The Prevalence of Bacterial Meningitis in Febrile Infants 29-60 Days With Positive Urinalysis.

OBJECTIVES: This study evaluates whether bacterial meningitis prevalence differs by urinalysis result and whether antibiotic treatment of presumed urinary tract infection without cerebrospinal fluid (CSF) culture produces adverse sequelae in febrile infants 29 to 60 days old. METHODS: This retrospective cohort study identified febrile infants 29 to 60 days old presenting to Kaiser Permanente Northern California sites from 2007 to 2015 who underwent urinalysis and blood, urine, and CSF cultures, comparing the prevalence of meningitis among infants with positive versus negative urinalysis results using a two 1-sided test for equivalence. Additionally, febrile infants treated with antibiotics for positive urinalysis results without CSF culture were identified and their charts were reviewed for adverse sequelae. RESULTS: Full evaluation was performed in 833 febrile infants (835 episodes). Three of 337 infants with positive urinalysis (0.9%; 95% confidence interval [CI]: 0.0%-1.9%) and 5 of 498 infants with negative urinalysis (1%; 95% CI: 0.1%-1.9%) had meningitis. These proportions were statistically equivalent within 1%, using two 1-sided test with a P value of .04. There were 341 febrile infants (345 episodes) with positive urinalysis treated with antibiotics without lumbar puncture. Zero cases of missed bacterial meningitis were identified (95% CI: 0%-1.1%). Zero cases of severe sequelae (sepsis, seizure, neurologic deficit, intubation, PICU admission, death) were identified (95% CI: 0%-1.1%). CONCLUSIONS: The prevalence of bacterial meningitis does not differ by urinalysis in febrile infants 29 to 60 days old. Antibiotic treatment of infants with positive results for urinalysis without lumbar puncture may be safe in selected cases.

High creatinine clearance in critically ill patients with community-acquired acute infectious meningitis.

BACKGROUND: A high dose of anti-infective agents is recommended when treating infectious meningitis. High creatinine clearance (CrCl) may affect the pharmacokinetic / pharmacodynamic relationships of anti-infective drugs eliminated by the kidneys. We recorded the incidence of high CrCl in intensive care unit (ICU) patients admitted with meningitis and assessed the diagnostic accuracy of two common methods used to identify high CrCl. METHODS: Observational study performed in consecutive patients admitted with community-acquired acute infectious meningitis (defined by >7 white blood cells/mm3 in cerebral spinal fluid) between January 2006 and December 2009 to one medical ICU. During the first 7 days following ICU admission, CrCl was measured from 24-hr urine samples (24-hr-UV/P creatinine) and estimated according to Cockcroft-Gault formula and the simplified Modification of Diet in Renal Disease (MDRD) equation. High CrCl was defined as CrCl >140 ml/min/1.73 m2 by 24-hr-UV/P creatinine. Diagnostic accuracy was performed with ROC curves analysis. RESULTS: Thirty two patients were included. High CrCl was present in 8 patients (25%) on ICU admission and in 15 patients (47%) during the first 7 ICU days for a median duration of 3 (1-4) days. For the Cockcroft-Gault formula, the best threshold to predict high CrCl was 101 ml/min/1.73 m2 (sensitivity: 0.96, specificity: 0.75, AUC = 0.90 ± 0.03) with a negative likelihood ratio of 0.06. For the simplified MDRD equation, the best threshold to predict high CrCl was 108 ml/min/1.73 m2 (sensitivity: 0.91, specificity: 0.80, AUC = 0.88 ± 0.03) with a negative likelihood ratio of 0.11. There was no difference between the estimated methods in the diagnostic accuracy of identifying high CrCl (p = 0.30). CONCLUSIONS: High CrCl is frequently observed in ICU patients admitted with community-acquired acute infectious meningitis. The estimated methods of CrCl could be used as a screening tool to identify high CrCl.

CSF levels of carnitine in children with meningitis, neurologic disorders, acute gastroenteritis, and seizure.

Carnitine concentrations in CSF, serum, and urine in normal febrile children and children with meningitis, neurologic disorders, and dehydration were studied. Carnitine levels in CSF were 1/10 compared with serum in normal febrile children. These levels increased two- to three-fold in the pathologic conditions studied. Since damage to the blood-brain barrier occurs in these conditions, higher blood-brain barrier permeability might explain CNS carnitine accumulation.

