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Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A
Brett Burstein1,2, Vikram Sabhaney3,4, Jeffrey N Bone5
1Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Insights
Feverish infants aged 29-60 days with positive urinalysis results have a low prevalence of bacterial meningitis. Lumbar puncture (LP) decisions for these infants should not solely rely on urinalysis findings.
Area of Science:
- Pediatrics
- Infectious Diseases
- Evidence-Based Medicine
Background:
- Fever in young infants is common, with urinary tract infections being frequent serious bacterial infections.
- Current guidelines often recommend lumbar puncture (LP) for febrile infants with positive urinalysis to rule out meningitis.
- However, the necessity of LP in well-appearing infants older than 28 days with abnormal urinalysis is debated.
Purpose of the Study:
- To determine the prevalence of bacterial meningitis in febrile infants aged 29 to 60 days who have positive urinalysis results.
- To evaluate whether routine LP is necessary for this specific infant population based on urinalysis findings.
Main Methods:
- A systematic review and meta-analysis of studies published between 2000 and 2018, updated in 2019.
- Included studies focused on healthy, full-term, well-appearing febrile infants aged 29 to 60 days with available urinalysis and meningitis data.
- Data extraction followed PRISMA guidelines, with bias assessed using the Newcastle-Ottawa Scale; random-effect models were used for analysis.
Main Results:
- The prevalence of culture-proven bacterial meningitis was 0.44% in infants with positive urinalysis versus 0.50% in those with negative results (OR, 0.74).
- The overall prevalence of bacterial meningitis (defined by CSF or clinical follow-up) was 0.25% in infants with positive urinalysis and 0.28% in those with negative results (OR, 0.89).
- These prevalences were not statistically different between infants with positive and negative urinalysis results.
Conclusions:
- The prevalence of bacterial meningitis in well-appearing febrile infants aged 29 to 60 days with positive urinalysis is low (0.25%-0.44%) and not higher than in infants with negative urinalysis.
- These findings suggest that urinalysis results alone should not dictate the decision to perform LP in this age group.
- Rethinking diagnostic strategies for febrile infants based on these low prevalence rates is warranted.
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 Reporting Items 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 random-effect models.
Main Outcomes And Measures:
The 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.
Results:
The 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 Relevance:
In 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 results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.
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