Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis

Wang, Marie E.; Biondi, Eric; McCulloh, Russell J.; Garber, Matthew; Natt, Beth C.; Lucas, Brian; Schroeder, Alan R.

doi:10.1542/peds.2018-3979

Cited by 12 publications

(16 citation statements)

References 29 publications

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“…Among included data sets, meningitis status was determined by CSF testing for 12 735 infants and by CSF testing or clinical follow-up for 25 374 infants. For both the primary and secondary outcomes, the unweighted proportion of infants with bacterial meningitis was higher among infants with negative urinalysis results in 9 data sets, 14,21,22,35,53,54,58,66,70 higher among infants with positive urinalysis results in a single data set, 61 and 0 in both groups in 7 data sets. 12,56,57,62,64,67,72 The 7 data sets reporting 0 cases of meningitis in both groups did not contribute to the pooled OR, and several data sets had estimated ORs greater than 1 despite 0 events in the group with positive urinalysis results because of imbalanced sample sizes.…”

Section: Resultsmentioning

confidence: 94%

“…14,21,22,53,54,56,57,70 Nine data sets were prospectively collected, 12,14,35,58,61,64,67,70,72 and 1 study 53 used a pre/post intervention design in which only infants from the postintervention period were analyzed prospectively. Two additional data sets were retrospective analyses 22,54 of infants managed in the context of quality improvement initiatives. These 2 data sets were included among the sensitivity analysis of prospective studies because all relevant covariates were collected prospectively.…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2021

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IMPORTANCE Fever in the first months of life remains one of the most common pediatric problems.Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial.OBJECTIVE To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required.DATA SOURCES MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included.STUDY SELECTION Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included. DATA EXTRACTION AND SYNTHESIS Data were extracted in accordance with Preferred ReportingItems for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using randomeffect models. MAIN OUTCOMES AND MEASURESThe primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up. RESULTSThe parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68). CONCLUSIONS AND RELEVANCEIn this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis (continued) Key Points Question Are well-appearing febrile infants 29 to 60 days of age with positive urinalysis results at increased risk for bacterial meningitis? Findings In a systematic review and meta-analysis of 17 distinct international data sets (25 374 infants), the pooled prevalence of bacterial meningitis among infants with positive urinalysis results ranged from 0.25% (by cerebrospinal fluid [CSF] cultures or clinical definition) to 0.44% (by CS...

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Section: Resultsmentioning

confidence: 94%

Section: Resultsmentioning

confidence: 99%

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

et al. 2021

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“…Our study group believes this subset of our cohort is small and therefore does not suspect it negatively impacted our research. There is neonatal literature that examined whether positive urinalysis is indicative of UTI or if the UA is actually a tool to facilitate risk stratification of serious bacterial infections [ 22 , 23 ]. The author has not been able to discover studies evaluating this same principle or efforts towards decision rules with adults.…”

Section: Discussionmentioning

confidence: 99%

Emergency Department Urosepsis and Abdominal Imaging

Siddiqui¹,

Abuelroos²,

Qu³

et al. 2021

Cureus

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IntroductionInsufficient attention has been directed towards urosepsis. Notably, no protocols or clinical decision rules currently exist outlining the appropriate use of imaging in uroseptic patients. The primary objective of our study was to retrospectively evaluate uroseptic emergency department (ED) patients who underwent abdominal imaging, to report the proportion of patients with imaging findings necessitating emergent surgical consultation. MethodsWe retrospectively identified 1142 patients ≥ 18 years of age that presented to the ED from January 2009 to December 2012 with ICD9 code indicative of urosepsis. All included patients underwent ED-ordered abdominal computerized tomography (CT) or retroperitoneal ultrasound (US). Imaging and urinalysis (UA) results were categorized. We report proportions with odds ratios and 95% confidence intervals. ResultsOf 1142 patients, we excluded 80 for neg UA, 167 for < 2 SIRS (systemic inflammatory response syndrome), 320 for positive blood cultures, and 37 for incomplete data. This yielded 538 patients which the authors reviewed the results of the CT or US to determine the proportion who required emergent surgical consultation and who underwent surgical or interventional procedure. There were 243 (45%) that had CT or US results that necessitated emergency surgical consultation, of those 180 (33%) underwent surgical or interventional procedure. Similar rates of emergency surgical consultation occurred when sub-divided by positive versus equivocal UA, with 43% and 47%, respectively. ConclusionsForty-five percent of our abdominally imaged urosepsis cohort had imaging findings that necessitated emergent surgical consultation, with a similar proportion in the subset with positive versus equivocal UA. The utility of abdominal imaging in this population should be studied prospectively.

