The publication by the National Institute for Health and Clinical Excellence (NICE) of its clinical guideline on the recognition and management of urinary tract infection (UTI) in children in August 20071 comes some 16 years after the UK consensus-based guidelines published by the Royal College of Physicians (RCP).2 It represents an important milestone in our understanding of this common and sometimes under-diagnosed condition.

For most children a UTI does not have any implications for their long-term health. However, a small minority is at risk of significant morbidity, and in the past concerns about the development of chronic pyelonephritis with accompanying renal insufficiency and/or hypertension have led to many children being investigated following an infection, particularly in early childhood, and an emphasis on the diagnosis and management of reflux nephropathy.

The RCP guidelines helped to achieve a more consistent approach to the investigation of children, but imposed a huge burden on paediatric and imaging departments by recommending imaging in all children after the first UTI (11% of girls and 3% of boys). Subsequent questions about the problems of diagnosis in very young children in primary care, the relation between vesico-ureteric reflux and subsequent scarring, and about the effectiveness of antibiotic prophylaxis, have led to a need for a reappraisal about the current strategy for effective management of the condition.

The NICE guideline signals a move away from the wholesale imaging of children following a UTI, and places a greater emphasis on the recognition and diagnosis in primary care, facilitating earlier antibiotic treatment in those at greatest risk. Age and severity of illness are key determinants of the level of investigation.

NICE has not assigned grades to its recommendations, but relies on assessment of the levels of evidence in a detailed analysis of the evidence used to formulate the recommendations. …