Written by Alex Chen
In this retrospective, multi-site cohort study, they found that among infants treated for UTI without CSF testing (n=505, mostly 31-60 days old), there were no cases (95% CI 0-0.6%) of delayed meningitis within 7 days of discharge.
Why does this matter?
The febrile infant has been a source of controversy for a long time. They often don’t look bad, but there is that ever looming fear of missing a serious/invasive bacterial illness (SBI/IBI). This study hopes to shed some light on whether or not patients who have a positive UA require an LP to evaluate for meningitis. A recent meta-analysis found the prevalence of meningitis among infants 29-60 days with UTI was 0.25%.
“I love doing LPs!” -said no ED doc ever
This was a retrospective cohort study which looked at 20,570 well-appearing febrile infants (7-60d old with a temperature >38C) presenting to 124 different hospitals. Out of this group, 89.4% of patients received a UA. Overall, 3,572 infants (19.4%) had a positive UA. Of those with a positive UA, 2,511 had CSF testing (70.3%). Not surprisingly, infants in the 7-30 day group were more likely to receive CSF testing (aOR 4.6). Of the 1,000 or so infants who did not receive CSF testing, approximately 70% of them received empiric antibiotics. This was further broken down into those who received treatment for the UTI and those who did not (505 vs 229). There were no cases of delayed meningitis (identified within 7d of discharge) in either of these groups. There were a total of 19 infants who developed bacteremia in the UTI treatment group (19/505).
First of all, if the above summary doesn’t make your head spin, you are a better person than I am. They don’t specifically tell you how many kids who had a positive UA had concomitant meningitis. They pull from previous data that it is around 0.8-1.2% in the first month of life and 0-0.3% in the second. Therefore, by their estimates there would be 0.78-2.4 patients who developed meningitis in the +UTI, +antibiotic group. This could easily be missed if just one or two patients presented to a different hospital or presented later than 7 days. The only thing I’m taking from this study is that people in the Midwest don’t like stabbing infants, and there is more practice variation on LPs in infants <30 days than I thought.
Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis. Pediatrics. 2019 Aug 8. pii: e20183979. doi: 10.1542/peds.2018-3979. [Epub ahead of print]
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Reviewed by Clay Smith