Utilidad de la tira reactiva de orina en el diagnóstico de meningitis bacteriana aguda / Utility of urine strip in the diagnosis of acute bacterial meningitis

La meningitis bacteriana aguda (MBA) es un cuadro grave de alto porcentaje de secuelas y alta letalidad, por lo que el laboratorio clínico tiene un papel fundamental en el diagnóstico precoz. Dado que es de gran utilidad disponer de métodos sencillos se evaluó la utilidad de la tira reactiva de orina Combur 10R (para los parámetros de glucosa, proteínas y leucocitos) y del resto de los exámenes de laboratorio en muestras de LCR en la obtención de un diagnóstico rápido de MBA. Para esto se estudiaron 87 muestras de LCR que ingresaron al Laboratorio de Urgencia del Hospital Clínico de la Pontificia Universidad Católica de Chile proveniente de pacientes con sospecha clínica de MBA. A estos se les realizó estudio citoquímico, recuento celular, tinción de Gram, test de aglutinación por látex y la tira reactiva de orina Combur 10MR, evaluando visualmente los parámetros de glucosa, proteínas y leucocitos. De los 87 LCR analizados, en 13 el diagnóstico definitivo fue MBA, en 2 meningitis viral y en 72 otros. La sensibilidad y especificadad diagnóstica de la tira reactiva para dos parámetros (cualquier combinación) fueron de 100 por ciento y 87,8 por ciento respectivamente. Para tres parámetros positivos la sensibilidad fue de 76,9 por ciento, que aumentó al 84,6 por ciento si se complementa con la información de la tinción de Gram y aun 92,3 por ciento si se agrega a lo anterior el test de aglutinación por látex. Se concluye que la tira reactiva de orina Combur 10MR es un método diagnóstico suficientemente sensible, rápido y simple que puede ser utilizado como método de aproximación diagnóstica en MBA. Dado el rendimiento y alto costo del test de aglutinación por látex, se recomienda reservarlo para aquellos casos en que los otros métodos diagnóticos orienten fuertemente al diagnóstico de MBA

Latex particle agglutination tests on the cerebrospinal fluid. A reappraisal.

Rapid diagnostic tests are often used to identify microbial etiology of infection early. Latex particle agglutination (LPA) tests on the cerebrospinal fluid (CSF) are frequently used for purpose of rapid diagnosis. We evaluated their usefulness in management of patients with suspected meningitis. We also evaluated the cost effectiveness of LPAs during an 11-month period; 1,540 CSF specimens were tested for H. influenzae type b, Group B streptococcal (GBS), N. meningitidis and S. pneumoniae using LPAs. Only 27 were positive. LPAs were useful in management of only the neonates with GBS infection. On the whole, LPAs were very expensive and not cost-effective.

Microalbuminuria: an index of severity in childhood meningitis.

Urinary albumin excretion (AE) was determined by a sensitive method (below dipstick positive values, 15 to 300 micrograms/minute) in 68 children with meningitis during 48 hours after hospital admission; 51 children had bacterial meningitis (BM) and 17 had aseptic meningitis. AE (results as mean +/- SD) during 0 to 24 hours was higher (P < 0.001) in patients with BM (36 +/- 40 micrograms/minute) than with aseptic meningitis (7 +/- 5 micrograms/minute), albeit no cutoff value distinguished the two conditions accurately. In BM the clinical course (uneventful, intermediate, complicated, fatal) correlated with AE of 0 to 24 hours (r = 0.34, P < 0.05) and AE of 25 to 48 hours (r = 0.63, P < 0.001). Cerebrospinal fluid protein concentration 24 to 36 hours after initiation of treatment correlated with AE of 25 to 48 hours (r = 0.34, P < 0.05). An index obtained by dividing AE by the weight of the child predicted the severity of clinical course more precisely (77% sensitivity, 85% specificity) than AE alone. Hence renal AE is an easily and non-invasively determined acute phase reactant of potential value as an early estimate of severity of BM.

Comparison of counterimmunoelectrophoresis, latex agglutination and bacterial culture for the diagnosis of bacterial meningitis using urine, serum and cerebrospinal fluid samples.

1. Urine, serum and cerebrospinal fluid (CSF) samples from 98 children with clinical and laboratory diagnosis of bacterial meningitis were evaluated by counterimmunoelectrophoresis (CIE) and latex agglutination (LA) methods and the results compared to those obtained with bacterial cultures of the CSF samples. Antigens of Neisseria meningitidis groups A, B and C, Haemophilus influenzae type b and Streptococcus pneumoniae were determined by both immunological methods. Serum was diluted (1:4) with 0.1 M sodium EDTA, pH 7.5, and held at 80 degrees C for 10 min before assay. Polysaccharide of the urine samples was precipitated overnight using an equal volume of 1:1 ethanol-acetone followed by a heat-treatment with 0.1 M sodium EDTA, pH 7.5, at 80 degrees C for 10 min.. 2. Sensitivity indices were 0.772 (CSF), 0.595 (urine) and 0.317 (serum) for CIE, and 0.914 (CSF), 0.930 (urine) and 0.683 (serum) for LA in relation to the 42 positive bacterial cultures. 3. The optimal diagnostic efficacy reached 52% for CIE and 72% for LA when urine was concentrated 20- to 30-fold. 4. These data show that immunological tests of urine samples were more effective than bacterial culture for diagnosing bacterial meningitis and may be indicated when negative results are obtained for CSF tested by bacterial culture and immunoassay methods.