Is It Time to Stop Classifying Febrile Infants With Positive Urinalyses as High-Risk for Meningitis?

Abstract

In this issue of Hospital Pediatrics, Young et al 1 present more evidence that a positive urinalysis result alone is not associated with a higher prevalence of bacterial meningitis in febrile infants 29 to 60 days of age. In this retrospective cohort study, 835 febrile infants underwent a full "sepsis workup," including cerebrospinal fluid (CSF) testing, and the prevalence of bacterial meningitis was equivalent among infants with a positive versus a negative urinalysis (0.9% vs 1.0%, respectively). Furthermore, the authors separately analyzed 345 febrile infants 29 to 60 days of age with a positive urinalysis who were treated with antibiotics without CSF testing. None of these infants were subsequently diagnosed with bacterial meningitis or experienced an adverse outcome within 1 month. 1To date, all of the criteria developed and commonly used for the risk stratification of febrile infants (Rochester, Philadelphia, Boston, Step-by-Step approach) include a positive urinalysis result as a parameter that classifies an infant as "not low-risk" for an invasive bacterial infection (ie, bacteremia and/or bacterial meningitis). 2-6 On 1 hand, this classification makes sense because the prevalence of bacteremia among infants with a positive urinalysis is ∼6% to 9%, 7-9 and these infants are theoretically at an increased risk for seeding the meninges leading to meningitis. However, with their data, Young et al 1 contradict this logic by showing that infants with a positive urinalysis are at no greater risk of meningitis than other febrile infants and that the urinalysis should not alter the pretest probability for meningitis in assessing the need for a lumbar puncture (LP) in this patient population. In other words, a positive urinalysis indicates that the infant likely has a febrile urinary tract infection (UTI) but does not itself inform the risk of meningitis.Authors of several studies over the past decade have similarly attempted to dispel the notion that febrile infants 29 to 60 days of age with a positive urinalysis result are at high-risk for meningitis. Combined, researchers of these investigations have reported a prevalence of meningitis of 0% to 0.3% among infants aged 29 to 60 days with UTIs. 8,10,11 Although limited to retrospective studies, the body of evidence is still sufficiently large at this point to suggest that a positive urinalysis alone should not be used in the decision of whether to obtain an LP. Although Young et al 1 explored factors associated with bacterial meningitis in this current study, only 8 infants had bacterial meningitis thereby limiting the use of this exploratory analysis in clinical practice. A large multicenter investigation is needed to attain sufficient power to determine predictors of bacterial meningitis among febrile infants.

Annual Research Review: Prenatal opioid exposure – a two‐generation approach to conceptualizing neurodevelopmental outcomes

“…False positives can result in neonates unnecessarily receiving pharmacological treatment (usually morphine) with corresponding prolonged hospitalization, possible separation from caregivers, and substantial cost, or false negatives, including unnecessary treatment that could lead to serious medical problems. Moreover, the landscape of NOWS is changing with the increased use of nonpharmacological treatment, despite recommendations since the 1970s that nonpharmacological care be used as the first‐line therapy for NOWS, which could potentially reducing pharmacological treatment (Berkwitt et al., 2018; Grossman et al., 2018).…”

Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results

“…Given the changing epidemiology of SBIs 17 and risks that decrease with infant age, 2,18 the necessity of LP for infants older than 28 days with a presumptive UTI has been questioned for decades. 19,20 Previous studies 21,22 suggest that a presumptive UTI is not associated with an increased risk of bacterial meningitis among well-appearing infants older than 28 days and that urinalysis results should not alter decisions regarding CSF testing. However, given the low overall prevalence of bacterial meningitis in this age group (approximately 0.4%), 18 no single study has been powered to determine the true risk of meningitis among well infants with a positive urinalysis result.…”

“…Given the changing epidemiology of SBIs and risks that decrease with infant age, the necessity of LP for infants older than 28 days with a presumptive UTI has been questioned for decades . Previous studies suggest that a presumptive UTI is not associated with an increased risk of bacterial meningitis among well-appearing infants older than 28 days and that urinalysis results should not alter decisions regarding CSF testing.…”

National Survey on the Emergency Department Management of Febrile Infants 29 to 60 Days Old With an Abnormal Urinalysis

“…Historically, all previously published guidelines and risk-stratification criteria for febrile infants include an abnormal urinalysis as a high-risk feature for bacterial infection, prompting further invasive testing, including lumbar puncture (LP), to rule out concomitant bacterial meningitis. [3][4][5][6][7][8] The need to perform an LP based on urinalysis results among infants in the second month of life has been questioned for decades, [9][10][11] leading to substantial variation in practice. 12,13 Evidence published over the last several years suggests that infants aged 29 to 60 days with an abnormal urinalysis are not at higher risk of bacterial meningitis compared with those with a normal urinalysis.…”