78 CONCOMITANT MENINGITIS AMONG FEBRILE YOUNG INFANTS 29-60 DAYS OLD WITH A POSITIVE URINALYSIS AND THE NEED FOR LUMBAR PUNCTURE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Mansouri Fahad , Sabhaney Vik , Meckler Garth , Doan Quyhn , Burstein Brett 
Published: August 2020

Abstract

Background
Fever among infants in the first months of life remains among the most common pediatric problems in the Emergency Department (ED) setting. These infants are at increased risk of potentially life-threatening serious bacterial infection (SBI), specifically urinary tract infections (UTIs), bacteremia and bacterial meningitis. Infants with UTIs have historically been considered at increased risk of bacterial meningitis. A presumptive diagnosis of UTI relies entirely upon abnormal urinalysis results in the ED, prompting further invasive testing by lumbar puncture, broad-spectrum antibiotic exposure and hospitalization. However, the necessity of lumbar puncture for infants older than 28 days on the basis of an abnormal urinalysis has been questioned for over a decade and remains controversial.

Objectives
The objective of this study was to estimate the prevalence of meningitis among well-appearing, febrile infants aged 29-60 days with a positive urinalysis, to inform whether routine CSF testing is required in these patients.

Design/Methods
We searched MEDLINE and Embase for articles published from January 1, 2000 to July 25, 2018, deliberately limiting the search to recent studies to account for: 1) changing SBI epidemiology; 2) evolving clinical definitions of UTI; and, 3) improvements in urinalysis diagnostic accuracy for febrile young infants. Studies were eligible for inclusion if they reported urinalysis results and SBI prevalence. In the case of studies reporting UTI prevalence but not UA results, or aggregate data only, the corresponding authors were contacted for details. The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with a positive urinalysis. The secondary outcome was the prevalence of bacterial meningitis among infants with a positive urinalysis, defined by either a positive CSF culture or a suggestive history at 1-month post-discharge if CSF testing was not undertaken in the ED. Studies were assessed for bias using the Critical Appraisal Skills Programme (CASP) tool, and prevalence estimates for bacterial meningitis were pooled in a random effects meta-analysis.

Results
The parent search yielded 2334 unique citations, of which screening by title and abstract identified 106 for full text review. Eleven studies met inclusion and were ultimately included in the final meta-analysis. Seven studies did not have significant risk of bias for the primary outcome of interest. Among 1430 febrile infants with a positive urinalysis and CSF testing performed, 5 infants had culture-proven bacterial meningitis (primary outcome; prevalence 0.33%, 95% CI: 0.1% to 0.79%). Only these same 5 infants were considered to have bacterial meningitis among 2311 infants with a positive urinalysis and meningitis status ascertained by either CSF testing or clinical follow-up (secondary outcome; prevalence 0.24%, 95% CI: 0.08 to 0.54%).

Conclusion
The prevalence of bacterial meningitis in well appearing febrile infants aged 29-60 days with a positive urinalysis is low. The practice of lumbar puncture in this subgroup of infants should not be guided by urinalysis results alone, but rather on the basis of other clinical criteria. Results should inform decisions regarding invasive testing and aid in shared decision-making.