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BACKGROUND. Meningitis is a substantial cause of morbidity and mortality in neonates. Clinicians frequently use the presence of positive blood cultures to determine whether neonates should undergo lumbar puncture. Abnormal cerebrospinal fluid (CSF) parameters are often used to predict neonatal meningitis and determine length and type of antibiotic therapy in neonates with a positive blood culture and negative CSF culture. METHODS. We evaluated the first lumbar puncture of 9111 neonates at [greater than or equal to] 34 weeks' estimated gestational age from 150 NICUs, managed by the Pediatrix Medical Group, Inc. CSF culture results were compared with results of blood cultures and CSF parameters (white blood cells [WBCs], glucose, and protein) to establish the concordance of these values in culture-proven meningitis. CSF cultures positive for coagulase-negative staphylococci and other probable contaminants, as well as fungal and viral pathogens, were excluded from analyses. RESULTS. Meningitis was confirmed by culture in 95 (1.0%) neonates. Of the 95 patients with meningitis, 92 had a documented blood culture. Only 57 (62%) of 92 patients had a concomitant-positive blood culture; 35 (38%) of 92 had a negative blood culture. In neonates with both positive blood and CSF cultures, the organisms isolated were discordant in 2 (3.5%) of 57 cases. In each case, the CSF pathogen required different antimicrobial therapy than the blood pathogen. For culture-proven meningitis, CSF WBC counts of >0 cells per [mm.sup.3] had sensitivity at 97% and specificity at 11%. CSF WBC counts of >21 cells per [mm.sup.3] had sensitivity at 79% and specificity at 81%. Culture-proven meningitis was not diagnosed accurately by CSF glucose or by protein. CONCLUSIONS. Neonatal meningitis frequently occurs in the absence of bacteremia and in the presence of normal CSF parameters. No single CSF value can reliably exclude the presence of meningitis in neonates. The CSF culture is critical to establishing the diagnosis of neonatal meningitis. Key Words CSF pleocytosis, neonatal sepsis, spinal tap Abbreviations CSF--cerebrospinal fluid LP--lumbar puncture WBC--white blood cell EGA--estimated gestational age CBC--complete blood cell count IQR--interquartile range RBC--red blood cell, NEONATAL MENINGITIS IS a devastating infection that is often difficult to diagnose. (1-5) Signs of meningitis are often subtle in the neonate; thus, the diagnosis of meningitis must be made […]

Context. Neonatal meningitis is associated with significant morbidity and mortality. We speculated that meningitis may be underdiagnosed among very low birth weight (VLBW) infants because of the failure to perform lumbar punctures (LPs) in infants with suspected sepsis. Objective. This study was undertaken to review the epidemiology of late-onset meningitis in VLBW (401-1500 g) infants and to evaluate the concordance of cerebrospinal fluid (CSF) and blood culture (BC) results. Methods. VLBW infants (excluding those with intraventricular shunts) born at centers of the National Institute of Child Health and Human Development Neonatal Research Network from September 1, 1998, through December 31, 2001, were studied. Late-onset meningitis was defined by culture-based criteria and classified as meningitis with or without associated sepsis. Unadjusted comparisons were made using [chi square] tests and adjusted comparisons using regression models. Results. Of 9641 VLBW infants who survived >3 days, 2877 (30%) had [greater than or equal to] 1 LPs, and 6056 (63%) had [greater than or equal to] 1 BC performed after day 3. One hundred thirty-four infants had late-onset meningitis (1.4% of all patients; 5% of those with an LP). Pathogens associated with meningitis were similar to those associated with sepsis. One third (45 of 134) of the infants with meningitis had negative BCs. Lower gestational age and prior sepsis increased risk for meningitis. Compared with uninfected infants, those with meningitis had a longer time on mechanical ventilation (28 vs 18 days), had longer hospitalizations (91 vs 79 days), were more likely to have seizures (25% vs 2%), and were more likely to the (23% vs 2%). Conclusions. Meningitis is a serious complication among VLBW infants, associated with increased severity of illness and risk of death. Of note, one third of the infants with meningitis had meningitis in the absence of sepsis. Because CSF cultures were performed only half as often as BCs, this discordance in blood and CSF culture results suggests that meningitis may be under-diagnosed among VLBW infants. Pediatrics 2004;113: 1181-1186; meningitis, sepsis, lumbar puncture, very low birth weight infants., ABBREVIATIONS. LP, lumbar puncture; VLBW, very low birth weight; LOM, late-onset meningitis; NICHD, National Institute of Child Health and Human Development; BC, blood culture; CSF, cerebrospinal fluid; CONS, coagulase-negative staphylococcus; [...]

