Impact of in-hospital enteroviral polymerase chain reaction testing on the clinical management of children with meningitis

Neurodevelopmental Outcomes Following Childhood Viral Meningitis in Canterbury New Zealand

BACKGROUND

Most childhood meningitis is viral in countries with widespread conjugate vaccine use. This study assessed clinical features and neurodevelopmental outcomes in preschool children following enteroviral and parechoviral meningitis.

METHODS

Children 18-42 months of age in Canterbury, New Zealand were included, who had enterovirus (EV) or parechovirus (HPEV) meningitis from 2015 to 2021. Comprehensive neurodevelopmental assessments were completed by a psychologist using the Bayley Scale for Infant Development-3 (BSID-3). Mean composite and scaled scores and proportion below the cutoff were assessed in each domain. Clinical data was analyzed.

RESULTS

There were 79 children 18-42 months old with previous EV or HPEV meningitis. BSID assessments were completed for 33 children (55% male), median age 32 months, from 2019 to 2022 including 23 with EV and 10 HPEV meningitis. At diagnosis, 32 (97%) received intravenous/intramuscular antibiotics, and 6 received a fluid bolus. Parents reported developmental speech concerns in 6 children, and delayed motor milestones in 1 child. There was no reported sensorineural hearing loss. BSID mean composite scores were in the expected range for cognition 102 (confidence interval: 98-106), language 96 (93-100) and motor 102 (98-106) domains. Overall, 12/33 (36%) children had below expected scores in 1 developmental domain, including scores 1-2 SD below the normative mean for cognition (2/33; 6%), receptive language (6/33; 18%), expressive language (5/33; 15%) and gross motor (6/33; 18%). There were no differences between scores in EV and HPEV meningitis.

CONCLUSION

Following viral meningitis, more than a third of preschool children had a mild developmental delay with comprehensive neurodevelopmental assessment, suggesting targeted follow-up should be considered.

Turnaround times for molecular testing of pediatric viral cerebrospinal fluid samples in United Kingdom laboratories

BACKGROUND

Rapid molecular testing has revolutionized the management of suspected viral meningitis and encephalitis by providing an etiological diagnosis in < 90 min with potential to improve outcomes and shorten inpatient stays. However, use of molecular assays can vary widely.

AIM

To evaluate current practice for molecular testing of pediatric cerebrospinal fluid (CSF) samples across the United Kingdom using a structured questionnaire.

METHODS

A structured telephone questionnaire survey was conducted between July and August 2020. Data was collected on the availability of viral CSF nucleic acid amplification testing (NAAT), criteria used for testing and turnaround times including the impact of the coronavirus disease 2019 pandemic.

RESULTS

Of 196/212 (92%) microbiology laboratories responded; 63/196 (32%) were excluded from final analysis as they had no on-site microbiology laboratory and outsourced their samples. Of 133 Laboratories included in the study, 47/133 (35%) had onsite facilities for viral CSF NAAT. Hospitals currently undertaking onsite NAAT (n = 47) had much faster turnaround times with 39 centers (83%) providing results in ≤ 24 h as compared to those referring samples to neighboring laboratories (5/86; 6%).

CONCLUSION

Onsite/near-patient rapid NAAT (including polymerase chain reaction) is recommended wherever possible to optimize patient management in the acute setting.

Turnaround times for molecular testing of pediatric viral cerebrospinal fluid samples in United Kingdom laboratories

BACKGROUND

Rapid molecular testing has revolutionized the management of suspected viral meningitis and encephalitis by providing an etiological diagnosis in < 90 min with potential to improve outcomes and shorten inpatient stays. However, use of molecular assays can vary widely.

AIM

To evaluate current practice for molecular testing of pediatric cerebrospinal fluid (CSF) samples across the United Kingdom using a structured questionnaire.

METHODS

A structured telephone questionnaire survey was conducted between July and August 2020. Data was collected on the availability of viral CSF nucleic acid amplification testing (NAAT), criteria used for testing and turnaround times including the impact of the coronavirus disease 2019 pandemic.