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“…50 A multicenter study of well-appearing febrile infants aged 7-60 days found 0/505 cases (95% CI: 0%-0.6%) of delayed meningitis within 7 days of discharge; 407 (81%) were aged 31-60 days. 51 In summary, studies have shown a low rate of concomitant meningitis and a low risk of delayed meningitis in infants aged 1-2 months treated for UTI without CSF testing. Given this, clinically targeted (eg, based on ill appearance and/or lethargy), rather than routine, CSF testing in this age group can be considered.…”

Section: Positive Urinalysis and Testing For Meningitismentioning

confidence: 93%

“…A northern California study that examined 345 episodes among 341 UA‐positive infants aged 29‐60 days found zero cases (95% CI: 0%‐1.1%) of delayed meningitis within 30 days of evaluation 50 . A multicenter study of well‐appearing febrile infants aged 7‐60 days found 0/505 cases (95% CI: 0%‐0.6%) of delayed meningitis within 7 days of discharge; 407 (81%) were aged 31‐60 days 51 . In summary, studies have shown a low rate of concomitant meningitis and a low risk of delayed meningitis in infants aged 1‐2 months treated for UTI without CSF testing.…”

Section: Special Considerationsmentioning

confidence: 99%

Diagnosis and Management of UTI in Febrile Infants Age 0–2 Months: Applicability of the AAP Guideline

Chang

Wang

Schroeder

2020

Journal of Hospital Medicine

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U rinary tract infections (UTIs) are the most common bacterial infection and one of the most common reasons for hospitalization in young infants. 1,2 The American Academy of Pediatrics (AAP) has published several clinical practice guidelines for the evaluation and management of febrile children ages 2-24 months with first-time UTIs, most recently in 2011 and affirmed in 2016. 3 These guidelines do not provide recommendations for infants aged <2 months, which leads to uncertainty regarding the diagnosis and management of UTIs for infants in this age group. We assess the applicability of the AAP UTI Guideline's action statements for infants aged <2 months presenting with first-time UTIs, with an emphasis on recent evidence. Because the considerations for bacterial infections differ for febrile infants aged <2 months compared with older infants, we do not discuss action statements one and two (determination of the likelihood of UTIs and decision to test urine) and statement seven (medical evaluation for fever after first UTI). 3 Additionally, because concomitant bacteremia and meningitis are more common in this age group than in older infants, we review some of the controversies surrounding the diagnosis and treatment of these disease entities. DIAGNOSIS"Action Statement 3: To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection (pyuria and/or bacteriuria) and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA." 3 To distinguish asymptomatic bacteriuria or contamination from a true UTI, the AAP Guideline requires both a positive urinalysis (UA) and culture for a diagnosis of a UTI. 3 Historically, the UA was considered to be poorly sensitive for infections in young infants, with older studies reporting sensitivities ranging from 40% to 82% using urine culture as the gold standard. 4-7 Thus, infants aged <2 months with positive urine cultures and negative UAs are often treated as having true UTIs, though this practice varies by institution. 8 Possible explanations for the low UA sensitivity in this population include rapid bladder emptying, immature immune systems, and inability to concentrate urine. However, a negative UA plus a positive urine culture could also represent a "true negative" UA and a "false positive" culture, a finding that may be more common in young infants in whom sterile urine obtainment is often challenging.Two recent studies have addressed this issue by evaluating the UA sensitivity in patients with bacteremic UTIs, as growth of the same pathogenic organism from the blood and urine almost certainly represents true infection. 9,10 In a retrospective study of 203 infants aged <3 months with bacteremic UTIs, the presence of any leukocyte esterase (LE) or pyuria (>3 white blood cells per high-powered field [WBC/HPF]) had a sensitivity of 99.5% (95% CI: 98.5%-100%) and specificity of 93.9% (95% CI: 87.8%-93.2%). 9 In a prospective, multicenter stu...

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Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis

Cited by 12 publications

References 29 publications

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

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

Emergency Department Urosepsis and Abdominal Imaging

Diagnosis and Management of UTI in Febrile Infants Age 0–2 Months: Applicability of the AAP Guideline

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