and GBS remain the most common causes of bacterial meningitis in the first 90 days of life. For empirical therapy of suspected bacterial meningitis, one should consider a third-generation cephalosporin (plus ampicillin for at least the first month), potentially substituting a carbapenem for the cephalosporin if there is evidence for Gram-negative meningitis.

Background There are variations in recommendations from different guidelines regarding the indications for repeat lumbar puncture (LP) in young infants with the diagnosis of bacterial meningitis. Objective To evaluate the frequency of repeat LPs and the characteristics of cerebrospinal fluid (CSF) parameters in repeated sampling and their predictive values for adverse outcomes in a national cohort. Methods This cohort study included infants born January 1, 2013 through December 31, 2014, who had proven or suspected bacterial meningitis within the first 90 days of life at seven paediatric tertiary care hospitals across Canada, and who underwent a repeat LP at the discretion of the treating physicians. Results Forty-nine of 111 infants (44%) underwent repeat LP at a median of 5 (IQR: 3, 13) days after the LP that led to the diagnosis of bacterial meningitis. Those who had meningitis caused by gram negative bacilli were more likely to have repeat LP than those with gram positive bacteria (77% versus 57%; p = 0.012). White blood cell (WBC) count on the second spinal tap yielded an area under the curve of 0.88 for predicting sequelae of meningitis at discharge from the hospital, with a cut-off value of 366 × 10 6 /L, providing a sensitivity of 91% and specificity of 88%. Conclusion In this multi-centre retrospective cohort study, infants with gram negative meningitis were more likely to have repeated LP. A high WBC on the second CSF sample was predictive of adverse outcome at the time of discharge from the hospital.

Background: The relative contribution of viruses to central nervous system (CNS) infections in young infants is not clear. For viral CNS infections, there are limited data on features that suggest HSV etiology or on predictors of unfavorable outcome. Methods: In this cross-sectional retrospective study, seven centers from the Pediatric Investigators Collaborative Network on Infections in Canada identified infants < 90 days of age with CNS infection proven to be due to enterovirus (EV) or herpes simplex virus (HSV) January 1, 2013 through December 31, 2014. Results: Of 174 CNS infections with a proven etiology, EV accounted for 103 (59%) and HSV for 7 (4%). All HSV cases and 41 (40%) EV cases presented before 21 days of age. Four HSV cases (57%) and 5 EV cases (5%) had seizures. Three (43%) HSV and 23 (23%) EV cases lacked cerebrospinal fluid (CSF) pleocytosis. HSV cases were more likely to require ICU admission (p = 0.010), present with seizures (p = 0.031) and have extra-CNS disease (p < 0.001). Unfavorable outcome occurred in 12 cases (11% of all EV and HSV infections) but was more likely following HSV than EV infection (4 (57%) versus 8 (8%); p = 0.002). Conclusions: Viruses accounted for approximately two-thirds of proven CNS infections in the first 90 days of life. Empiric therapy for HSV should be considered in suspected CNS infections in the first 21 days even in the absence of CSF pleocytosis unless CSF parameters are suggestive of bacterial meningitis. Neurodevelopmental follow-up should be considered in infants whose course of illness is complicated by seizures.

Background The relative contribution of viruses to central nervous system (CNS) infections in young infants is not clear. For viral CNS infections, there are limited data on features that suggest HSV etiology or that are predictors of unfavorable outcome. Methods In this cross-sectional study, the Pediatric Investigators Collaborative Network on Infections in Canada identified infants <90 days of age with CNS infection proven to be due to viruses. Results Of 174 proven CNS infections, viral causes accounted for 111 (64%) including enterovirus (EV) (N=103; 93%), HSV (N=7; 6%) and human parechovirus (HPeV) (N=1; 1%). All HSV cases and 45 (43%) non-HSV cases presented before 21 days of age. HSV cases were more likely to require ICU admission (p=0.010), present with seizures (p=0.031) and have extra-CNS disease (p<0.001). Three HSV cases (43%) did not have seizures while 4 (57%) HSV and 33 (32%) non-HSV cases lacked cerebrospinal fluid (CSF) pleocytosis. Conclusions Viruses account for about half of proven CNS infections in the first 90 days of life. Empiric therapy for HSV should be considered in suspected CNS infections in the first 21 days even in the absence of CSF pleocytosis unless CSF parameters are suggestive of bacterial meningitis.

