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
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Urinary tract infection
Watt K, Waddle E, Jhaveri R (2010) Changing epidemiology of serious bacterial infections in febrile infants without localizing signs. PLoS One 5(8):e12448. https://doi.org/10.1371/journal.pone.0012448
Byington CL, Rittichier KK, Bassett KE, Castillo H, Glasgow TS, Daly J, Pavia AT (2003) Serious bacterial infections in febrile infants younger than 90 days of age: the importance of ampicillin-resistant pathogens. Pediatrics 111(5 Pt 1):964–968
Bressan S, Andreola B, Cattelan F, Zangardi T, Perilongo G, Da Dalt L (2010) Predicting severe bacterial infections in well-appearing febrile neonates: laboratory markers accuracy and duration of fever. Pediatr Infect Dis J 29(3):227–232. https://doi.org/10.1097/INF.0b013e3181b9a086
Olaciregui I, Hernández U, Muñoz JA, Emparanza JI, Landa JJ (2009) Markers that predict serious bacterial infection in infants under 3 months of age presenting with fever of unknown origin. Arch Dis Child 94(7):501–505. https://doi.org/10.1136/adc.2008.146530
Tzimenatos L, Mahajan P, Dayan PS, Vitale M, Linakis JG, Blumberg S, Borgialli D, Ruddy RM, Van Buren J, Ramilo O, Kuppermann N, (PECARN) PECARN (2018) Accuracy of the urinalysis for urinary tract infections in febrile infants 60 days and younger. Pediatrics 141(2):e20173068. https://doi.org/10.1542/peds.2017-3068
Velasco R, Benito H, Mozun R, Trujillo JE, Merino PA, de la Torre M, Gomez B, Network GSFIR-S (2015) Using a urine dipstick to identify a positive urine culture in young febrile infants is as effective as in older patients. Acta Paediatr 104(1):e39–e44. https://doi.org/10.1111/apa.12789
Roberts KB, Subcommittee on Urinary Tract Infection SeCoQIaM (2011) Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 128(3):595–610. https://doi.org/10.1542/peds.2011-1330
Tebruegge M, Pantazidou A, Clifford V, Gonis G, Ritz N, Connell T, Curtis N (2011) The age-related risk of co-existing meningitis in children with urinary tract infection. PLoS One 6(11):e26576. https://doi.org/10.1371/journal.pone.0026576
Schnadower D, Kuppermann N, Macias CG, Freedman SB, Baskin MN, Ishimine P, Scribner C, Okada P, Beach H, Bulloch B, Agrawal D, Saunders M, Sutherland DM, Blackstone MM, Sarnaik A, McManemy J, Brent A, Bennett J, Plymale JM, Solari P, Mann DJ, Dayan PS, Committee AAoPPEMCR (2010) Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics 126(6):1074–1083. https://doi.org/10.1542/peds.2010-0479
Thomson J, Cruz AT, Nigrovic LE, Freedman SB, Garro AC, Ishimine PT, Kulik DM, Uspal NG, Grether-Jones KL, Miller AS, Schnadower D, Shah SS, Aronson PL, Balamuth F, Group PEMCRCPCHS (2017) Concomitant bacterial meningitis in infants with urinary tract infection. Pediatr Infect Dis J 36(9):908–910. https://doi.org/10.1097/INF.0000000000001626
Tebruegge M, Pantazidou A, Curtis N (2011) Question 1. How common is co-existing meningitis in infants with urinary tract infection? Arch Dis Child 96(6):602–606. https://doi.org/10.1136/adc.2011.215277
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097
Lin DS, Huang SH, Lin CC, Tung YC, Huang TT, Chiu NC, Koa HA, Hung HY, Hsu CH, Hsieh WS, Yang DI, Huang FY (2000) Urinary tract infection in febrile infants younger than eight weeks of age. Pediatrics 105(2):E20
Shah SS, Zorc JJ, Levine DA, Platt SL, Kuppermann N (2008) Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. J Pediatr 153(2):290–292. https://doi.org/10.1016/j.jpeds.2008.02.044
Bonsu BK, Harper MB (2007) Leukocyte counts in urine reflect the risk of concomitant sepsis in bacteriuric infants: a retrospective cohort study. BMC Pediatr 7:24. https://doi.org/10.1186/1471-2431-7-24
Dayan PS, Hanson E, Bennett JE, Langsam D, Miller SZ (2004) Clinical course of urinary tract infections in infants younger than 60 days of age. Pediatr Emerg Care 20(2):85–88
Doby EH, Stockmann C, Korgenski EK, Blaschke AJ, Byington CL (2013) Cerebrospinal fluid pleocytosis in febrile infants 1-90 days with urinary tract infection. Pediatr Infect Dis J 32(9):1024–1026. https://doi.org/10.1097/INF.0b013e31829063cd
Meehan WP, Bachur RG (2008) Predictors of cerebrospinal fluid pleocytosis in febrile infants aged 0 to 90 days. Pediatr Emerg Care 24(5):287–293. https://doi.org/10.1097/PEC.0b013e31816ecbb0
Nosrati A, Ben Tov A, Reif S (2014) Diagnostic markers of serious bacterial infections in febrile infants younger than 90 days old. Pediatr Int 56(1):47–52. https://doi.org/10.1111/ped.12191
Paquette K, Cheng MP, McGillivray D, Lam C, Quach C (2011) Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis? Pediatr Emerg Care 27(11):1057–1061. https://doi.org/10.1097/PEC.0b013e318235ea18
