DMSA scanning following UTI; are there changes after nice guideline introduction?. (24th May 2012) - Pal, S
Abstract : Aims: NICE guideline CG54 (August 2007) recommends DMSA scan in children under 3 years with recurrent and/or atypical UTI and for all children with recurrent UTI. Prior to this, most children under five years with a proven UTI underwent a DMSA scan (Royal College of Physicians guideline, 1991). We aimed to assess the impact of the introduction of NICE guideline 54 in terms of DMSA scan rate, indication and results following UTI in children. Methods: All children (under 16 year) who had a DMSA scan following UTI in 2007 (Jan-July) prior to the introduction of the NICE guidelines were identified, and compared with those undergoing DMSA scanning in 2010 (Jan-Dec). Cases with no proven UTI, previously known anatomical urinary tract abnormalities or other indications were excluded. Results: We compared cases from 2007 (n=39) and 2010 (n=26), with no significant difference in terms of sex (p=0.903) or age distribution (p=0.812). The monthly scan rate reduced significantly from an average of 6.5 scans in 2007 to 2.2 scans in 2010 (p<0.01, 41% reduction, CI 22-60%), with similar numbers of culture positive UTI (2007 n=858, 2010 n=866). The proportion of DMSA scans following UTI has therefore reduced significantly from 9% to 3% (p<0.01, z=11.4). In 2007, the proportion of positive scans was 13%, compared to 23% in 2010, demonstrating a tendency towards increasing (P=0.25). Twenty of the 39 scans in 2007 would not now be indicated according to NICE guidelines, and none of these had a positive result. Positive scan results showed evidence of renal scarring either in terms of reduced DMSA uptake or reduced renal function. Conclusion: Our results suggest that prior to the introduction of the NICE guideline, children were being over investigated with DMSA scans, with the associated implications of radiation from isotope exposure, child/parental stress and financial implications. We have significantly reduced the number and rate of DMSA scans in our unit following UTI. Results demonstrate a tendency towards a higher positive scan rate. Importantly, all those scans which would no longer be indicated were normal suggesting that the reduction in DMSA scans is unlikely to lead to missing significant pathology.