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LP for febrile infants with UTI

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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

What age febrile infant with UTI would you LP?

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pemsou5_wp • May 8, 2020

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  1. Kelly May 10, 2020 - 1:52 am Reply

    Nugent et al (PMID 31230888) published a systematic review and meta-analysis of the risk of meningitis in infants aged 29-90 days with UTI. They found a pooled prevalence of concomitant bacterial meningitis of 0.25% (95% CI 0.09% to 0.70%); sensitivity analysis adding in probably but not culture-proven cases yielded a prevalence estimate of 0.37% (95% CI 0.16% to 0.84%). Sterile pleocytosis was a common finding. The number needed to LP to find one case would be ~400 infants (95% CI 143-1,111).

    Wang et al (PMID 31395621) studied 3,572 well-appearing infants aged 7-60 days old seen in 124 hospitals with a positive UA; 2511 (70.3%) underwent LP. No cases of delayed meningitis diagnosis occurred in 505 infants (98 that were 0-30 days old and 407 that were 31-60 days old) that were treated for UTI without LP performance. Thomson et al (PMID 28472006) performed a 23-center retrospective study of 1,737 infants <= 60 days old with UTI and found a meningitis rate of 0.9% (95% CI 0.4% to 1.9%) in 0-28 day olds, but 0.2% (95%CI 0 to 0.8%) in 29-60 day olds. Wallace et al (PMID 28185626) retrospectively studied 236 infants <= 30 days old with UTI and found none with meningitis (95% CI 0 to 1.6%).

  2. Kelly May 16, 2020 - 11:28 pm Reply

    Additionally, a hot off the press abstract presented at SAEM on Friday (Mahajan PV et al, Prevalence of bacteremia and meningitis in febrile infants less than or equal to 60 days with positive urinalyses) reported results of a planned secondary analysis of a PECARN study of febrile infants < 60 days old, looking at a subset of 1,090 infants with positive UAs. Bacteremia was present in 5.8% of febrile infants with UTI vs 1.1% of febrile infants w/o UTI. There was no significant difference in prevalence of bacterial meningitis among those with UTI (0.4%) vs. w/o UTI (0.6%), even when looking at only those < 28 days old (1% vs 1.3%). The difference in bacterial meningitis prevalence for infants 29-60 days old was statistically significantly lower (0/697 infants) in those with UTI vs those without (9/4153, 0.2%).

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