RESULTS

Of 196/212 (92%) microbiology laboratories responded; 63/196 (32%) were excluded from final analysis as they had no on-site microbiology laboratory and outsourced their samples. Of 133 Laboratories included in the study, 47/133 (35%) had onsite facilities for viral CSF NAAT. Hospitals currently undertaking onsite NAAT (n = 47) had much faster turnaround times with 39 centers (83%) providing results in ≤ 24 h as compared to those referring samples to neighboring laboratories (5/86; 6%).

CONCLUSION

Onsite/near-patient rapid NAAT (including polymerase chain reaction) is recommended wherever possible to optimize patient management in the acute setting.

Epidemiology and Trends of Infective Meningitis in Neonates and Infants Less than 3 Months of Age in Hong Kong

INTRODUCTION AND AIMS

Meningitis in neonates and young infants leads to significant morbidity and mortality worldwide. This study aims to investigate pathogens, antibiotics resistance and secular change of incidence in Hong Kong.

METHODS

We performed a retrospective search on meningitis in neonates and infants <3 months old in three Hong Kong public hospitals from 2004 to 2019. Medical charts were reviewed, focusing on the identification and antibiotics resistance of the pathogens.

RESULTS

200 cases of meningitis were identified (67% were bacterial). Group B Streptococcus (GBS) and Escherichia coli (E. coli) were the commonest bacterial pathogens. The annual rates of early-onset GBS meningitis decreased since the implementation of the universal GBS screening and intrapartum antibiotics prophylaxis (IAP) in 2012, while that of late-onset GBS meningitis remained similar. A significant portion of E. coli isolates were resistant to ampicillin and/or gentamicin.

CONCLUSION

GBS and E. coli remained the commonest bacteria for meningitis in this age group. The annual rate of bacterial meningitis in Hong Kong declined in recent years, which was attributed by the decline in that of early-onset GBS meningitis due to the universal GBS screening and IAP. Antimicrobial-resistant bacterial strains that caused meningitis require further clinical and public health attention.

Impact of rapid enterovirus polymerase chain reaction testing on management of febrile young infants < 90 days of age with aseptic meningitis

Background

Diagnostic evaluation of febrile young infants is challenging. Empirical antimicrobial treatment is therefore common practice in this setting despite high percentage of causative viral infections. The objective of this study was to investigate the impact of rapid enterovirus cerebrospinal fluid polymerase chain reaction (CSF EV PCR) test on hospital length of stay (LOS) and antimicrobial treatment duration in young febrile infants.

Methods

Retrospective observational study comparing duration of antimicrobial treatment and hospital LOS before (May 1, 2014 - May 30, 2015, untested group) and after (June 1, 2015 - June 30, 2017, tested group) the introduction of rapid CSF EV PCR testing in infants < 90 days of age presenting with fever and CSF pleocytosis at the University Children’s Hospital Zurich. Additionally, the same variables were compared after test introduction between CSF EV PCR positive and negative children.

Results

One hundred twenty-eight children were enrolled in the study, 58 before and 70 after the introduction of rapid CSF EV PCR testing. Duration of antimicrobial treatment was significantly shortened in EV positive (n = 42) compared to both EV negative (n = 28) (median 18 h and 48 h, respectively, p < 0.001) and untested patients (n = 58) (median 18 h and 48 h, respectively, p < 0.001), and also in tested compared to untested group patients (median 36 vs 48 h, p < 0.001). Hospital LOS was significantly shortened in EV positive compared to EV negative patients (median 3 days and 4 days respectively, p = 0.013), while an overall reduction was not observed between tested and untested group patients.

Conclusions

In this study we demonstrate that antimicrobial treatment duration could be significantly shortened in neonates and young infants < 90 days of age with aseptic meningitis after the introduction of a rapid CSF EV PCR test compared to untested patients before test introduction.

Comparison of antibiotic and acyclovir usage before and after the implementation of an on-site FilmArray meningitis/encephalitis panel in an academic tertiary pediatric hospital: a retrospective observational study

BACKGROUND

Prompt initiation of empiric therapy is common practice in case of suspected meningitis or encephalitis. However, in children the most common pathogens are viruses that usually do not require and are not covered by the applied anti-infective treatment. Novel multiplex PCR (mPCR) panels provide rapid on-site diagnostic testing for a variety of pathogens. This study compared empiric antibiotic and acyclovir usage before and after the introduction of an on-site FilmArray Meningitis/Encephalitis Panel (FA ME Panel).