Antibiotic treatment for patients with Streptococcus (S.) pneumonieae infections appears to lower but not eliminate the risk for developing meningitis. Risk for developing meningitis in treated and untreated S. pneumoniae infections was evaluated in 656 infected children from 10 research studies. Only 0.8% of the 399 children treated with antibiotics developed meningitis while 2.8% of the 257 untreated children developed it. There were fewer serious bacterial infections among treated children than untreated children., Objective. To determine whether oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. Data Sources. Using the Medline database, the English-language literature was searched for all publications concerning bacteremia, fever, or S pneumoniae from 1966 to April 1996. Study Selection. All studies that included a series of children with S pneumoniae occult bacteremia containing orally treated and untreated groups. Children were excluded from individual studies if they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or received parenteral antibiotics. Data Extraction. Three authors independently reviewed each article to determine the number of eligible children and the outcome of children meeting entry criteria. Data Synthesis. Eleven of 21 studies were excluded, leaving 10 evaluable studies with 656 total cases of S pneumoniae occult bacteremia identified. Patients who received oral antibiotics had fewer serious bacterial infections than untreated patients (3.3% vs 9.7%; pooled odds ratio, 0.35; 95% confidence interval, 0.17 to 0.73). Meningitis developed in 3 (0.8%) of 399 children in the oral antibiotic group and 7 (2.7%) of 257 untreated children (pooled odds ratio, 0.51; 95% confidence interval, 0.12 to 2.09). Conclusion. Although oral antibiotics modestly decreased the risk of serious bacterial infections in children with S pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral antibiotics prevent meningitis. Published recommendations that oral antibiotics be administered to prevent serious bacterial infections in children with possible S pneumoniae occult bacteremia should be reevaluated in light of the lower risk of sequelae from S pneumoniae occult bacteremia and newer data concerning side effects from treatment., Pediatrics 1997;99:438-444; bacterial infections, meningitis, occult bacteremia, oral antibiotics, Streptococcus pneumoniae. ABBREVIATION. OR, odds ratio. Occult bacteremia occurs in 2.8% to 11.1% of febrile children 3 to 36 months of [...]

BACKGROUND. Differentiating Lyme meningitis (LM) from other forms of aseptic meningitis (AM) in children is a common diagnostic dilemma in Lyme disease-endemic regions. Prior studies have compared clinical characteristics of patients with LM versus patients with documented enteroviral infections. No large studies have compared patients with LM to all patients presenting with AM and attempted to define a clinical prediction model. OBJECTIVE. To create a statistical model to predict LM versus AM in children based on history, physical, and laboratory findings during the initial presentation of meningitis. METHODS. Children older than 2 years presenting to the Alfred I. duPont Hospital for Children between October 1999 and September 2004 were identified if both Lyme serology and cerebrospinal fluid (CSF) were collected during the same hospital encounter. Patients were considered to have Lyme disease only if they met Centers for Disease Control and Prevention criteria (documented erythema migrans and/or positive Lyme serology). Patients were eligible for study inclusion if they had documented meningitis (CSF white blood cell count: >8 per mm3). Retrospective chart review abstracted duration of headache and cranial neuritis (papilledema or cranial nerve palsy) on physical examination and percent CSF mononuclear cells. Using logistic-regression analysis, the type of meningitis (LM versus AM) was simultaneously regressed on these 3 variables. The Hosmer-Lemeshow test was performed and the area under the receiver operating characteristic curve was calculated. RESULTS. A total of 175 children with meningitis were included in the final statistical model. Logistic-regression analysis included 27 patients with LM and 148 patients classified as having AM. Duration of headache, cranial neuritis, and percent CSF mononuclear cells independently predicted LM. The Hosmer-Lemeshow test revealed a good fit for the model, and the Nagelkerke [R.sup.2] effect size demonstrated good predictive efficacy. Odds ratios based on the logistic-regression results were calculated for these variables. The final model was transformed into a clinical prediction model that allows practitioners to calculate the probability of a child having LM. CONCLUSIONS. Longer duration of headache, presence of cranial neuritis, and predominance of CSF mononuclear cells are predictive of LM in children presenting with meningitis in a Lyme disease-endemic region. The clinical prediction model can help guide the clinician about the need for parenteral antibiotics while awaiting serology results. KEY WORDS. Lyme disease, meningitis, regression analysis. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2005-0955