Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis

Nugent, James T; Childers, Molly; Singh-Miller, Nicholas E.; Howard, Robin S.; Allard, Rhonda J.; Eberly, Matthew D.

doi:10.1016/j.jpeds.2019.04.053

Cited by 24 publications

(24 citation statements)

References 53 publications

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“…The parents were instructed to review the table comparing the risks and benefits of LP versus no LP (Figure 3B). For infants with likely UTIs, the risk of bacterial meningitis was estimated as 0.4%, which is the upper limit of the 95% confidence interval (CI) for the prevalence of meningitis among infants with UTIs or positive urinalyses in a recent meta‐analysis 45 . For low‐risk infants, the risk of bacterial meningitis was estimated as 0.1%, which was the upper limit of the 95% CI for the prevalence of meningitis among low‐risk infants, combined from studies of prediction models that do not include cerebrospinal fluid testing for infants 29 to 60 days of age 3,8,11 .…”

Section: Resultsmentioning

confidence: 99%

“…Fourth, the translation of the English language version of e‐Care to Spanish was done by a bilingual, native Spanish speaker but not a certified interpreter. Fifth, the risk estimates for bacterial meningitis were calculated using the upper limit of the 95% CI for infants with UTIs or positive urinalysis based on a recent meta‐analysis, 45 and for low‐risk infants based on the upper limit of the 95% CI combined from studies of prediction models that do not include cerebrospinal fluid testing for infants 29 to 60 days of age 3,8,11 . While these risk estimates were based on the best available evidence, actual risks may be different.…”

Section: Limitationsmentioning

confidence: 99%

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Development of an App to Facilitate Communication and Shared Decision‐making With Parents of Febrile Infants ≤ 60 Days Old

Aronson

Politi

Schaeffer³

et al. 2020

Academic Emergency Medicine

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Objectives We aimed to develop and test a tool to engage parents of febrile infants ≤ 60 days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision‐making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60 days of age. Methods We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a “storyboard” of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e‐Care; and 4) usability testing of e‐Care, using qualitative assessment and the system usability scale (SUS). Results We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web‐based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e‐Care for infants ≤ 28 days and 29 to 60 days of age, in both English and Spanish. The e‐Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60 days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e‐Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval = 84 to 96.6), representing “excellent” usability. Conclusions The e‐Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants ≤ 60 days of age in the ED.

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Section: Resultsmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 99%

Development of an App to Facilitate Communication and Shared Decision‐making With Parents of Febrile Infants ≤ 60 Days Old

Aronson

Politi

Schaeffer³

et al. 2020

Academic Emergency Medicine

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“…While their presentations can be similar and prior studies have analyzed them as a group, the prognosis and the consequences of misdiagnosis for each are substantially different, particularly for bacteremia and bacterial meningitis. (8, [23][24][25][26][27] Recent investigators have also attempted to separate UTI from bacteremia and bacterial meningitis, using the term invasive bacterial infection for the latter. (4,(11)(12)(13)(14) In this study, developing disease speci c models allowed for a better understanding of how each rule performed across the spectrum of disease, from the low risk and low costs of UTI to the high risk and high costs of bacterial meningitis.…”

Section: Discussionmentioning

confidence: 99%

Title of Manuscript: Risk-Stratification in Febrile Infants 29 to 60 Days Old: A Cost-Effectiveness Analysis

Noorbakhsh

Ramgopal

Rixe

et al. 2021

Preprint

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Background: Multiple clinical prediction rules have been published to risk-stratify febrile infants ≤60 days of age for serious bacterial infections (SBI), which is present in 8-13% of infants. We evaluate the cost-effectiveness of strategies to identify infants with SBI in the emergency department.Methods: We developed a Markov decision model to estimate outcomes in well-appearing, febrile term infants, using the following strategies: Boston, Rochester, Philadelphia, Modified Philadelphia, Pediatric Emergency Care Applied Research Network (PECARN), Step-by-Step, Aronson, and clinical suspicion. Infants were categorized as low risk or not low risk using each strategy. Simulated cohorts were followed for one year from a healthcare perspective. Our primary model focused on bacteremia, with secondary models for urinary tract infection and bacterial meningitis. One-way, structural, and probabilistic sensitivity analyses were performed. The main outcomes were SBI correctly diagnosed and incremental cost per quality-adjusted life-year (QALY) gained.Results: In the bacteremia model, the PECARN strategy was the least expensive strategy ($3,671, 0.779 QALYs). The Boston strategy was the most cost-effective strategy and cost $9,799/QALY gained. All other strategies were less effective and more costly. Despite low initial costs, clinical suspicion was among the most expensive and least effective strategies. Results were sensitive to the specificity of selected strategies. In probabilistic sensitivity analyses, the Boston strategy was most likely to be favored at a willingness-to-pay threshold of $100,000/QALY. In the urinary tract infection model, PECARN was preferred compared to other strategies and the Boston strategy was preferred in the bacterial meningitis model.Conclusions: The Boston clinical prediction rule offers an economically reasonable strategy compared to alternatives for identification of SBI.

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“…39,[46][47][48] A meta-analysis of 20 studies reporting rates of concomitant meningitis with UTI in infants aged 29-90 days found a pooled prevalence of 0.25% (95% CI: 0.09%-0.70%). 49 Furthermore, a study of febrile infants ages 29-60 days found that the prevalence of meningitis did not differ between those with a positive vs negative UA (3/337 [0.9%] vs 5/498 [1.0%], respectively), suggesting that a positive UA alone should not modify the pretest probability of meningitis in this age group. 50 Two studies have also examined the risk of delayed meningitis among infants ≤60 days old treated for UTIs without CSF testing.…”

Section: Positive Urinalysis and Testing For Meningitismentioning

confidence: 96%

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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Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis

Cited by 24 publications

References 53 publications

Development of an App to Facilitate Communication and Shared Decision‐making With Parents of Febrile Infants ≤ 60 Days Old

Development of an App to Facilitate Communication and Shared Decision‐making With Parents of Febrile Infants ≤ 60 Days Old

Title of Manuscript: Risk-Stratification in Febrile Infants 29 to 60 Days Old: A Cost-Effectiveness Analysis

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

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