Concomitant Bacterial Meningitis in Infants with Urinary Tract Infection: Prevalence and Age Stratification

1. Journal Club: Concomitant Bacterial Meningitis in Infants with Urinary Tract Infection Jason King, M.D PEM Fellow Usha Sethuraman MD Attending

2. Article Concomitant Bacterial Meningitis in Infants with Urinary Tract Infection Journal: Pediatric Infectious Disease 2017

3. Topic • Article set to determine age-stratified prevalence of concomitant bacterial meningitis in infants ≤ 60 days with a UTI

4. Search Strategy • Article identified through PEM database’s recent publications • Relevance to ED practice

5. Questions to answer before selecting an article • Does this study address a clearly focused question? • Yes • Did the study use valid methods to address this question? • Yes • Are the valid results of this study important? • - Yes • Are these valid, important results applicable to my patient or population? • - Yes

6. Study design • 23 center Cross sectional Retrospective study • PEM CRC HSV group study

7. Research Methodology • All infants ≤ 60 days with UTIs and who also had CSF studies were included. • Excluded: Non catheterized samples

8. Research Methodology • Data was abstracted from medical records • Presenting 1/1/2005 – 12/31/2013 • Data included: age, gender, ED triage temperature, laboratory values [complete blood count (CBC) with differential, urinalysis, CSF cell counts, CSF glucose, protein, and Gram stain, and bacterial culture results (blood, urine, CSF)

9. Primary Outcome/Definitions • Rate of concomitant bacterial meningitis in infants with UTI • UTI - >50k colony forming unites or 10k-50K with an abnormal UA • Concomitant meningitis – growth of same pathogenic organism in both urine and CSF

10. Statistics • Data not normally distributed • Hence continuous data reported as medians with IQR • Categorical with frequencies and percentages • Prevalence is reported with 95% confidence intervals for 2 age groups (<28 days and >28-60 days)

11. Results • 23,882 infants with both CSF and UC • 1,737 infants had a UTI (7.3%, 95% CI: 6.9-7.6%). • 62.7% male (median age of 30 days) • UA in infants with UTI: • positive LE, 90.9% (1438/1582) • positive nitrite, 35.9% (572/1595) • >5 WBC, 84.3% (1128/1338).

12. Results • Of the 1,737 infants with UTI, 175 had positive BC without concomitant bacterial meningitis (10.6%, 95% CI: 8.6-11.6%) • Most infants with UTI and bacteremia had growth of the same organism from blood and urine cultures (n=170/175, 97.1%). • Concomitant bacterial meningitis was present in 9 infants (0.5%, 95% CI: 0.2-1.0%)

13. Results • Concomitant meningitis • 0-28 days = 7/803 patients (0.9% 95% CI: 0.4-1.8%) • Prevalence= 1.2% (95% CI 0.15-4.36% ) • 29-60 days of age (n=2/934, 0.2%, 95% CI: 0-0.7%) • Prevalence = 0% (95% CI: 0-1.25%).

14. Characteristics of the 9 patients with concomitant meningitis

15. Limitations • No data on antibiotics prior to LP • May lead to underestimation of concomitant meningitis. • No data regarding clinical appearance of the infants • May be valuable in infants 29-60 days • No information on whether ALL kids with UTI got a LP- Selection bias

16. Article Summary • All 9 infants with meningitis/UTI also had bacteremia, • goes along with the thought of hematologic spread. • There was higher concomitant UTI/Meningitis in 0-28 days. • Similar in other studies • Only 2 cases of meningitis+UTI in > 29 days of age • Similar to previous studies

17. Critical appraisal

18. Is the study’s question relevant? • Yes • Need for LP in young infants with UT is a clinical dilemma frequently faced by ED physicians • This study aims to answer that question

19. Does the study add anything new? • There have been small previous studies looking at prevalence of concomitant UTI and meningitis • Tebruegge et al • Australia, 745 cases • 1.2% had concomittant meningits/UTI in < 28 days • None in 29-1 year of age • Concluded that physicians should have low threshold to tap <28 day old infants

20. Wallace et al • 9 years data • <28 days • 236 patients - 0.8% had probable meningitis

21. Does the study add anything new? • For < 28 days – No • Current recs include LP for this age group • For > 29 days – Perhaps • No information available regarding clinical appearance • We may not have tapped to begin with??

22. What kind of research question did the study pose? • Question about frequency of events • Occurrence of meningitis in infants with UTI

23. Was study design appropriate for the research question? • Yes • Observational studies are the most appropriate for research question on frequency of events

24. Did the Study Methods Address the Key Potential Sources of Bias? • No • Bias can be random (chance) or systematic (methodology error) • Random errors affect precision of results • Systematic errors can result in overestimation • Study did not include those children with UTI who did not get a LP and vice versa • This may have overestimated meningitis rates in those age groups

25. Statistical methodology correct? • Yes • They reported medians due to non normal distribution of continuous data • They used confidence intervals rather than p values

26. How precise are the estimates of likelihood? • The confidence intervals are narrow, so relatively precise

27. Does data justify conclusions? • Yes • Meningitis did not occur their cohort of patients >29 days of age with UTI • Meningitis still occurred in small percent of neonates < 29 days

28. Any conflict of interest? • None reported

29. Final thoughts…. • Useful study with some application in our practice • May not change practice in < 29 days old • May change practice for > 29 days old non sick appearing children with suspected UTI

30. Group Discussion • ???