LAKE BUENA VISTA, FLA. – Does every baby who presents to the emergency department with a urinary tract infection need a lumbar puncture to rule out meningitis?
Maybe not, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly. Age, past medical history, and the child’s overall demeanor are the best clues as to whether to proceed with a spinal tap in babies with a confirmed source of infection.
The topic is worth reviewing because childhood meningitis cases are on the decline, said Dr. Callahan of Children’s Hospital of Pennsylvania, Philadelphia.
Michele G. Sullivan/IMNG Medical Media
Dr. James Callahan
When a disease begins to fade from a patient population, it also can fade from the collective consciousness of clinicians. "There are residents and fellows in emergency medicine and pediatrics now who have never seen a case of [Haemophilus] influenzae meningitis," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
That can mean tragedy for patients and families, and disaster for doctors. "Missed meningitis remains the number-one cause of settled lawsuits in pediatric emergency medicine, and carries the highest settlement and indemnity costs," he said.
A number of signs can help rule in the disease, but few can completely rule it out. "Although several clinical features are useful in diagnosing meningitis, no one isolated clinical feature is diagnostic. Nor can any isolated clinical feature completely exclude meningitis as a diagnostic possibility, and it’s not clear what the most accurate combination of clinical features is – or if there even is such a combination," Dr. Callahan explained.
That leaves clinicians with what seems to be the only concrete option – the lumbar puncture. "I personally think an LP is a relatively simple procedure, but there is a lot of parental resistance to it," he noted.
Dr. Callahan examined the question in light of infants’ most common bacterial infection – the urinary tract infection (UTI). Studies from the last 15 years agree that, while the risk of meningitis in conjunction with UTI is very low, it is there.
The largest of these included nearly 2,000 infants with culture-proven UTI. Most (1,609) underwent an LP. Of those patients, 3% had bacterial meningitis. A combination of clinical findings – not clinically ill on exam, no dehydration or acute respiratory distress, no concomitant acute disease or high-risk medical history – ruled out meningitis with a 98% sensitivity and 99.9% negative predictive value (Pediatrics 2010;126:1074-83).
A 2011 study found a 1% rate of meningitis associated with UTI in infants younger than 28 days, but there were no cases at all in the older babies. All of those with meningitis were symptomatic on admission, with fever, irritability, and lethargy (PLoS One 2011;6:e26576).
"Meningitis appears exceedingly rare in children older than 28 days," Dr. Callahan said. "All neonates who present with a culture-proven UTI should have an LP. But those who are older, and who look well, without a negative past history – you might consider not doing one."
Whether or not the child will be admitted to the hospital plays a part in Dr. Callahan’s decision.
"If they have a UTI and they’re getting admitted, but look well and have a negative past medical history, I don’t tap. I really think the data say if they look like they are well, they will not get meningitis."
If, on the other hand, the baby will be going home from the emergency visit, he does the procedure. "And make sure you have someone who’s going to follow that child very closely," he advised.
Dr. Callahan had no financial disclosures.