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

Introduction Why?
 To avoid a potentially unnecessary invasive test
 First article to assess this possibility
Incidence:
 Most common in the 1st month than any other time in life
Risk Factors for meningitis:
 Low birth weight, preterm births, premature rupture of membranes, septic or traumatic
deliver, fetal hypoxia, maternal peripartum infection, galactosemia, and urinary tract
abnormalities
Common pathogens for meningitis:
<1mo Strep agalactiae, E. coli, Listeria, Ampicillin+cefotaxime or ampicillin and
Klebsiella aminoglycoside
1-23mo Strep pneumonia, Neisseria Vancomycin+third generation cephalosporin
meningitides, S, agalactiae, (ceftriaxone or cefotaxime)
Haemophilus influenza, E.colie
Common pathogens for neonatal UTI:
 Community: E. coli, klebsiella, proteus, entrobacter, and citrobacter, enterococcus, Coagulase
(-) staph
 Hospital (premies): Coagulase (-) staph, klebsiella, candida
 Treatment typically includes ampicillin and gentamicin
Current Guidelines/Practice:
Definitions:
 CSFPerformed….
Methods  Retrospective cohort study
 REVISE??
 3,572 infants with positive urinalysis2,511 CSF testing
 Each site reviewed chart for eligible patients and placed into database (unknown reasons for
exclusion)
 Two age groups: [7-30 days] or [31-60 days]
 UTI: Positive leukocyte esterase, positive nitrite, or >5WBC per high-power field
 Inflammatory markers: More than one of
Inclusion Exclusion
 Well child 7-60 days old with fever of unknown  “toxic” “ill-appearing”, “lethargic” “sick-
origin ≥38◦C appearing”
 Comorbidities pron to recurrent bacterial
 Only included sites with more than 10 UTI (+) illness(genetic, congenital, chromosomal,
babies in the statistics (internal validity?) neuromuscular, or neurodevellopmnet
 Bronchiolits:
 Transferred from another inpatient setting
1. Did the urine culture grow an organism that was treated as a pathogen with a full course of
antibiotics?
2. Did the CSF culture grow an organism that was treated as a pathogen with a full course of
antibiotics?
3. Did the patient return to the ED or get readmitted to the hospital for new diagnosis of bacterial
meningitis with 7 days of the date of treat and release or hospital discharge?
Statistics  Inclusion: all who had a urinalysis performed before admission or discharge
 Mixed-effects logistics regression to determine factors associated with CSF testing
o Appropriate for binary outcome variables (nomial data) to determine correlations
between variables
 X2 test used for nominal data
 Account for confounding variables such as location by adjusting for clustering
  ZERO cases of delayed meningitis
Results  Had (+) UTI and CSF testing vs (-) UTI and NO CSF testing: 70% vs 58.1%; P<0.001
 No difference detected in % of people receiving treatment: 0.7% vs 0.9%; P=0.37
 Babies 7-30 days old with (+) UTI were more likely to be CSF tested than those older
o [aOR]: 4.6; 95% CI: 3.8-5.5 and had inflammatory markers [aOR]: 2.2; 95% CI 1.2-2.6
 CSF occurred more frequently in larger hospitals
 CSF less likely to be done in the Midwest
 Sex, university affiliation, and urban setting were not associated with CSF testing
 P. 5 for site specific intraclass correlations (It describes how strongly units in the same group
resemble each other, closet to 1 is best)
 NO delayed meningitis in either group
Author’s May not be necessary to test infant’s CSF 31-60 days old with positive urinalysis
Conclusions
Critique Weaknesses:
points  Retrospective
 Rely on charting
 Can manipulate variables for direct causality
 Population relies on investigator bias for inclusion (potentially)
 No information on antimicrobial therapy, possibly treating UTI may treat meningitis? Result in
decreased reporting of meningitis
 Not gold standard (to eliminate bias and control confounding variables
 Unsure of 10% people may have tested urine incorrectly….

Strengths:
 Large population
 Has well-defined variables and provided training for investigators gathering data as an attempt to
have objectivity in data-collection (UTI diagnosis)
 Parameters for UTI diagnosis appropriate
 Use clinician judgement per charting for diagnosis vs ICD 9 codes
 Based bacterial infection definition and days duration for delayed-onset on previous studies
Questions 1. What are complications of lumbar puncture?
a. Pain, brain herniation
2. How could we apply this study to a real clinical scenario
Real Life 2 month old with positive UTI has left the ED. Should they be instructed to return to the hospital for
admission?