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

Relevance of enteroviruses in neonatal meningitis

INTRODUCTION

Enterovirus (EV) infections are the most frequent infections in the neonatal period and in many cases lead to hospital admission of the newborn (NB). The aim of this study was to determine the incidence of EV in the etiology of neonatal meningitis and to define the clinical characteristics of newborns with EV meningitis.

MATERIAL AND METHOD

Retrospective observational cohort study. Including 91 NBs with meningitis and gestational age greater than 34 weeks gestational age (GA) attended in our center over a period of 16 years.

RESULTS

The percentage of NBs with EV meningitis was higher than that of NBs with bacterial meningitis (BM) and accounted for 78% (n=71). Half of the NBs with EV infection had a history of epidemic environment among their caregivers. Fever was present in 96% of cases as a clinical sign and, in general, sensory disturbances represented the main neurological alterations. Antibiotics (ATB) were given to 71.4% of patients with EV infection. Detection of EV in CSF samples showed a high sensitivity for the diagnosis of EV meningitis. The most frequently implicated EV types were echovirus 11, coxsackievirus B5, echovirus 18, 25 and 7.

CONCLUSIONS

The results of this series show that enterovirus infection is a common cause of neonatal meningitis. These data underline the importance of rapid EV testing of infants with suspected meningitis. This allows early diagnosis and reduces antibiotic treatment, hospitalization time and related costs.

Non-polio enterovirus aseptic meningitis in infants up to three months of age, the bacterial mask of viral disease: A retrospective cohort study

BACKGROUND

Non-polio enterovirus aseptic meningitis (NPE-AM) is a self-limiting illness that can mimic serious bacterial infection (SBI) in infants during their first months of life.

OBJECTIVES

To compare the clinical features of febrile infants diagnosed with NPE-AM with those of infants who had SBI or non-bacterial infection (NBI).

STUDY DESIGN

A systematic series of febrile infants < 3-months-old hospitalized between 2010 and 2019 with febrile illness in a tertiary hospital. Clinical and laboratory data were compared between the three groups.

RESULTS

Overall 1278 infants were included; 207 (16.2%) had NPE-AM, 210 (16.4%) SBI and 861 (67.4%) NBI. The median age was 34 (IQR: 21.5-51.7) days. NPE-AM was documented in 25% of infants < 29 days and 9.9% of infants aged 29-90 days. Infants with NPE-AM or SBI had fever >39°C more frequently, 24.2% and 17.1% compared with 10% in infants with NBI (p < 0.001). Fever duration ≥ 2 days was reported in 3.4% of infants with NPE-AM vs 18.6% in SBI and 26.3% in NBI (p < 0001); rash occurred in 37.7% in NPE-AM compared to 4.6% in NBI and 5.7% in SBI (p < 0.001). The mean white blood count, C-reactive protein and absolute neutrophil count were significantly lower in infants with NPE-AM compared to infants with the SBI (p < 0.001) and similar to the means in infants with NBI (p = 0.848, 0.098 and 0.764 respectively). A high proportion of bloody tap 346/784 (53.1%) was detected. Infants with NPE-AM were more likely to be treated with antibiotics than infants with NBIs (88.9% vs 50.7%, p < 0.001), similarly to infants with SBIs (p = 0.571).

CONCLUSIONS

The clinical presentation of infants with NPE-AM that could mimic bacterial infection and the high rate of bloody taps may lead to more hospital admissions and antibiotic prescriptions. Rapid molecular testing for detection of NPE may be of additional value in the evaluation of febrile infants.

Risk factors and early markers for echovirus type 11 associated haemorrhage-hepatitis syndrome in neonates, a retrospective cohort study

Background

Echovirus type 11(E-11) can cause fatal haemorrhage-hepatitis syndrome in neonates. This study aims to investigate clinical risk factors and early markers of E-11 associated neonatal haemorrhage-hepatitis syndrome.

Methods

This is a multicentre retrospective cohort study of 105 neonates with E-11 infection in China. Patients with haemorrhage-hepatitis syndrome (the severe group) were compared with those with mild disease. Clinical risk factors and early markers of haemorrhage-hepatitis syndrome were analysed. In addition, cytokine analysis were performed in selective patients to explore the immune responses.