METHODS

We retrospectively compared data for empiric antibiotic and acyclovir usage between pediatric patients with suspected central nervous system (CNS) infection receiving mPCR testing and a matched historical control group. Patients were matched by age and suspected CNS infection. We included all patients for whom empiric antibiotics and/or acyclovir were prescribed.

RESULTS

Each study group consisted of 46 patients with 29 (63.0%) infants and 17 (37.0%) older children. A viral pathogen was diagnosed in 5/46 (10.9%) patients in the control group (all enteroviruses) and in 14/46 (30.4%) patients in the mPCR group (enterovirus n = 9; human herpesvirus 6 (HHV-6) n = 5), (p = 0.038)). Length of Therapy (LoT) and Days of Therapy (DoT) for antibiotics were significantly lower for infants (4.0 vs. 3.0, p = 0.038 and 8.0 vs. 6.0, p = 0.015, respectively). Acyclovir therapy was significantly shorter for both, infants and older children (3.0 vs. 1.0 day, p < 0.001 for both age groups).

CONCLUSION

The findings of our study suggest that the introduction of a FA ME Panel into clinical routine procedures is associated with a significantly reduced LoT and DoT of empiric anti-infective treatment in children with suspected meningoencephalitis. The largest effect was observed in infants.

To LP or not to LP? Identifying the Etiology of Pediatric Meningitis

Introduction of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has led to a substantial reduction in cases of acute bacterial meningitis in countries with high routine childhood immunization coverage. The majority of children hospitalized with meningitis in high-income countries have viral or aseptic meningitis and do not require antibiotic treatment. Cerebrospinal fluid analysis is irreplaceable in appropriately diagnosing and treating bacterial meningitis and avoiding unnecessary antibiotics and prolonged hospitalizations in children with viral meningitis. New diagnostic tests have improved detection of bacterial and viral pathogens in cerebrospinal fluid, underscoring the importance of promptly performing lumbar puncture when meningitis is suspected. This article provides an overview of acute bacterial and viral meningitis in children, focusing on the changing epidemiology, the advantages and limitations of conventional and newer diagnostic methods, and considerations for clinical practice.

Impact of Enterovirus Molecular Assay Turnaround Time on Hospitalization Length During an Echovirus 30 Meningitis Outbreak, France, Fall 2014

Background:

The impact of Enterovirus Real Time-Polymerase Chain Reaction assay (EV RT-PCR) on hospitalization lengths of patients with aseptic meningitis has been investigated but the impact of early EV RT-PCR results released on time before patient discharge remains unclear during Echovirus meningitis outbreaks.

Objective:

To assess a potential correlation between EV RT-PCR turn-around time and hospitalization lengths during an Echovirus meningitis outbreak.

Method:

Eighteen patients demonstrating a positive EV RT-PCR assay performed on Cerebrospinal Fluid (CSF) samples collected between October 1st 2014 and December 31st 2014 were retrospectively included. Viral protein 1 (VP1) gene region was amplified and sequenced using a classical Sanger sequencing reaction. Clinical data were retrospectively collected from patient’s records. Quantitative variables expressed as median values and ranges were compared using Mann Whitney U test. Correlations were performed using simple regression analysis.

Results:

Phylogenetic VP1 sequence analyses identified that the outbreak was related to an Echovirus 30 strain in 7 out of the 10 cases with available sequencing data. The three remaining sequences analyses evidenced Echovirus 14, 9 and 7 strains. Hospitalization length was statistically shorter in children without comorbidity (n=5) than in adult patients (n=10) or neonates and children with comorbidity (n=3) (p=0.003 and 0.01 respectively), whereas EV RT-PCR turnaround time was not statistically different between these groups. Correlation between hospitalization length and EV RT-PCR turnaround time was poor (R2=0.06), especially in adults (R2=0.01)

Conclusion:

Our data indicated that EV RT-PCR turnaround time was not correlated to hospitalization length during a short Echovirus meningitis outbreak.

