have missed had we been following NICE guidelines. Methods A retrospective study in a large district general hospital from January 1998 - April 2008, looking at all children <1 year of age who had an MCUG investigation for UTI. Notes for all with abnormal scans were reviewed to determine if they met the criteria for scan under NICE. We could then identify patients with VUR who would have been missed if we followed NICE. Results Over a period of 10 years, 368 MCUGs were done for UTI in children under 1 year, of these, 73 (19.8%) were reported abnormal. Applying NICE guidelines retrospectively, 15 of these 73 would have been recommended by NICE, 58 were therefore performed in our study that went against the NICE guidelines, all of which were abnormal to some degree. Most showed evidence of grade I or II VUR but 9 showed evidence of grade III or VI reflux. Conclusion In rationalising investigation of UTI according to NICE guidelines we would have missed 58 children with a diagnosis of VUR. Many of these have grade I or II reflux, the clinical significance of which is unclear. However there are 9 children in our cohort with Grade III or IV VUR who would have been missed. Controversy continues to remain as to whether or not the presence of primary VUR predicts renal scarring and damage but some paediatric nephrologists continue to believe there to be a causative effect between the two.