Results

In addition to prematurity, low birth weight, premature rupture of fetal membrane, total parenteral nutrition (PN) (OR, 28.7; 95% CI, 2.8-295.1) and partial PN (OR, 12.9; 95% CI, 2.2-77.5) prior to the onset of disease were identified as risk factors of developing haemorrhage-hepatitis syndrome. Progressive decrease in haemoglobin levels (per 10 g/L; OR, 1.5; 95% CI, 1.1-2.0) and platelet (PLT) < 140 × 10⁹/L at early stage of illness (OR, 17.7; 95% CI, 1.4-221.5) were associated with the development of haemorrhage-hepatitis syndrome. Immunological workup revealed significantly increased interferon-inducible protein-10(IP-10) (P < 0.0005) but decreased IFN-α (P < 0.05) in peripheral blood in severe patients compared with the mild cases.

Conclusions

PN may potentiate the development of E-11 associated haemorrhage-hepatitis syndrome. Early onset of thrombocytopenia and decreased haemoglobin could be helpful in early identification of neonates with the disease. The low level of IFN-α and elevated expression of IP-10 may promote the progression of haemorrhage-hepatitis syndrome.

Impact of CSF Meningitis and Encephalitis Panel on Resource Use for Febrile Well-Appearing Infants

OBJECTIVES

To determine whether the BioFire FilmArray Meningitis/Encephalitis (ME) panel is associated with decreased resource use for febrile infants. The ME panel has a rapid turnaround time (1-2 hours) and may shorten length of stay (LOS) and antimicrobial use for febrile well-appearing infants.

METHODS

Retrospective cohort study of febrile well-appearing infants ≤60 days with cerebrospinal fluid culture sent in the emergency department from July 2017 to April 2019. We examined the frequency of ME panel use and its relationship with hospital LOS and initiation and duration of antibiotics and acyclovir. We used nonparametric tests to compare median durations.

RESULTS

The ME panel was performed for 85 (36%) of 237 infants. There was no difference in median hospital LOS for infants with versus without ME panel testing (42 hours, interquartile range [IQR] 36-52 vs 40 hours, IQR: 35-47, P = .09). More than 97% of infants with and without ME panel testing were initiated on antibiotics. Patients with ME panel were more likely to receive acyclovir (33% vs 18%; odds ratio: 2.2, 95%: confidence interval 1.2-4.0). There was no difference in median acyclovir duration with or without ME panel testing (1 hour, IQR: 1-7 vs 4.2 hours, IQR: 1-21, P = .10). When adjusting for potential covariates, these findings persisted.

CONCLUSIONS

ME panel use was not associated with differences in hospital LOS, antibiotic initiation, or acyclovir duration in febrile well-appearing infants. ME panel testing was associated with acyclovir initiation.

Evaluation of Discordant Results Between FilmArray Meningitis/Encephalitis Panel and Conventional Testing in Pediatric Patients: A Multisite Retrospective Cohort Study

BACKGROUND

The FilmArray Meningitis/Encephalitis panel (MEP) has an 11% false-positive and 2.2% false-negative rate compared with conventional testing. We describe clinical characteristics, treatment decisions, and outcomes in children with discordant results between MEP and conventional testing.

METHODS

We conducted a multisite review of patients ≤ 18 years with suspected central nervous system infection and positive results by MEP or conventional testing (cerebrospinal fluid [CSF] culture, herpes simplex virus [HSV] polymerase chain reaction (PCR), and enterovirus [EV] PCR). Descriptive results are provided for patients with discordant results. Comparison between group 1 (MEP and CSF culture positive) and group 2 (MEP positive, CSF culture negative, or showing a different pathogen) was made by Mann-Whitney test for continuous and Fisher's test for categorical variables.

RESULTS

A total of 355 patients had at least one pathogen identified. More than half of patients with bacterial pathogens identified that are included in the MEP had discordant results (30/52; 58%). There were 28 samples with bacterial pathogen identified on MEP only, 1 with different bacterial pathogens on MEP and culture, and 1 with Escherichia coli identified on CSF culture only. Patients in group 1 were more likely to have CSF pleocytosis, elevated CSF protein, and decreased CSF glucose than group 2 (P < .05). Two patients were HSV positive by MEP while HSV negative by PCR. Ten patients had discordant results between MEP and EV PCR.

CONCLUSIONS

Discordant results between MEP and conventional testing are common. Treatment decisions based on a positive MEP should be made in the appropriate clinical context.

Blood enterovirus polymerase chain reaction testing in young febrile infants

OBJECTIVE

To analyse the impact of blood enterovirus and human parechovirus PCR (ev-PCR) testing in young infants with fever without a source (FWS).

DESIGN

Observational study, subanalysis of a prospective registry.

SETTING

Paediatric emergency department.

PATIENTS

Infants ≤90 days of age with FWS seen between September 2015 and August 2019 with blood ev-PCR, blood and urine cultures and urine dipstick test performed.

