Abstract
The National Institute of Care Excellence (NICE) 2007 guidance CG54, on urinary tract infection (UTI) in children, states that clinicians should use urgent microscopy and culture as the preferred method for diagnosing UTI in the hospital setting for severe illness in children under 3 years old and from the GP setting in children under 3 years old with intermediate risk of severe illness. NICE also recommends that all ‘infants and children with atypical UTI (including non-Escherichia coli infections) should have renal imaging after a first infection’. We surveyed all microbiology laboratories in England with Clinical Pathology Accreditation to determine standard operating procedures (SOPs) for urgent microscopy, culture and reporting of children's urine and to ascertain whether the SOPs facilitate compliance with NICE guidance. We undertook a computer search in six microbiology laboratories in south-west England to determine urine submissions and urine reports in children under 3 years. Seventy-three per cent of laboratories (110/150) participated. Enterobacteriaceae that were not E. coli were reported only as coliforms (rather than non-E. coli coliforms) by 61 % (67/110) of laboratories. Eighty-eight per cent of laboratories (97/110) provided urgent microscopy for hospital and 54 % for general practice (GP) paediatric urines; 61 % of laboratories (confidence interval 52–70 %) cultured 1 μl volume of urine, which equates to one colony if the bacterial load is 106 c.f.u. l− 1. Only 22 % (24/110) of laboratories reported non-E. coli coliforms and provided urgent microscopy for both hospital and GP childhood urines; only three laboratories also cultured a 5 μl volume of urine. Only one of six laboratories in our submission audit had a significant increase in urine submissions and urines reported from children less than 3 years old between the predicted pre-2007 level in the absence of guidance and the 2008 level following publication of the NICE guidance. Less than a quarter of laboratories were providing a service that would allow clinicians to fully comply with the first line recommendations in the 2007 NICE UTI in children guidance. Laboratory urine submission report figures suggest that the guidance has not led to an increase in diagnosis of UTI in children under 3 years old.
Highlights
Urine testing remains important to obtain a definitive diagnosis in the management of urinary tract infection (UTI), and culture and susceptibility are needed to guide antibiotic treatment
The National Institute of Health and Care Excellence (NICE) 2007 guidance CG54, on ‘Urinary tract infection (UTI) in children: diagnosis, treatment and long-term management’, states that clinicians should refer all infants under 3 months old with suspected UTI to paediatric specialist care, and a urine sample should be sent from all children with suspected UTI for urgent microscopy and culture (Box 1) (NICE, 2007)
In children between 3 months and 3 years with suspected UTI, the guidance recommends that clinicians should use urgent microscopy and culture as the preferred diagnostic method over dipsticks with leukocyte esterase and nitrite
Summary
Urine testing remains important to obtain a definitive diagnosis in the management of urinary tract infection (UTI), and culture and susceptibility are needed to guide antibiotic treatment. This is just as important in UTI in children as in adults. The guidance states that the dipstick can be used in this age group if urgent microscopy facilities are not available It recommends that children under 3 months as well as children with severe illness and those with intermediate level of illness who are assessed as needing hospital care should be referred to hospital where urgent microscopy should be used (Box 1) (NICE, 2007)
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