Management of suspected paediatric meningitis: a multicentre prospective cohort study

OBJECTIVE

To quantify delays during management of children with suspected meningitis.

DESIGN

Multicentre prospective cohort study.

SETTING

Three UK tertiary paediatric centres; June 2011-June 2012 PATIENTS: 388 children aged <16 years hospitalised with suspected meningitis or undergoing lumbar puncture (LP) during sepsis evaluation.

MAIN OUTCOME MEASURES

Time of prehospital and in-hospital assessments, LP, antibiotic treatment and discharge; types of prehospital medical assessment and microbiological results. Data collected from hospital records and parental interview.

RESULTS

220/388 (57%) children were seen by a medical professional prehospitalisation (143 by a general practitioner). Median times from initial hospital assessment to LP and antibiotic administration were 4.8 hours and 3.1 hours, respectively; 62% of children had their LP after antibiotic treatment. Median time to LP was shorter for children aged <3 months (3.0 hours) than those aged 3-23 months (6.2 hours, P<0.001) or age ≥2 years (20.3 hours, P<0.001). In meningitis of unknown cause, cerebrospinal fluid (CSF) PCR was performed for meningococcus in 7%, pneumococcus in 10% and enterovirus in 76%. When no pathogen was identified, hospital stay was longer if LP was performed after antibiotics (median 12.5 days vs 5.0 days, P=0.037).

CONCLUSIONS

Most children had LP after antibiotics were administered, reducing yield from CSF culture, and PCRs were underused despite national recommendations. These deficiencies reduce the ability to exclude bacterial meningitis, increasing unnecessary hospital stay and antibiotic treatment.

Impact of Enteroviral Polymerase Chain Reaction Testing on Length of Stay for Infants 60 Days Old or Younger

OBJECTIVE

To determine the impact of a cerebrospinal fluid enterovirus polymerase chain reaction (PCR) test performance on hospital length of stay (LOS) in a large multicenter cohort of infants undergoing evaluation for central nervous system infection.

STUDY DESIGN

We performed a planned secondary analysis of a retrospective cohort of hospitalized infants ≤60 days of age who had a cerebrospinal fluid culture obtained at 1 of 18 participating centers (2005-2013). After adjustment for patient age and study year as well as clustering by hospital center, we compared LOS for infants who had an enterovirus PCR test performed vs not performed and among those tested, for infants with a positive vs negative test result.

RESULTS

Of 19 953 hospitalized infants, 4444 (22.3%) had an enterovirus PCR test performed and 945 (21.3% of tested infants) had positive test results. Hospital LOS was similar for infants who had an enterovirus PCR test performed compared with infants who did not (incident rate ratio 0.98 hours; 95% CI 0.89-1.06). However, infants PCR positive for enterovirus had a 38% shorter LOS than infants PCR negative for enterovirus (incident rate ratio 0.62 hours; 95% CI 0.57-0.68). No infant with a positive enterovirus PCR test had bacterial meningitis (0%; 95% CI 0-0.4).

CONCLUSIONS

Although enterovirus PCR testing was not associated with a reduction in LOS, infants with a positive enterovirus PCR test had a one-third shorter LOS compared with infants with a negative enterovirus PCR test. Focused enterovirus PCR test use could increase the impact on LOS for infants undergoing cerebrospinal fluid evaluation.

Fifteen-minute consultation: enterovirus meningitis and encephalitis-when can we stop the antibiotics?

Enterovirus (EV) is the most common cause of aseptic meningitis and has a benign course, unlike EV encephalitis, which can result in long-term neurological sequelae. There are no active treatments or prophylactic agents, and management is purely supportive. Obtaining an EV-positive cerebrospinal fluid result usually allows antimicrobial treatment to be stopped. This review will answer some of the common questions surrounding EV meningitis/encephalitis.

Interpretation of Cerebrospinal Fluid White Blood Cell Counts in Young Infants With a Traumatic Lumbar Puncture

STUDY OBJECTIVE

We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures.

METHODS

We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm³) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm³ for infants aged 28 days or younger and greater than or equal to 10 cells/mm³ for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis.

RESULTS

Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days.

CONCLUSION

Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.