MAIN OUTCOME MEASURES

Prevalence of invasive bacterial infection (IBI: bacterial pathogen in blood or cerebrospinal fluid) in infants with positive or negative ev-PCR test results. Secondarily, we also compared length of stay and antibiotic treatment in hospitalised infants.

RESULTS

Of 703 infants, 174 (24.7%) had a positive blood ev-PCR and none of them were diagnosed with an IBI (vs 2.6% (95% CI 1.3% to 4.0%) of those with a negative result, p=0.02). Prevalence of non-IBI (mainly urinary tract infection) was also lower among infants with a positive blood ev-PCR (2.3% (95% CI 0.1% to 4.5%) vs 17.6% (95% CI 14.3% to 20.8%), p<0.01).Overall, 258 infants were hospitalised (36.6%) and 193 (74.8%) of them received antibiotics. Length of hospital stay and antibiotic treatment were shorter in those with a positive blood ev-PCR (median: 3 days vs 5 days and 1 day vs 5 days, respectively; p<0.01). Differences remained statistically significant among well-appearing infants >21 days old with normal urine dipstick.

CONCLUSION

Blood ev-PCR identifies a group of infants under 90 days of age with FWS at very low risk of IBI. This test may help to guide clinical decision making in young febrile infants.

Clinical and laboratory detection of nonpolio enteroviruses among different age groups of aseptic meningitis patients in Alexandria, Egypt

BACKGROUND

Viral meningitis is the most common type of meningitis. Worldwide, nonpolio enteroviruses (NPEVs) account for 23%-60% of all cases of viral meningitis. We aimed to detect NPEV among aseptic meningitis cases using reverse transcription-polymerase chain reaction (RT-PCR) and evaluate molecular testing versus clinical and laboratory parameters.

PATIENTS AND METHODS

A 2-year prospective study was conducted for all clinically suspected meningitis patients, who underwent lumbar puncture in Alshatby University and Alexandria Fever Hospitals. Clinical manifestations were reviewed; cytological, microbiological, and biochemical examinations were done. One-step RT-PCR for NPEV was introduced to a routine workflow using Pan-Enterovirus primers.

RESULTS

Out of 2519 patients, 994 (40%) patients were found to have positive cerebrospinal fluid findings, out of which 716 (72%) patients had positive findings of aseptic meningitis. Ninety-four samples were randomly selected and divided across four age groups: neonates, infants, children, and adults. The significant difference was found among adult patients regarding fever, vomiting, headache, signs of meningeal irritation, cranial nerve affection, and focal neurological deficits (p ≤ .05). Seven cases (7.4%) were found to be NPEV positive by RT-PCR. Positive NPEV PCR samples were shown to be statistically significant among neonates (p ≤ .05). The statistical significance was found among the NPEV group regarding the length of hospital stay and duration of IV antibiotic intake while no statistical significance was found with any clinical or laboratory findings.

CONCLUSION

RT-PCR was reliable to identify NPEV while clinical and laboratory findings were inconclusive. NPEV showed low incidence and slight seasonal variation which rings the bell to investigate other causes of viral meningitis throughout the year.

Clinical utility of the FilmArray meningitis/encephalitis panel in children at a tertiary center in South Korea

BACKGROUND

We retrospectively evaluated the pathogens in the cerebrospinal fluid (CSF) of pediatric meningitis/encephalitis (M/E) by FilmArray meningitis/encephalitis panel (FA-MEP), and the characteristics of children showing positive and negative FA-MEP results.

METHOD

FA-MEP along with conventional tests (bacterial/viral cultures, and polymerase chain reaction tests) was performed in children who presented symptoms of M/E. Clinical and laboratory data were reviewed to evaluate the characteristics of children with pathogens detected by FA-MEP.

RESULTS

The CSF specimens from 110 pediatric M/E patients were enrolled. Mean age of the patients was 5.9 ± 5.2 years. Overall positive rate of FA-MEP was 46.4% (51/110). The pathogens detected in the patients were enterovirus (23/51, 45.1%), parechovirus (10/51, 19.6%), S. pneumoniae (7/51, 13.7%), human herpesvirus type 6 (6/51, 11.8%), S. agalactiae (3/51, 5.9%), herpes simplex virus type 2 (1/51, 2.0%), and E. coli (1/51, 2.0%). Aseptic meningitis (OR, 3.24, 95% CI, 1.18-12.73) and a duration of <2 days from onset of symptoms to CSF test (OR, 3.56, 95% CI, 0.1-0.91) significantly contributed to detection of pathogens by the FA-MEP. Among the 14 children who were administered empiric antibiotics before the CSF test, the detection rate was significantly higher in the FA-MEP than in the conventional test (28.6 vs. 0.0%, p = 0.031).