Syrogiannopoulos GA, Grivea IN, Anastassiou ED, Triga MG, Dimitracopoulos GO, Beratis NG (2001) Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infection. Pediatr Infect Dis J 20(10):927–930
Velasco R, Benito H, Mozún R, Trujillo JE, Merino PA, Mintegi S, Tiago S, Network GftSoFIotR-S (2015) Febrile young infants with altered urinalysis at low risk for invasive bacterial infection. A Spanish Pediatric Emergency Research Network's Study. Pediatr Infect Dis J 34(1):17–21. https://doi.org/10.1097/INF.0000000000000482
Velasco R, Gómez B, Hernández-Bou S, Olaciregui I, de la Torre M, González A, Rivas A, Durán I, Rubio A (2016) Validation of a predictive model for identifying febrile young infants with altered urinalysis at low risk of invasive bacterial infection. Eur J Clin Microbiol Infect Dis 36(2):281–284. https://doi.org/10.1007/s10096-016-2798-2
Vuillermin PJ, Starr M (2007) Investigation of the rate of meningitis in association with urinary tract infection in infants 90 days of age or younger. Emerg Med Australas 19(5):464–469. https://doi.org/10.1111/j.1742-6723.2007.01001.x
Yam AO, Andresen D, Kesson AM, Isaacs D (2009) Incidence of sterile cerebrospinal fluid pleocytosis in infants with urinary tract infection. J Paediatr Child Health 45(6):364–367. https://doi.org/10.1111/j.1440-1754.2009.01502.x
Adler-Shohet FC, Cheung MM, Hill M, Lieberman JM (2003) Aseptic meningitis in infants younger than six months of age hospitalized with urinary tract infections. Pediatr Infect Dis J 22(12):1039–1042. https://doi.org/10.1097/01.inf.0000100576.99266.07
Bonadio W, Maida G (2014) Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation. Pediatr Infect Dis J 33(4):342–344. https://doi.org/10.1097/inf.0000000000000110
Wallace SS, Brown DN, Cruz AT (2017) Prevalence of concomitant acute bacterial meningitis in neonates with febrile urinary tract infection: a retrospective cross-sectional study. J Pediatr 184:199–203. https://doi.org/10.1016/j.jpeds.2017.01.022
Magín EC, García-García JJ, Sert SZ, Giralt AG, Cubells CL (2007) Efficacy of short-term intravenous antibiotic in neonates with urinary tract infection. Pediatr Emerg Care 23(2):83–86. https://doi.org/10.1097/PEC.0b013e3180302c47
Goldman RD, Matlow A, Linett L, Scolnik D (2003) What is the risk of bacterial meningitis in infants who present to the emergency department with fever and pyuria? CJEM 5(6):394–399
Mintegi S, Gomez B, Carro A, Diaz H, Benito J (2018) Invasive bacterial infections in young afebrile infants with a history of fever. Arch Dis Child 103(7):665–669. https://doi.org/10.1136/archdischild-2017-313578
Davis T (2013) NICE guideline: feverish illness in children--assessment and initial management in children younger than 5 years. Arch Dis Child Educ Pract Ed 98(6):232–235. https://doi.org/10.1136/archdischild-2013-304792
Biondi EA, Lee B, Ralston SL, Winikor JM, Lynn JF, Dixon A, McCulloh R (2019) Prevalence of bacteremia and bacterial meningitis in febrile neonates and infants in the second month of life: a systematic review and meta-analysis. JAMA Netw Open 2(3):e190874. https://doi.org/10.1001/jamanetworkopen.2019.0874
Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Dagan R, Powell KR (1994) Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 94(3):390–396
Greenhow TL, Hung YY, Herz AM (2012) Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics 129(3):e590–e596. https://doi.org/10.1542/peds.2011-1546
Lacour AG, Zamora SA, Gervaix A (2008) A score identifying serious bacterial infections in children with fever without source. Pediatr Infect Dis J 27(7):654–656. https://doi.org/10.1097/INF.0b013e318168d2b4
Mintegi S, Bressan S, Gomez B, Da Dalt L, Blázquez D, Olaciregui I, de la Torre M, Palacios M, Berlese P, Benito J (2014) Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. Emerg Med J 31(e1):e19–e24. https://doi.org/10.1136/emermed-2013-202449
Tosif S, Baker A, Oakley E, Donath S, Babl FE (2012) Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. J Paediatr Child Health 48(8):659–664. https://doi.org/10.1111/j.1440-1754.2012.02449.x
Glissmeyer EW, Korgenski EK, Wilkes J, Schunk JE, Sheng X, Blaschke AJ, Byington CL (2014) Dipstick screening for urinary tract infection in febrile infants. Pediatrics 133(5):e1121–e1127. https://doi.org/10.1542/peds.2013-3291
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.
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Elisa Poletto and Lorenzo Zanetto are joint first authors
Communicated by Nicole Ritz
Electronic supplementary material
About this article
Cite this article
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
- Emergency department
- Urinary tract infection
- Lumbar puncture