The challenges of implementing the 2007 UK guidelines for paediatric urinary tract infection

In 2007, the National Institute for Health and Care Excellence (NICE), which advises the UK National Health Service, published guidelines on the diagnosis, treatment and long-term management of urinary tract infections (UTI) in children (1). Previous management had required extensive investigation, and follow-up of children after a UTI, which placed a heavy burden on the health system, was costly and was based on limited evidence. The aim of the NICE guidelines was to promote more consistent clinical practice, with the emphasis on improving outcomes through accurate diagnosis, appropriate investigations, treatment and follow-ups. Platt et al. are to be congratulated on their paper in this issue of Acta Paediatrica, which reports the findings of a large retrospective audit on how well the management of children under the age of 16 years complied with the NICE guidelines (2). Studies like these are important because they help us to evaluate the success or failure of guidances that are based on current research and developed to promote best practice. The audit involved 1149 children who presented to primary and secondary healthcare services with a UTI over a one-year period. They were located in four distinct geographical areas of England, representing a cross-sectional view of the target clinical practice for which the NICE guidance was written. Six standards were audited, which focussed on three key clinical themes: improving the rate of diagnosis, acute management of the very young child and how to select children for renal tract imaging. The services audited were as follows: general practitioners working in primary care surgeries, emergency departments, emergency paediatric departments and paediatric units. The audit demonstrated significant shortcomings in the implementation of all six standards across all primary and secondary care settings, with compliance as low as 13% for the composite criterion, comprising 12 subcriteria, which determined the necessity of performing further imaging. This was despite a period of more than two years between publication of the guidance and the audit, allowing what should have been a reasonable time for dissemination and education relating to the recommendations. In contrast, a publication by Jerardi et al. (3) described a quality improvement implementation programme that successfully achieved rapid adoption of the American Academy of Pediatrics (AAP) childhood UTI guidelines, also across multiple settings (4). For example, they were able to reduce the number of voiding cystograms performed in children following a UTI, and with normal renal ultrasonography, from 92% to 0% within one month of the initiation of the programme. This striking result was accomplished because the authors of that study identified key drivers of change and targeted them with well-orchestrated education and other interventions, then tested the outcomes. In the retrospective study by Platt et al. (2), strategies for implementing the NICE guidelines and providing education of the content were not explored. It appears, therefore, that the importance of education had been largely overlooked in this setting. It is worth noting that this audit was funded by the Healthcare Quality Improvement Partnership, the body that in 2013 commissioned Improvement Science London to analyse and report on engaging clinicians in quality improvements as an extension of the national requirement for clinical audit. It is important to note that theNICE guidancewas the first to recommenda less aggressive approach to the investigation, management and follow-up of paediatric UTIs. As with all situations requiring a radical change in established practice, there was considerable resistance to the new guidance in some quarters (5) and this proved an impediment to its widespread implementation. The low uptake of the NICE guidelines two years after publication is consistent with a paper reporting that it takes an average of 17 years for research-based evidence to result in changed clinical practices (6). The problem of poor compliance with guidelines on the management of childhood UTIs is not isolated to England. In recent times, a variety of guidelines addressing the same clinical topic have emerged in different countries (1,4,7). In Europe, compliance with three widely disseminated guidelines, including the NICE guidelines, was found to be poor, with the same concerns around over-complexity and inadequate education (8). Both papers make it clear that there is a gap between the ideals of the academics that formulate them and their real world application by primary care physicians (2,8). In the UK, children with UTIs are initially seen by general practitioners, who were the primary target audience for the NICE guidelines. Apart from the obviousnecessity of a precise implementation programme, as