CONCLUSIONS

FA-MEP had a higher detection rate in children with M/E compared with conventional tests, particularly aseptic meningitis, and in case of shorter duration of time-to-test. This test was more effective than the conventional test in pediatric M/E patients that had been administered empiric antibiotics.

Fever Without an Apparent Source in Young Infants: A Multicenter Retrospective Evaluation of Adherence to the Dutch Guidelines

BACKGROUND

The Dutch fever without an apparent source (FWS) guidelines were published to timely recognize and treat serious infections. We determined the adherence to the Dutch FWS guidelines and the percentage of serious infections in infants younger than 3 months of age. Second, we identified which clinical criteria, diagnostic tests, and management were associated with nonadherence to the guidelines.

METHODS

A retrospective cohort study was performed in 2 Dutch teaching hospitals. We assessed the charts of all infants with FWS who presented at the emergency departments from September 30, 2017, to October 1, 2019. Diagnostic and therapeutic decisions were compared with the recommendations, as published in the Dutch guidelines. Infants were categorized into the nonadherence group in case 1 or more recommendations were not adhered to.

RESULTS

Data on 231 infants were studied; 51.5% of the cases adhered to the Dutch guidelines and 16.0% suffered from a serious infection. The percentage of infants with a serious infection was higher in the adherence compared with the nonadherence group. We observed no relevant differences in clinical outcomes. Univariate regression analysis showed that an abnormal white blood cell count was associated with nonadherence (OR 0.4, P = 0.049). Not obtaining a urine and blood culture and not starting intravenous antibiotic treatment were the most frequent reasons for nonadherence to the guidelines.

CONCLUSIONS

Our study indicates that there was nonadherence in a large proportion of FWS cases. The guidelines may need to be adjusted to increase adherence.

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.

Impact of decreasing cerebrospinal fluid enterovirus PCR turnaround time on costs and management of children with suspected enterovirus meningitis

To estimate the impact of implementing in-hospital enterovirus (EV) polymerase chain reaction (PCR) testing of cerebrospinal fluid (CSF) with same-day turn-around-time (TAT) on length-of-stay (LOS), antibiotic use and on cost per patient with suspected EV meningitis, compared with testing at an outside reference laboratory. A model-based analysis using a retrospective cohort of all hospitalized children with CSF EV PCR testing done between November 2013 and 2017. The primary outcome measured was the potential date of discharge if the EV PCR result had been available on the same day. Patients with positive EV PCR were considered for potential earlier discharge once clinically stable with no reason for hospitalization other than intravenous antibiotics. Descriptive statistics and cost-sensitivity analyses were performed. CSF EV PCR testing was done on 153 patients, of which 44 (29%) had a positive result. Median test TAT was 5.3 days (IQR 3.9–7.6). Median hospital LOS was 5 days (IQR 3–12). Most (86%) patients received intravenous antibiotics with mean duration of 5.72 ± 6.51 days. No patients with positive EV PCR had a serious bacterial infection. We found that same-day test TAT would reduce LOS and duration of intravenous antibiotics by 0.50 days (95%CI 0.33–0.68) and 0.67 days (95%CI 0.42–0.91), respectively. Same-day test TAT was associated with a cost reduction of 342.83CAD (95%CI 178.14–517.00) per patient with suspected EV meningitis. Compared with sending specimens to a reference laboratory, performing CSF EV PCR in-hospital with same-day TAT was associated with decreased LOS, antibiotic therapy, and cost per patient.

Enteroviral infection in neonates

Enteroviruses generally cause mild and self-limited diseases, but they have been found to affect neonates much differently, and often more severely than older children. Clinical manifestations are difficult to differentiate from those of bacterial sepsis, such as fever, poor feeding, lethargy, respiratory distress and cardiovascular collapse. Severe life threatening complications, including hepatic necrosis with coagulopathy, meningoencephalitis and myocarditis, usually present during the first week of life. Factors affecting severity and outcome include virus serotype, mode of transmission, and presence or absence of passively acquired, serotype-specific maternal antibodies. Echoviruses and coxsackievirus B viruses are most common serotypes associated with the neonatal sepsis. An awareness of the clinical syndromes, recognition of the risk factors and monitoring parameters associated with severe cases and use of rapid reverse-transcriptase polymerase chain reaction test for viral load may help physicians in diagnosing severe cases in a timely manner. Prompt aggressive treatment including early intravenous immunoglobulin treatment may help in reducing morbidity and mortality. Enterovirus infections in neonates are common and should be routinely considered in the differential diagnosis of febrile neonates, particularly during enterovirus season. This article provides an overview of what is known about non-polio enteroviruses in neonates including epidemiology, transmission, clinical presentation, diagnosis, and treatment.

