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Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review

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Abstract

Urinary tract infections, the most common severe bacterial infections in young infants, may be associated with co-existing meningitis. There is no consensus on when to perform a lumbar puncture in these infants. Our aim was to quantify the frequency of co-existing bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infections. We systematically reviewed PubMed, EMBASE, and the Cochrane Library for studies including infants ≤ 3 months with suspected/confirmed urinary tract infections, who underwent a lumbar puncture. Two investigators independently reviewed articles for inclusion and extracted relevant data. Our outcomes were culture-confirmed meningitis and identification of low-/high-risk criteria of meningitis. Overall 20/2079 studies, including 4191 infants, met inclusion criteria. A total of 11 infants had bacterial meningitis (frequency between 0 and 2.1% across studies) and were mostly neonates. Of 253 infants meeting the low-risk criteria (well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, and C reactive protein ≤ 20 mg/L) none developed meningitis, but only 15 underwent lumbar puncture.

Conclusion: Co-existing bacterial meningitis in febrile young infants with urinary tract infection is rare. In those meeting low-risk criteria, a lumbar puncture may not be indicated. A case by case assessment should be made in infants not meeting low-risk criteria.

Trial registration: CRD42018105339

What is known:

• When caring for febrile infants ≤ 3 months with urinary tract infections, clinicians may have uncertainty on whether to perform a lumbar puncture (LP) for possible co-existing meningitis

What is new:

• An up-to-date systematic review of 20 studies found the frequency of co-existing meningitis in this population to be between 0 and 2.1%

• Despite limited data, an LP may not be indicated in infants meeting low-risk criteria (being well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, C reactive protein ≤ 20 mg/L). Ill-appearance and neonatal age appear to be significant risk factors of co-existing meningitis

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Abbreviations

CI:

Confidence interval

ED:

Emergency department

LP:

Lumbar puncture

UTI:

Urinary tract infection

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Acknowledgments

We would like to thank medical librarian Lisa Dainese, M.Ed., University of Padova (Padova, Italy), for her help in building and executing the literature search strategy.

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Authors and Affiliations

  1. Division of Emergency Medicine, Department of Women’s and Children’s Health, University of Padova, via Giustiniani, 3, 35128, Padova, Italy

    Elisa Poletto, Lorenzo Zanetto, Liviana Da Dalt & Silvia Bressan

  2. Pediatric Emergency Unit, Department of Pediatrics, Rio Hortega Universitary Hospital, Valladolid, Spain

    Roberto Velasco

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  1. Elisa Poletto
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  2. Lorenzo Zanetto
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  3. Roberto Velasco
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  4. Liviana Da Dalt
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  5. Silvia Bressan
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Contributions

Elisa Poletto and Lorenzo Zanetto designed the study protocol and built the search strategy, searched the literature and undertook selection of retrieved articles, performed data extraction and quality assessment of selected studies, drafted the initial manuscript, and reviewed and revised the manuscript.

Roberto Velasco reviewed the study protocol, contributed to drafting the manuscript, and critically reviewed and revised the manuscript for important intellectual content.

Liviana Da Dalt reviewed the study protocol, co-supervised the study conduct, and critically reviewed and revised the manuscript for important intellectual content.

Silvia Bressan conceptualized the study and designed the study protocol, supervised study selection, data extraction, and quality assessment of selected studies, drafted the initial manuscript, and reviewed and revised the manuscript.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Silvia Bressan.

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The authors declare that they have no conflict of interest.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Communicated by Nicole Ritz

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Elisa Poletto and Lorenzo Zanetto are joint first authors

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Poletto, E., Zanetto, L., Velasco, R. et al. Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review. Eur J Pediatr 178, 1577–1587 (2019). https://doi.org/10.1007/s00431-019-03442-4

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