Sterile Cerebrospinal Fluid Pleocytosis in Young Infants with Urinary Tract Infections

Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
The Journal of pediatrics (Impact Factor: 3.79). 08/2008; 153(2):290-2. DOI: 10.1016/j.jpeds.2008.02.044
Source: PubMed


In a multicenter prospective study, 91 of 1025 febrile infants <or=60 days of age had urinary tract infections. Among patients with urinary tract infections and without traumatic lumbar punctures, sterile cerebrospinal fluid pleocytosis was uncommon (0%-8%, depending on the definition) in contrast to earlier studies reporting this association.

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    • "Since the publication by Bergstrom et al., several other studies have investigated co-existing meningitis in children with UTI [3], [7], [11]–[19]. However, the majority are limited by the size of the study population, which in most instances comprised fewer than 200 patients with UTI who had a lumbar puncture [4], [14], [17], [19], or even less than 100 patients [6], [13], [15], [16], [18]. This is a significant limitation, in the light of more recent data suggesting that co-existing meningitis is uncommon in patients with UTI. "
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    ABSTRACT: The primary aim of this study was to determine age-stratified rates of co-existing bacterial meningitis in children with urinary tract infection (UTI). The secondary aims of this study were to determine the causative pathogens of UTI, and the clinical features and outcome of children with co-existing meningitis. Analysis of data collected over a nine-year period at a tertiary pediatric hospital in Australia. Study population: children below 16 years of age with culture-confirmed UTI and a paired CSF sample. A total of 748 episodes in 735 cases were included in the final analysis. The commonest pathogens causing UTI were Escherichia coli (67.4%), Enterococcus faecalis (8.4%), Klebsiella oxytoca (3.5%) and Klebsiella pneumoniae (3.5%). Only two (1.2%; 95% CI: 0.15-4.36%) of 163 neonates (between 0 and 28 days of age) with UTI had co-existing meningitis. Both presented with pyrexia, irritability and lethargy, and recovered uneventfully with antibiotic treatment. There were no cases of co-existing meningitis among 499 infants (between 29 days and 12 months of age) with UTI (95% CI: 0.00-0.74%), or any of the 86 children aged 12 months or over (95% CI: 0.00-4.20%). These findings indicate that clinicians should have a low threshold to perform a lumbar puncture in neonates with UTI, as the risk of co-existing meningitis is not insignificant in this age group. In contrast, beyond the neonatal period, the risk is small and a more selective approach is warranted.
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    ABSTRACT: The goal was to examine the feasibility of outpatient management for 1- to 3-month-old infants with febrile urinary tract infections. A cohort study was performed with all children 30 to 90 days of age who were evaluated for presumed febrile urinary tract infections in the emergency department of a tertiary-care pediatric hospital between January 1, 2005, and September 30, 2007. Patients were treated with intravenously administered antibiotics as outpatients in a day treatment center unless they met exclusion criteria, in which case they were hospitalized. Of 118 infants included in the study, 67 (56.8%) were admitted to the day treatment center and 51 (43.2%) were hospitalized. The median age of day treatment center patients was 66 days (range: 33-85 days). The diagnosis of urinary tract infection was confirmed for 86.6% of patients treated in the day treatment center. Escherichia coli was identified in 84.5% of urine cultures; 98.3% of isolates were sensitive to gentamicin. Six blood cultures (10.3%) yielded positive results, 5 of them for E coli. Treatment with intravenously administered antibiotics in the day treatment center lasted a mean of 2.7 days. The mean number of visits, including appointments for voiding cystourethrography, was 2.9 visits. The rate of parental compliance with day treatment center visits was 98.3%. Intravenous access problems were seen in 8.6% of cases. Successful treatment in the day treatment center (defined as attendance at all visits, normalization of temperature within 48 hours, negative control urine and blood culture results, if cultures were performed, and absence of hospitalization from the day treatment center) was obtained for 86.2% of patients with confirmed urinary tract infections. Ambulatory treatment of infants 30 to 90 days of age with febrile urinary tract infections by using short-term, intravenous antibiotic therapy at a day treatment center is feasible.
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    ABSTRACT: Cerebrospinal fluid (CSF) white blood cell (WBC) counts for neonates and young infants are usually interpreted on the basis of values reported in reference texts or handbooks; however, current reference texts either present normal CSF parameters without citation or cite studies with significant limitations. The objective of this study was to determine accurate, age-specific reference values for CSF WBC counts in a large population of neonates and young infants. This cross-sectional study included patients who were aged < or =56 days and had a lumbar puncture performed in the emergency department from January 1, 2005, to June 30, 2007. Patients were excluded from analysis for conditions that are suspected to cause CSF pleocytosis, including traumatic lumbar puncture, serious bacterial infection, congenital infection, seizure, and presence of a ventricular shunt. Children who tested positive for enterovirus (EV) in the CSF by polymerase chain reaction were also excluded. Two-sample Wilcoxon rank-sum tests were used to compare median CSF WBC values of those who had negative EV testing with those who did not have EV testing. A total of 380 (36%) of 1064 patients met inclusion criteria; 54% were male, 15% were preterm, and 39% presented during EV season. The median CSF WBC count was significantly higher in infants who were aged < or =28 days (3/microL, 95th percentile: 19/microL) than in infants who were aged 29 to 56 days (2/microL, 95th percentile: 9/microL; P < .001). In both age groups, infants with a negative EV PCR had a higher upper bound of the 95% confidence interval of the mean values compared with infants who did not have EV testing performed. We determined age-specific CSF WBC reference values in a large cohort of neonates and young infants that can be used to interpret accurately the results of lumbar punctures in this population.
    PEDIATRICS 02/2010; 125(2):257-64. DOI:10.1542/peds.2009-1181 · 5.47 Impact Factor
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