Neonatal parechovirus infection mimicking a surgical abdomen

Human parechovirus-3 (PeVA3) infection is a common cause of febrile illness in young infants and the spectrum of clinical presentation is broad. We describe a term infant who presented with marked abdominal distension and anorexia, concerning for an acute surgical abdomen. Evaluation revealed that the infant had PeVA3 infection. This case highlights the importance of recognising severe abdominal distension and discomfort as a clinical presentation associated with PeV and the potential utility of rapid testing for PeV.

A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections

IMPORTANCE

In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs.

OBJECTIVE

To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs.

DESIGN, SETTING, AND PARTICIPANTS

Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018.

EXPOSURES

Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis.

MAIN OUTCOMES AND MEASURES

Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis.

RESULTS

We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia.

CONCLUSIONS AND RELEVANCE

We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

Retrospective Evaluation of Infants Aged 1 to 60 Days with Residual Cerebrospinal Fluid (CSF) Tested Using the FilmArray Meningitis/Encephalitis (ME) Panel

In pediatric practice it is common for infants under 2 months of age to undergo evaluation for sepsis when they are ill, often including lumbar puncture to assess for central nervous system (CNS) infection. The FilmArray Meningitis/Encephalitis (ME) panel is a newly approved test for rapid identification of CNS pathogens. Our objective was to study the epidemiology of CNS infection in young infants and the potential impact of rapid multiplex PCR on their care. A performance evaluation of the FilmArray ME panel was conducted from February 2014 to September 2014 at 11 sites. FilmArray ME panel results were compared to reference standards but not shared with providers. In our study, medical records for infants (aged 1 to 60 days) enrolled at three sites were reviewed for clinical, laboratory, and outcome data. A total of 145 infants were reviewed. The median age was 25 days. Most of the infants were hospitalized (134/145 [92%]) and received antibiotics (123/145 [85%]), and almost half (71/145 [49%]) received acyclovir. One infant had a bacterial pathogen, likely false positive, identified by the FilmArray ME panel. Thirty-six infants (25%) had a viral pathogen detected, including 21 enteroviruses. All infants with enteroviral meningitis detected by the FilmArray ME panel and conventional PCR were hospitalized, but 20% were discharged in less than 24 h when conventional PCR results became available. The FilmArray ME panel may play a role in the evaluation of young infants for CNS infection. Results may be used to guide management, possibly resulting in a decreased length of stay and less antimicrobial exposure for infants with low-risk viral infection detected.

Cerebrospinal Fluid Reference Values for Young Infants Undergoing Lumbar Puncture

OBJECTIVES

To determine age-specific reference values and quantify age-related changes for cerebrospinal fluid (CSF) white blood cell (WBC) counts and protein and glucose concentrations in infants ≤60 days of age.

METHODS

This multicenter, cross-sectional study included infants ≤60 days old with CSF cultures and complete CSF profiles obtained within 24 hours of presentation. Those with conditions suspected or known to cause abnormal CSF parameters (eg, meningitis) and those with a hospital length of stay of >72 hours were excluded. Reference standards were determined for infants ≤28 days of age and 29 to 60 days of age by using the third quartile +1.5 interquartile range for WBC and protein and the first quartile -1.5 interquartile range for glucose. CSF parameter centile curves based on age were calculated by using the LMST method.

RESULTS

A total of 7766 patients were included. CSF WBC counts were higher in infants ≤28 days of age (upper bound: 15 cells/mm³) than in infants 29 to 60 days of age (upper bound: 9 cells/mm³; P < .001). CSF protein concentrations were higher in infants ≤28 days of age (upper bound: 127 mg/dL) than in infants 29 to 60 days of age (upper bound: 99 mg/dL; P < .001). CSF glucose concentrations were lower in infants ≤28 days of age (lower bound: 25 mg/dL) than in infants 29 to 60 days of age (lower bound: 27 mg/dL; P < .001).

CONCLUSIONS

The age-specific CSF WBC count, protein concentration, and glucose concentration reference values identified in this large, multicenter cohort of infants can be used to interpret the results of lumbar puncture in infants ≤60 days of age.