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Background The relative contribution of viruses to central nervous system (CNS) infections in young infants is not clear. For viral CNS infections, there are limited data on features that suggest HSV etiology or on predictors of unfavorable outcome. Methods In this cross-sectional retrospective study, seven centers from the Pediatric Investigators Collaborative Network on Infections in Canada identified infants <90 days of age with CNS infection proven to be due to enterovirus (EV) or herpes simplex virus (HSV) January 1, 2013 through December 31, 2014. Results Of 174 CNS infections with a proven etiology, EV accounted for 103 (59%) and HSV for 7 (4%). All HSV cases and 41 (40%) EV cases presented before 21 days of age. Four HSV cases (57%) and 5 EV cases (5%) had seizures. Three (43%) HSV and 23 (23 %) EV cases lacked cerebrospinal fluid (CSF) pleocytosis. HSV cases were more likely to require ICU admission (p=0.010), present with seizures (p=0.031) and have extra-CNS disease (p<0.001). Poor long-term outcomes were more common in infants who had seizures. Conclusions Viruses accounted for approximately two-thirds of proven CNS infections in the first 90 days of life. Empiric therapy for HSV should be considered in suspected CNS infections in the first 21 days even in the absence of CSF pleocytosis unless CSF parameters are suggestive of bacterial meningitis.

BackgroundIn the pre-acyclovir era, HSV CNS infection was associated with very high morbidity and mortality. Since antiviral drugs recommended for therapy and long-term prophylaxis improve outcomes, clinicians need to be able to clinically detect young infants most likely to have HSV to facilitate early initiation of therapy. Limited data exist on outcomes of infants who require prolonged therapy and those completing prophylaxis. The objective of this study was to identify clinical and laboratory features associated with HSV CNS disease and describe outcomes following antiviral therapy and prophylaxis.MethodsInfants <90 days old with a discharge diagnosis of meningitis or encephalitis from whom a virus was identified from cerebrospinal fluid (CSF) were included. These were identified using PICNICs retrospective database of microbiologically confirmed CNS infections detected January 2013 to December 2014. Clinical features and outcomes of HSV and non-HSV infection were compared.ResultsOf the 112 cases of viral infections, HSV accounted for 8 (7%) and enterovirus for 103 (92%). Eight (100%) HSV cases and 45 (43%) non-HSV cases presented at <21 days. Four (50%) HSV cases had no pleocytosis. HSV cases were more likely to require ICU admission (P = 0.016), present with seizures (P < 0.001) and have extra-CNS disease (P < 0.001). Among infants <3 weeks of age, seizures were more likely in HSV than non-HSV cases (4 (50%) vs. 4 (8%); P = 0.013). All HSV cases received acyclovir for a median of 23 days. Two (25%) remained PCR-positive at 21 days; these were treated for 51 and 42 days, respectively, until PCR negative or death (acyclovir resistance was confirmed postmortem). Four infants received suppressive acyclovir until 6 months, one of whom developed virologically proven CNS recurrence and subsequent infantile spasms. Neurodevelopmental morbidity (4 (57%) vs. 7 (7%)) was more likely in HSV than non-HSV (P = 0.003).ConclusionHigh levels of suspicion for viral infections must be maintained for young infants presenting with seizures in the first 3 weeks of life. CSF pleocytosis may often be absent. Resistance testing should be considered if PCR remains positive beyond 21 days. CNS recurrences may still occur beyond the recommended period of prophylaxis.Disclosures All authors: No reported disclosures.