PEDIATRIC UROLOGY

A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial
Coulthard MG, Vernon SJ, Lambert HJ, Matthews JN
Department of Paediatric Nephrology, Royal Victoria Infirmary, Newcastle NE1 4LP, United Kingdon
BMJ. 2003; 327: 656

• Objectives: To determine whether a nurse led education and direct access service improves the care of children with urinary tract infections.
• Design: Prospective cluster randomised trial.
• Setting: General practitioners in the catchment area of a UK paediatric nephrology department.
• Participants: 88 general practices (346 general practitioners, 107,000 children).
• Main outcome measures: Rate and quality of diagnosis of urinary tract infection, use of prophylactic antibiotics, convenience for families, and the number of infants with vesicoureteric reflux in whom renal scarring may have been prevented.
• Results: The study practices diagnosed twice as many urinary tract infections as the control practices (6.42 v 3.45/1000 children/year; ratio 1.86, 95% confidence interval 1.42 to 2.44); nearly four times more in infants (age < 1 year) and six times more in children without specific symptoms. Diagnoses were made more robustly by study practices than by control practices; 99% v 89% of referred patients had their urine cultured and 79% v 60% had bacteriologically proved urinary tract infections (P < 0.001 for both). Overall, 294 of 312 (94%) children aged under 4 years were prescribed antibiotic prophylaxis by study doctors compared with 61 of 147 (41%) by control doctors (P < 0.001). Study families visited hospital half as much as the control families. Twice as many renal scars were identified in patients attending the study practices. Twelve study infants but no control infants had reflux without scarring.
• Conclusion: A nurse led intervention improved the management of urinary tract infections in children, was valued by doctors and parents, and may have prevented some renal scarring.
  
  
• Editorial Comment
  Despite advances in medical knowledge, many primary care physicians fail to diagnose urinary tract infections in children promptly. The authors studied whether a nurse assigned specifically to educate primary care physicians on the indications for urine tests and on whom to evaluate potential infections could effect a change in clinical practice among primary care physicians.
  Indeed, compared to control primary care practices, those educated by the nurse diagnosed twice as many urinary tract infections (and 4 times more in infants). The diagnosis was made using cultures more often and similarly antibiotic prophylaxis was more frequently used. Interestingly, more renal scars were identified in the children treated by the primary care physicians who had been educated. The authors conclude that the management of urinary tract infection was improved by the nurse-led intervention.
  It is intuitively obvious that more aggressive diagnosis is beneficial. However, despite the fact that the education program clearly led to more diagnosis of infections and renal scarring, it remains to be shown that there is really a health benefit to this more aggressive program. Furthermore, costs in this group were clearly higher. It seems that longer follow-up will be needed to determine if there are truly benefits to this aggressive education program.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA