Clinical utility of the polymerase chain reaction for diagnosis of enteroviral meningitis in infancy

Prevalence of Enterovirus Meningitis in Children: Report from a Tertiary Center

Meningitis is the most frequent infection of the central nervous system and viruses aret he most common agents. Enteroviruses are among the most important causative agents. The goal of this study was to determine Coxsackievirus and echovirus infections in children referred to Bahrami Hospital with the diagnosis of meningitis. Forty children with the diagnosis of meningitis, who were referred betweeen January 2017 and February 2018, were evaluated. Forty cases were evaluated. Twenty two (55%) were males and 18 (45%) females (M/F=2.1). The most common age group was 0-4 years and the most cases were admitted in autumn and summer. Entroviruses are the causative agent of meningitis in 26 (65%) cases, including coxsackieviruse type B5 in 18(69%) and coxsackieviruse type B4 in 2(10%). Six meningitis cases were caused by echoviruses(30%). In both coxsackieviruus and echovirus groups, the most frequent age group was less than four year. Among the 26 cases with enterovirus infection, three were admitted in spring (11.5%), eight in summer (30.7%), 10 in autumn (38.4%) and fice (19.2%) in winter. The most common symptoms in cases with entroviruses infection were fever in 26 (100%) patients and nausea/vomiting in 18 (69.2%). Entroviruses are among the most common viral infections leading to meningitis in Iranian children. Rapid diagnosis will result in early and proper treatment.

Antibiotic Use in Febrile Children Presenting to the Emergency Department: A Systematic Review

Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.

Cerebrospinal fluid non-pleocytosis in pediatric enteroviral meningitis: Large-scale review

BACKGROUND

Lack of cerebrospinal fluid (CSF) pleocytosis has been reported in some children with enteroviral meningitis (EVM). The aim of this paper was to investigate the clinical spectrum and related factors in EVM with CSF non-pleocytosis.

METHODS

The databases of children diagnosed with EVM on CSF polymerase chain reaction between 2011 and 2014 were retrospectively reviewed. CSF pleocytosis was defined at each age using the criteria. Clinical and laboratory variables were compared between patients with CSF pleocytosis and non-pleocytosis.

RESULTS

Of the 802 children of EVM, 25.4% (204/802) had CSF non-pleocytosis. In particular, CSF non-pleocytosis was found in 63.3% of the neonates versus in 22.2% of the children aged ≥1 year old, indicating that the ratio of CSF non-pleocytosis had a negative correlation with age (P < 0.001). As the main symptoms, fever (91.8% vs 86.8%, P = 0.038), headache (80.3% vs 63.7%, P < 0.001), and vomiting (75.9% vs 61.8%, P < 0.001) were significantly more frequent in CSF pleocytosis than in CSF non-pleocytosis. Patients with CSF non-pleocytosis had much lower peripheral leukocytosis (10 656 ± 3,662 vs 12 403 ± 4,207/mm³ , P = 0.014) and C-reactive protein (0.7±0.8 vs 1.2±1.5 mg/dL, P < 0.001), and earlier lumbar puncture <24 h after onset (42.6% vs 21.4%, p<0.001). No significant difference during the summer and autumn months was seen between the two groups (76.9% vs 81.9%, P = 0.169).

CONCLUSION

CSF non-pleocytosis in childhood EVM was frequently observed, especially in young infants, regardless of season. We propose that CSF PCR testing for enterovirus can be helpful to recognize EVM in children with CSF non-pleocytosis.

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.

Enteroviruses and Parechoviruses

Infections with enteroviruses and human parechoviruses are highly prevalent, particularly in neonates, where they may cause substantial morbidity and mortality. Individuals with B-cell-related immunodeficiencies are at risk for severe enteroviral infections, usually a chronic and fatal meningoencephalitis. In transplant recipients and patients with malignancy, enterovirus infections typically involve the respiratory tract, but cases of severe, disseminated infection have been described. The mainstay of diagnosis for enterovirus and human parechovirus infections involves the use of molecular diagnostic techniques. However, routine nucleic acid-detection methods for enteroviruses will not detect human parechoviruses. Laboratory diagnosis of these viral infections is important in determining a patient's prognosis and guiding clinical management.

Analysis of clinical information and reverse transcriptase-polymerase chain reaction for early diagnosis of enteroviral meningitis

Purpose

Meningitis is among the most common infections affecting the central nervous system. It can be difficult to determine the exact pathogen responsible for the infection and patients are often treated with empiric antibiotics. This study was conducted to identify the most common clinical characteristics of enteroviral meningitis in children and evaluate the diagnostic efficacy of reverse transcriptase-polymerase chain reaction (RT-PCR) for early detection of an enterovirus.

Methods

We analyzed the medical records of children admitted to Korea University Medical Center and diagnosed with meningitis on the basis of cerebrospinal fluid (CSF) analysis and RT-PCR from CSF and other samples from January 2010 to August 2013.

Results

A total of 333 patients were enrolled and classified into four groups based on diagnosis: enteroviral meningitis (n=110), bacterial meningitis (n=23), other viral meningitis (n=36), and unknown etiology (n=164). Patients with bacterial meningitis were younger than those in the other groups (P<0.001). Pleocytosis in CSF was similar across all groups. Of patients in the enteroviral meningitis group, 92.7% were diagnosed based on RT-PCR findings. Mean length of hospital stay for patients with enteroviral meningitis was 6.08 days, which was significantly shorter than that for patients with meningitis of bacterial etiology (19.73 days, P<0.001).

Conclusion

Diagnosis of enteroviral meningitis before viral culture results are available is possible using RT-PCR. Accurate diagnosis reduces the length of hospital stay and helps to avoid unnecessary empiric antibiotic treatment.

Enterovirus infections in England and Wales, 2000-2011: the impact of increased molecular diagnostics

There have recently been significant changes in diagnostic practices for detecting enterovirus (EV) infections across England and Wales. Reports of laboratory-confirmed EV infections submitted by National Health Service (NHS) hospital laboratories to Public Health England (PHE) over a 12-year period (2000-2011) were analysed. Additionally, the PHE Virus Reference Department (VRD) electronic database containing molecular typing data from 2004 onwards was interrogated. Of the 13,901 reports, there was a decline from a peak of 2254 in 2001 to 589 in 2006, and then an increase year-on-year to 1634 in 2011. This increase coincided with increasing PCR-based laboratory diagnosis, which accounted for 36% of reported cases in 2000 and 92% in 2011. The estimated annual incidence in 2011 was 3.9/100,000 overall and 238/100,000 in those aged <3 months, who accounted for almost one-quarter of reported cases (n = 2993, 23%). During 2004-2011, 2770 strains were submitted for molecular typing to the VRD, who found no evidence for a predominance of any particular strain. Thus, the recent increase in reported cases closely reflects the increase in PCR testing by NHS hospitals, but is associated with a lower proportion of samples being submitted for molecular typing. The high EV rate in young infants merits further investigation to inform evidence-based management guidance.

Prospective comparison of the detection rates of human enterovirus and parechovirus RT-qPCR and viral culture in different pediatric specimens

BACKGROUND

Reverse-transcriptase quantitative real-time polymerase chain reaction (RT-qPCR) has become the gold standard for the diagnosis of human enterovirus (EV) and parechovirus (HPeV) infections. The detection rate of RT-qPCR in different pediatric body specimens has not been compared prospectively in a multicentre study.

OBJECTIVES

This study compared the diagnostic detection rates of EV and HPeV RT-qPCR and viral culture in different specimens (feces, nasopharynx, blood, urine and cerebrospinal fluid (CSF)) of pediatric patients.

STUDY DESIGN

This prospective, multicenter study performed an EV and HPeV RT-qPCR on nasopharynx, blood, urine, feces and CSF specimens and a viral culture on nasopharynx, feces and CSF specimens in symptomatic children<16 years.

RESULTS

Of 285 included children EV was detected in 140 (49%) and HPeV in 44 (15%) children. Both EV and HPeV RT-qPCR had a higher sensitivity and negative predictive value than EV and HPeV viral culture, respectively. EV and HPeV RT-qPCR in feces specimen had the highest sensitivity (99.2% and 95.1%) of all specimens. Pooling results of specimens increased the detection rate for both viruses.

CONCLUSION

Of all specimens, RT-qPCR in feces had the highest detection rate for both EV and HPeV in symptomatic pediatric patients. An EV was detected in all EV positive patients if a RT-qPCR was performed on both feces and CSF specimens or in both feces and urine specimens. HPeV was detected in all HPeV positive patients if a RT-qPCR was performed on both feces and CSF specimens, feces and nasopharynx specimens or CSF and nasopharynx specimens.

[Value of polymerase chain reaction in serum for the diagnosis of enteroviral meningitis]

Enteroviruses (EV) are a common cause of aseptic meningitis in children. Virological diagnosis of EV meningitis is currently based on the detection of the viral genome in the cerebrospinal fluid (CSF). This study attempted to determine the correlation and the temporality of the polymerase chain reaction (PCR) assay in serum and CSF and to evaluate the possibility of diagnosing EV infection only on the serum PCR. The EV genome was sought by RT real-time PCR (Smart Cycler EV Primer and Probe Set(®), Cepheid) in CSF and serum, collected at the same time, for all children who underwent a lumbar puncture for suspected meningitis, between 1 June and 31 July 2010 at the Versailles Hospital. Forty-four patients were included in the study. EV infection was documented for 22 of them. In 10 patients, the EV genome was detected in CSF only; in 3 patients in serum only, and in 9 patients in both. Among patients with acute EV neurological infection, viremic children were significantly younger (1.6 months versus 5.8 years; P<0.001). Viremia was detected when the serum was sampled within 30 h after the beginning of symptoms. These results confirm previous reports of early and transient viremia in young children. This preliminary study shows the limits and added value of EV PCR in serum. It suggests that in some children and under certain conditions (age >3 months, clinical and biological compatibility with a viral infection, no previous antibiotic therapy, time from symptom onset to blood sampling <30 h, PCR in serum analyzed within 3h), PCR in serum, when positive, is a possible alternative. Therefore, it may be possible to diagnose EV infection without performing a lumbar puncture in a limited number of young children (11.4% of our suspected cases). This study needs to be reinforced by a multicenter study with a broader panel of patients.

Laboratory diagnosis of CNS infections by molecular amplification techniques

The initial presentation of symptoms and clinical manifestations of CNS infectious diseases often makes a specific diagnosis difficult and uncertain, and the emergence of polymerase chain reaction-led molecular techniques have been used in improving organism-specific diagnosis. These techniques have not only provided rapid, non-invasive detection of microorganisms causing CNS infections, but also demonstrated several neurologic disorders linked to infectious pathogens. Molecular methods performed on cerebrospinal fluid are recognized as the new 'gold standard' for some of these infections caused by microorganisms that are difficult to detect and identify. Although molecular techniques are predicted to be widely used in diagnosing and monitoring CNS infections, the limitations as well as strengths of these techniques must be clearly understood by both clinicians and laboratory personnel.

Infecciones neonatales (II)☆

Las infecciones neonatales son un problema de salud pública mundial. Su incidencia se aproxima al 1 % de los nacimientos en los países industrializados, pero es más elevada en los países en desarrollo. En 1996, las infecciones aparecidas en el primer mes de vida eran responsables de cinco millones de fallecimientos anuales.

Casi todos los microorganismos patógenos (bacterias, hongos y virus) pueden ser causantes de infecciones en el recién nacido. La epidemiología bacteriana varía según las épocas, los países e incluso las regiones, lo que impide extrapolar las propuestas terapéuticas formuladas a partir de la expenencia de un centro, tanto en lo que se refiere a los protocolos curativos como a los preventivos.

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

BACKGROUND

Enteroviral meningitis is a common cause of meningitis in children which requires only supportive care.

OBJECTIVE

To evaluate the impact of implementing an in-hospital enteroviral polymerase chain reaction (EVPCR) testing protocol on the clinical management of children with meningitis.

DESIGN

Retrospective cohort study.

POPULATION

Children <19 years old with meningitis.

INTERVENTION

EVPCR testing differed by time period: send-out testing protocol from July 1, 2006-June 23, 2008 (pre-period) versus in-house testing protocol from June 24, 2008-June 30, 2010 (post-period).

MEASUREMENTS

Test turnaround time, test utilization, length of stay, and duration of parenteral antibiotics.

RESULTS

Of the 441 study patients, 216 (49%) presented during the post-period. Median age was 2.9 months (interquartile range, 1.5-96 months). Test turnaround time decreased with the in-house test (53 hours pre vs 13 hours post, P < 0.001), and test utilization increased (28% pre vs 62% post, P < 0.001). Among children with a positive EVPCR test, both length of stay (44 hours pre vs 28 hours post, P = 0.005) and duration of parenteral antibiotics (48 hours pre vs 36 hours post, P = 0.04) decreased in the post-period. No change in either of these outcomes was observed in children with meningitis and a negative EVPCR test.

CONCLUSION

In-house EVPCR testing reduced test turnaround time, increased test utilization, and reduced both length of stay and duration of parenteral antibiotics for children with a positive result. Clinicians caring for children with meningitis should have access to in-hospital EVPCR testing.

Clinical and analytical characteristics and short-term evolution of enteroviral meningitis in young infants presenting with fever without source

OBJECTIVE

The objective of this study was to describe the characteristics of the enteroviral meningitis diagnosed in a pediatric emergency department among infants younger than 3 months with fever without source and its short-term evolution.

METHODS

This was a retrospective, cross-sectional, 6-year descriptive study including all infants younger than 3 months who presented with fever without source and who were diagnosed with enteroviral meningitis.

RESULTS

A lumbar puncture was practiced at their first emergency visit in 398 (29.5%) of 1348 infants, and 65 (4.8%) were diagnosed with enteroviral meningitis, 33 of them (50.7%) between May and July. Among these 65 infants, 61 were classified as well-appearing; parents referred irritability in 16 (25.3%) of them (without statistical significance when compared with infants without meningitis). Forty-one (63.0%) had no altered infectious parameters (white blood cell [WBC] count between 5000 and 15,000/μL, absolute neutrophil count less than 10,000/μL, and C-reactive protein less than 20 g/L), and 39 (60%) had no pleocytosis. All of the 65 infants recovered well, and none of them developed short-term complications.

CONCLUSIONS

The symptoms in infants younger than 3 months with enteroviral meningitis were similar to those in infants with a self-limited febrile process without intracranial infection. C-reactive protein and WBC count were not good enteroviral meningitis predictors. Cerebrospinal fluid WBC count was normal in many of these infants, so performing a viral test is recommended for febrile infants younger than 3 months in which a lumbar puncture is practiced during warm months. The short-term evolution was benign.

Characteristics of pediatric patients with enterovirus meningitis and no cerebral fluid pleocytosis

Human non-polio enterovirus (EV) is the most important cause of aseptic meningitis in children. Only a few studies report the lack of cerobrospinal fluid (CSF) pleocytosis in children with confirmed EV meningitis; however, the characteristics of these children have not been well defined. This paper describes the clinical and laboratory features of EV meningitis in children with no CSF pleocytosis. Clinical, laboratory, and virological data of Dutch patients <16 years diagnosed with EV meningitis, between 2003 and 2008, were analyzed retrospectively. Data of children with and without CSF pleocytosis were compared. A total of 149 children were infected with EV. Patients presented mainly with fever (n = 113), malaise (n = 43), abdominal pain (n = 47), and irritability (n = 61). Of the 60 patients with EV meningitis, 23 had no pleocytosis. Those who lacked CSF pleocytosis were younger [odds ratio (OR) 1.00; 95% confidence interval (CI) 1.000-1.002; p = 0.001], had experienced drowsiness more (OR 9.60; 95% CI 2.24-41.15; p = 0.002), had lower white blood cell counts (OR 0.73; 95% CI 0.61-0.89; p = 0.001), and had higher C-reactive protein (OR 1.13; 95% CI 1.03-1.23; p = 0.006) than those with pleocytosis.

CONCLUSION

These findings show that EV meningitis occurs in the absence of CSF pleocytosis, particularly in young infants, meaning that EV meningitis in this age group cannot be solely excluded by the absence of CSF pleocytosis. They also confirm the importance of genome detection in the diagnosis of EV meningitis in young infants.

Detection of enterovirus RNA in cerebrospinal fluid: comparison of two molecular assays

Enterovirus (EV) and human parechovirus (HPeV) are a major cause of infection in childhood. A rapid diagnostic test may improve the management of patients with EV and HPeV infection. The aim of this study is to evaluate the performance of the GeneXpert enterovirus assay (GXEA) for detection of EV RNA compared to a user-developed reverse-transcriptase (RT) quantitative real-time PCR (qPCR) in routine clinical practice. Also a RT-qPCR assay for detection of HPeV RNA in different clinical samples was developed and evaluated. Cerebrospinal fluid (CSF) from 232 patients suspected for meningitis was collected and tested for EV and HPeV using RT-qPCR assays. In parallel an aliquot of the samples was tested using the GXEA and viral culture. EV RNA was detected in 22 (19.0%) and 28 (24.1%) of 116 samples using the GXEA and RT-qPCR assay, respectively. EV was isolated from 10 of 116 (8.6%) samples by viral culture. GXEA had a sensitivity, specificity, positive predictive value and negative predictive value of 82.1%, 100%, 100% and 96.2%, respectively. In this study, molecular assays were superior to viral culture for detecting EV RNA in CSF. GXEA showed a high specificity but a lower sensitivity for the detection of EV RNA compared to the RT-qPCR assay.

Low prevalence of invasive bacterial infection in febrile infants under 3 months of age with enterovirus infection

Infants under 3 months of age with fever without source (FWS) generally undergo a full, invasive septic evaluation to exclude invasive bacterial infection (IBI). Enterovirus (EV) infections are mostly banal and self-limiting and show a high prevalence rate at this age. We aimed to investigate the prevalence of IBI in EV-infected and uninfected infants under 3 months of age with FWS. This was a prospective observational cohort study of infants aged <90 days who were admitted because of FWS. As per protocol, blood and urine analysis and culture were obtained in all cases, and RNA EV from blood and/or cerebrospinal fluid samples was determined by real-time PCR. Three hundred and eighty-one previously healthy infants with FWS were included. EV infection was diagnosed in 64 children (16.8%; 95% confidence interval, 13.2-20.9%) and showed an uneventful evolution in all cases. Laboratory markers of infection were consistently lower in EV-infected patients; only one case of IBI (1.6%) was observed in an EV-infected patient as compared with 25.2% in EV-negative infants (p <0.001). Intravenous antibiotic use and length of stay were no different in EV-infected and uninfected patients. In our study, febrile infants (<90 days) diagnosed with EV infection showed a low risk of IBI when compared with uninfected patients. The systematic investigation of EV infection in young infants with FWS may allow a more conservative approach to the management of these patients. Further studies on this diagnostic approach are needed.

Enhanced detection of enteroviruses in clinical samples by reverse transcription-PCR using complementary locked primer technology

To increase detection sensitivity, we modified primers using complementary locked primer (CLP) technology. The sensitivity of the reverse transcription-PCR (RT-PCR) with CLP-modified primers was 10- to 100-fold higher than that of RT-PCR without these primers. CLP-modified primers can increase sensitivity, providing a widely accessible method for molecular diagnosis.

Rapid routine detection of enterovirus RNA in cerebrospinal fluid by a one-step real-time RT-PCR assay

BACKGROUND AND OBJECTIVES

This study provides a one-step transcription/real-time (TaqMan probe) PCR assay (TM-PCR) with new consensus primer and probe sequences for generic detection of human pathogenic enteroviruses including difficult to detect ones like for instance Echovirus 30. The amplicon included parts of domain IV and V of the highly conserved internal ribosomal entry site. Generic detection was confirmed by testing a panel of 41 prototypes representing all five human enterovirus/poliovirus species.

STUDY DESIGN AND RESULTS

The 95% detection limit was found to be 100 copies per run using in vitro transcribed coxsackievirus B3 RNA. TM-PCR was compared to an in house nested-PCR assay implemented in detecting enterovirus RNA from CSF samples of patients suffering from meningitis and encephalitis. Concordant results were obtained in all samples (11 positive, 101 negative). Specificity was confirmed with laboratory strains of other neurotropic viruses, and by testing 76 CSF samples of patients with encephalomyelitis disseminata, which all gave negative results.

CONCLUSIONS

The new TM-PCR is a convincing alternative to conventional PCR protocols for the diagnosis of enterovirus meningitis. The one-step strategy limits hands on time and cross contamination risk combined with accelerated assay procedure of only 100 min.

Outbreak of Neurologic Enterovirus Type 71 Disease: A Diagnostic Challenge

BACKGROUND

Similar to poliovirus, enterovirus type 71 (EV71) causes severe disease, including aseptic meningitis, encephalitis, acute flaccid paralysis, and acute cardiopulmonary dysfunction. Large epidemics of EV71 infection have been reported worldwide.

METHODS

After recognition of a cluster of cases of EV71 disease, we reviewed records of patients with EV71 disease who required hospitalization at The Children's Hospital in Denver, Colorado, from 2003 through 2005. The presence of enterovirus was detected by reverse-transcriptase polymerase chain reaction (PCR) and/or viral culture of specimens from multiple sources, and the virus was typed as EV71 using genetic sequencing.

RESULTS

Eight cases of EV71 disease were identified in both 2003 and 2005. Fifty-six percent of patients with EV71 disease were < or = 6 months of age (range, 4 weeks to 9 years). All 16 patients had EV71 central nervous system infection. Enterovirus PCR (EV-PCR) of cerebrospinal fluid specimens yielded positive results for only 5 (31.2%) of the 16 patients; all of these patients were < 4 months of age and had less severe disease. However, EV-PCR of upper respiratory tract specimens yielded positive results for 8 (100%) of 8 patients, and EV-PCR of lower gastrointestinal tract specimens yielded positive results for 7 (87.5%) of 8 patients.

CONCLUSIONS

An outbreak of neurologic EV71 disease occurred in Denver, Colorado, during 2003 and 2005. Likely, EV71 disease remains unrecognized in other parts of the United States, because EV-PCR of cerebrospinal fluid frequently yields negative results. EV-PCR of specimens from the respiratory and gastrointestinal tracts had higher diagnostic yields than did EV-PCR of cerebrospinal fluid. EV71 infection should be considered in young children presenting with aseptic meningitis, encephalitis, acute flaccid paralysis, or acute cardiopulmonary collapse. EV71 infection may be an underrecognized emerging disease in the United States.

Routine cerebrospinal fluid enterovirus polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days of age or younger

OBJECTIVE

The goal was to evaluate the impact of cerebrospinal fluid enterovirus polymerase chain reaction testing on the length of hospitalization and the duration of antibiotic use for infants < or = 90 days of age with suspected aseptic meningitis.

METHODS

This retrospective cohort study was conducted at an urban, tertiary-care children's hospital. Data were collected for 478 patients < or = 90 days of age for whom cerebrospinal fluid enterovirus polymerase chain reaction testing was performed during the enteroviral seasons of 2000 to 2006. The length of hospitalization and the duration of antibiotic use were assessed.

RESULTS

Cerebrospinal fluid enterovirus polymerase chain reaction test results were positive for 154 patients (34.8%). The mean length of stay was 3.65 days. The median polymerase chain reaction turnaround time was 23 hours. In multivariate analysis, having a positive cerebrospinal fluid enterovirus polymerase chain reaction result was associated with a 1.54-day decrease in the length of stay and a 33.7% shorter duration of antibiotic use. When patients were stratified according to the presence or absence of pleocytosis, both groups demonstrated significant reductions in the length of stay with positive cerebrospinal fluid enterovirus polymerase chain reaction results (1.32 and 1.38 days, respectively). Furthermore, increasing the polymerase chain reaction turnaround time by 24 hours increased the length of stay by 13.6% for patients with positive cerebrospinal fluid enterovirus polymerase chain reaction results.

CONCLUSIONS

Having positive cerebrospinal fluid enterovirus polymerase chain reaction results decreases the length of hospitalization and the duration of antibiotic use for young infants. These results support the routine use of this test during periods of peak enterovirus prevalence.

Aseptic meningitis in children: analysis of 506 cases

BACKGROUND

Non-polio human enteroviruses are the leading cause of aseptic meningitis in children. The role of enterovirus PCR for diagnosis and management of aseptic meningitis has not been fully explored.

METHODOLOGY/PRINCIPAL FINDINGS

A retrospective study was conducted to determine the epidemiological, clinical, and laboratory characteristics of aseptic meningitis and to evaluate the role of enterovirus PCR for the diagnosis and management of this clinical entity. The medical records of children who had as discharge diagnosis aseptic or viral meningitis were reviewed. A total of 506 children, median age 5 years, were identified. The annual incidence rate was estimated to be 17/100,000 children less than 14 years of age. Most of the cases occurred during summer (38%) and autumn (24%). The dominant clinical symptoms were fever (98%), headache (94%) and vomiting (67%). Neck stiffness was noted in 60%, and irritation in 46% of the patients. The median number of CSF cell count was 201/mm(3) with polymorphonuclear predominance (>50%) in 58.3% of the cases. Enterovirus RNA was detected in CSF in 47 of 96 (48.9%) children tested. Children with positive enterovirus PCR had shorter hospitalization stay as compared to children who had negative PCR or to children who were not tested (P = 0.01). There were no serious complications or deaths.

CONCLUSIONS

Enteroviruses accounted for approximately one half of cases of aseptic meningitis. PCR may reduce the length of hospitalization and plays important role in the diagnosis and management of children with aseptic meningitis.

Épidémie estivale de méningites à entérovirus en 2005: expérience d'un service de pédiatrie générale

OBJECTIVE

To describe the clinical and biological characteristics of children presenting with enteroviral (EV) meningitis in a French paediatric unit during summer 2005.

METHODS

Retrospective study of children with EV meningitis from May to September 2005, diagnosed by PCR and/or viral culture in cerebrospinal fluid (CSF), serum or throat.

RESULTS

We reported 99 cases of EV meningitis (96 confirmed and 3 probable). The sex ratio was 2/1, and the median age was 5 years. Peak incidence was reached during the second week of July. The predominant symptom was meningism. ENT (16%), digestive (10%), cutaneous (15%) or respiratory (4%) symptoms were rare. Blood leucocyte count found a predominance of neutrophils (73%), and lymphopenia in half of the children. The mean value of CRP was 25,5 mg/l. The median leukocyte count in CSF was 65 cells/mm(3), with a prevalence of neutrophils in 60% of cases. Pleiocytosis was absent in 20 children. CSF protein level was increased in 20% of cases. The rate of hospitalization was 57,5%. Intravenous antibiotic treatment, initiated among 18 patients, was stopped in 66,6% of the cases on reception of PCR result. The latter result was obtained in 2,3 days on average.

CONCLUSION

The epidemic of 2005 EV meningitis was as widespread as that of summer 2000. Characteristics of these meningitis are strong proportion of CSF without pleiocytose and high prevalence of neutrophils in blood and CSF.

Neonatal enterovirus infections reported to the national enterovirus surveillance system in the United States, 1983-2003

BACKGROUND

Neonatal enterovirus (EV) infections lead to a wide range of clinical manifestations, from mild febrile illness to severe, sometimes fatal, sepsislike disease.

METHODS

To determine the relationship of EV serotypes with the risk of neonatal infection and its fatal outcome, we analyzed data reported to the National Enterovirus Surveillance System (NESS) during 1983-2003.

RESULTS

Of the 26,737 EV detections reported during this period, neonates accounted for 2544 (11.4% of those with known age). Serotypes most commonly isolated from neonates included echovirus (E) 11 (14.0% of EV with known serotype), coxsackievirus (CV) B2 (8.9%), CVB5 (7.5%), E6, E9 and CVB4 (6.8% each). CVB1-4, E11, and E25 were significantly more common, whereas CVA16, E4, E9, E21, E30, and human parechovirus 1 (formerly E22) were less common among neonates than among persons aged > or =1 month. Fatal outcome was noted for 3.3% of reports, with neonates at a higher risk of death than persons aged > or =1 month (11.5% versus 2.5%; odds ratio [OR] 5.1; 95% confidence interval [CI] = 3.3-7.8). Neonates infected with CVB4 were at a higher risk of death (OR 6.5; 95% CI = 2.4-17.7) than those infected with other EV.

CONCLUSION

EV are important neonatal pathogens associated with high risk of infection and death. Because of the limitations of the NESS (incomplete reporting, limited clinical data, bias towards more severe and younger cases), additional studies are needed to better evaluate the role of different EV in neonatal infections.

Molecular and epidemiologic analysis of enterovirus B neurological infection in Argentine children

BACKGROUND

Human enteroviruses are one of the major causes of central nervous system (CNS) infections in pediatrics.

STUDY DESIGN

We have studied 1242 children under 15 years old with suspicion of CNS infection from January 1998 to December 2003. CSF was obtained and molecular typing of human enterovirus B serotypes was performed by RT-PCR and sequencing of the N-terminal part of VP1 gene.

RESULTS

According to the clinical syndromes, patients were grouped as aseptic meningitis (n=654, 52.6%), encephalitis (n=239, 19.2%), febrile seizures (n=153, 12.3%), febrile infant (n=84, 6.7%), neonatal disease (n=70, 5.6%),), acute flaccid paralysis (n=31, 2.4%) and acute disseminated encephalomyelitis (n=11, 0.9%). HEV was detected in 335/1242 CSF samples (26.97%) and was associated to aseptic meningitis (n=243, 72.5%); febrile infant (n=31, 9.2%); neonatal infection (n=26, 7.7%); encephalitis (n=25, 7.5%), febrile seizures (n=9, 2.68%); acute flaccid paralysis (n=1, 0.3%). Seasonal incidence of HEV-B species was analyzed showing that in Buenos Aires infections occur mainly during late spring and summer. Molecular serotyping was completed in 60/335 samples. Echovirus 30, Echovirus 9, Coxsackie B3 to B5 and Echovirus 33 were the most frequently identified.

CONCLUSIONS

We showed that HEV are responsible for a considerable proportion of hospitalizations in children with central nervous system compromise reaching 27% of overall etiology.

Diagnosis and outcomes of enterovirus infections in young infants

BACKGROUND

Enterovirus (EV) infections commonly cause fever in infants younger than 90 days of age. The polymerase chain reaction (PCR) has improved our ability to diagnose EV infections.

OBJECTIVE

To evaluate the utility of blood and cerebrospinal fluid (CSF) specimens for the diagnosis of EV infections by PCR and to describe a large cohort of EV-infected infants.

DESIGN/METHODS

Febrile infants younger than 90 days of age evaluated for sepsis at Primary Children's Medical Center in Salt Lake City, UT, were enrolled in a prospective study designed to identify viral infections from December 1996 to June 2002. All patients had bacterial cultures of blood, urine and CSF. Testing for EV was performed by PCR and/or viral cultures. Patients who were positive for EV were identified for this study.

RESULTS

Of 1779 febrile infants enrolled, 1061 had EV testing and 214 (20%) were EV-positive. EV infections were diagnosed by PCR of blood, CSF or both in 93% of infants. PCR testing was positive in blood in 57%, and blood was the only positive specimen for 22% of EV infected infants. PCR of CSF was positive in 74%. The mean age of infants with EV infection was 33 days, with 18% younger than 14 days and 5% younger than 7 days. Fifty percent of EV-positive infants had CSF pleocytosis. Of EV PCR-positive infants, 91% were admitted, and 2% required intensive care. Possible serious EV disease was diagnosed in <1%, and there were no deaths. Twelve infants (5.6%) had concomitant urinary tract infection, and 3 (1%) had bacteremia.

CONCLUSIONS

EV infections are common in febrile infants younger than 90 days. Blood and CSF are equally likely to yield positive results by PCR, but the combination of both specimens improved the diagnostic yield.

Defining bacterial meningitis and other infections of the central nervous system

OBJECTIVE

To define central nervous system infections of infants and children that occur as co-morbid or predisposing conditions of sepsis.

DESIGN

Standard pediatric infectious disease references and the pertinent literature in English were reviewed from 1960 to 2002 to ascertain the previous methods and definitions utilized in clinical studies of the epidemiology and treatment of bacterial infections of the central nervous system. An accepted definition of bacterial meningitis defined by the Infectious Disease Society of America was reviewed and adapted to the previous clinical definitions. The information was formulated into a proposed standard for definite, probable, and possible bacterial infections of the central nervous system.

RESULTS

The diagnosis of definite bacterial infection of the central nervous system, including bacterial meningitis, requires the isolation of the pathogen from the cerebrospinal fluid or other significant clinical site such as surgical tissue, an implanted device, or blood. Probable bacterial infection is defined by the association of a compatible clinical syndrome or cerebrospinal fluid changes associated with bacterial meningitis or other central nervous system infection, and confirmed as an anatomically defined infection by imaging or surgery, in association with positive blood cultures or bacterial antigen from cerebrospinal fluid. Possible bacterial meningitis may be defined as a compatible clinical syndrome with predefined cerebrospinal fluid changes in the absence of a confirmatory culture or antigen test from any site.

CONCLUSIONS

Bacterial meningitis and other central nervous system bacterial infections can be defined as definite, probable, and possible with a combination of a defining compatible clinical syndrome and an anatomic definition by surgery or imaging, coupled with isolation of the organism, bacterial antigen, or other defining molecular component of the organism.

[Neuromeningeal enterovirus infections in Tunisia: epidemiology, clinical presentation, and outcome of 26 pediatric cases]

Non-polio enteroviruses are the most common identified cause of viral neuromeningeal infections following the introduction of the mumps and polio vaccines.

OBJECTIVE

The aim of this study was to describe the epidemiology, clinical presentation, and the outcome of enteroviral infections of the CNS.

METHOD AND PATIENTS

We performed a prospective study on 41 children admitted for viral neuromeningeal infections in the pediatric department of Monastir between December 2001 and November 2002. Enteroviruses were detected from cerebrospinal fluid by RT-PCR.

RESULTS

This study showed that enteroviruses were responsible for 63.4% of the infections. The mean age of patients was 6.1 years. Aseptic meningitis was diagnosed in 14 cases and encephalitis in 10. The most frequent symptom was fever (61.5%), followed by seizures (42.3%), and confusion (23%). On follow-up, all patients with meningitis had recovered without sequels. Neurological complications in patients with encephalitis were epilepsy (3 cases), cerebral palsy (2 cases), and mental retardation (1 case).

CONCLUSION

This study confirmed that enteroviruses were the most common cause of viral infections of the CNS. Common use of RT-PCR can have a significant impact on the outcome of patients with enterovirus infections.

Presentation, diagnosis, and management of enterovirus infections in neonates

The nonpoliovirus enteroviruses commonly infect newborns, with consequences ranging from asymptomatic infection and benign illness, to severe, life-threatening disease. Frequently occurring symptoms include fever, irritability, lethargy, anorexia, and rash. Although most illnesses are mild, severe disease develops in a subset of newborns infected in the first 2 weeks of life. Severe disease may consist of sepsis, meningoencephalitis, myocarditis, pneumonia, hepatitis, and/or coagulopathy. Substantial mortality rates have been reported, and long-term sequelae may occur among survivors. Risk factors and clinical features associated with severe disease include absence of neutralizing antibody to the infecting serotype, maternal illness prior to or at delivery, prematurity, illness onset within the first few days of life, multiorgan disease, severe hepatitis, positive serum viral culture, and specific infecting serotype (e.g. group B coxsackieviruses and echovirus 11). Whereas the mainstay of diagnosis has traditionally been viral isolation in tissue culture, the polymerase chain reaction has been demonstrated to be more sensitive than culture, highly specific, and rapid. Immunoglobulin has been used as a therapeutic agent for neonates with enterovirus disease; however, clinical efficacy has not been proven. Specific antiviral therapy for enteroviruses is in development. Pleconaril is an investigational agent that inhibits viral attachment to host cell receptors and uncoating of viral nucleic acid. It has broad and potent anti-enterovirus activity, excellent oral bioavailability, and is well tolerated. Some clinical trials have demonstrated benefit in children and adults with enterovirus meningitis, and in adults with upper respiratory tract infections caused by picornaviruses (rhinoviruses or enteroviruses). Data summarizing compassionate use for severe enterovirus diseases (including neonatal sepsis) also suggest possible benefit. Limited pharmacokinetic data are available in infants and neonates. A multicenter, placebo-controlled, randomized trial of pleconaril in neonates with severe hepatitis, coagulopathy, and/or myocarditis is currently being conducted.

Diagnosis of enterovirus infection in the first 2 months of life by real-time polymerase chain reaction

During summer and fall, enterovirus infections are responsible for a considerable proportion of hospitalizations of young infants. We prospectively studied the incidence of enterovirus infections via real-time polymerase chain reaction (PCR) in blood, feces, and cerebrospinal fluid samples from infants <or=60 days old who had received a clinical diagnosis of sepsis. Forty-five patients were included: 19 were admitted to the pediatric wards of 2 general hospitals, and 26 had been hospitalized since birth in the neonatal intensive care unit (NICU) of a tertiary care hospital. None of the NICU patients developed enteroviral disease. In contrast, an enterovirus was detected in 11 (58%) of the patients admitted to the 2 general hospitals, 10 of whom (53%) showed evidence of systemic infection. Enterovirus infections are an important cause of sepsis in infants admitted to the hospital. Real-time PCR in serum was a rapid and sensitive method for diagnosis of enterovirus infection.

Molecular Techniques in the Diagnosis of Central Nervous System Infections

Development of polymerase chain reaction (PCR)-based molecular techniques has initiated a revolution in the field of diagnostic microbiology. These techniques have not only provided rapid, noninvasive detection of microorganisms that cause central nervous system (CNS) infections, but have also demonstrated that several neurologic disorders are linked to infectious agents. While PCR-based techniques are predicted to be widely used in diagnosing and monitoring CNS infections, the limitations, as well as strengths, of these techniques must be clearly understood by both clinicians and laboratory personnel to ensure proper utilization.

Impact of rapid polymerase chain reaction results on management of pediatric patients with enteroviral meningitis

BACKGROUND

Enterovirus (EV) infections can be rapidly detected by PCR. However, several studies suggest that results must be available early in the management of the patient to impact significantly on patient care. We evaluated this hypothesis directly during an outbreak of EV aseptic meningitis.

METHODS

From June through November, 1998, EV PCR was performed 5 days a week on cerebrospinal fluid specimens from pediatric patients evaluated for meningitis. We compared antibiotic use, length of stay and hospital charges in a group of patients with EV meningitis whose positive EV PCR results were available within 24 h of specimen collection, to a group of similar patients whose results were available >24 h after collection.

RESULTS

Cerebrospinal fluid specimens were submitted for EV PCR from 113 patients with suspected EV meningitis, and 50 of 113 (44%) were positive. Of these 50 EV-PCR-positive patients, 17 of 50 (34%) had EV PCR results available in < or = 24 h and 33 of 50 (66%) had results available in >24 h. Patients with EV-positive results reported < or = 24 h after specimen collection had 20 h less of antibiotic use (P = 0.006) and $2,798 less in hospital charges (P = 0.001) than patients with positive results available in >24 h. Hospitalized patients who received positive results rapidly did not have significantly less antibiotic therapy or shorter length of stay, but hospital charges were reduced by $2,331 (P = 0.009).

CONCLUSION

Rapid reporting of PCR results can have a significant impact on several outcome measures for patients with EV meningitis.

Epidemiological survey of neonatal non-polio enterovirus infection in the Netherlands

The epidemiological, virological, and clinical data of 119 infants less than 30 days of age with enteroviral infection collected from January 1993 to November 1995 by the diagnostic virology laboratories were analyzed retrospectively. Ninety-eight isolates (83%) were obtained in the period of May 1 to December 1 with a peak in the summer months. Sixty-five percent (n = 78) of neonates became ill within the first 2 weeks of life. Echoviruses and Coxsackie virus type B were isolated most frequently, in 77 (65%) and 29 (24%) infants, respectively. Diagnosis was made by viral isolation from stool, nasopharyngeal swab, cerebrospinal fluid, and blood. One hundred four (87%) infants developed fever and 25 (21%) infants had diarrhea. A clinical diagnosis of sepsis was made in 42 (35%) infants and meningitis was diagnosed in 28 (24%) cases. The great majority of sepsis cases (36/86%) occurred in infants less than 15 days of age. In conclusion, non-polio enteroviruses (especially echoviruses) are a common and underreported cause of neonatal infection in the Netherlands in the summer months and are associated with a clinical diagnosis of sepsis or meningitis cases in the first 2 weeks of life in a high proportion of cases.

Enterovirus infections: diagnosis and treatment

Enteroviruses cause infections that present in diverse ways and affect people of all ages. Infections peak during summer and fall epidemics and cause 10 to 15 million symptomatic infections annually in the United States. The 70 enteroviral serotypes cause illness that ranges from nonspecific fevers and rashes to life-threatening myocarditis or central nervous system disease. These common infections create a significant burden on our society and healthcare system. New developments in rapid diagnosis of enterovirus infections using polymerase chain reaction (PCR) positively affect patient management and have the potential to reduce the healthcare impact of enterovirus infection. The future holds promise for effective antiviral drugs that can treat enterovirus infections and decrease their significant morbidity and mortality.

Enterovirus infections: diagnosis and treatment

Enterovirus infections are common in both children and adults and range from benign short-lived febrile illnesses to life-threatening infections. Recent developments in nucleic acid amplification techniques now allow the rapid and sensitive diagnosis of enterovirus infections, which in turn can lead to improvements in patient management that shorten hospitalizations and reduce costs. New antiviral drugs have been developed that inhibit enterovirus replication, and early clinical trials of these compounds suggest that effective therapy for enterovirus infections is now possible.

Evaluation of the roche AMPLICOR enterovirus PCR assay in the diagnosis of enteroviral central nervous system infections

BACKGROUND

Enteroviruses cause a substantial number of cases of aseptic meningitis annually in the USA. While culture has been useful in the detection of patients with viral meningitis it is time-consuming and lacks sensitivity. Detection of viral nucleic acid in patient specimens has been demonstrated to improve enteroviral detection.

OBJECTIVES

A research use only commercial amplification assay, the Roche AMPLICOR EV test, was compared to culture for the diagnosis of enteroviral meningoencephalitis.

STUDY DESIGN

Four-hundred and sixty-five consecutive CSF samples sent prospectively for suspicion of enteroviral infection were evaluated by PCR and shell-vial culture. Clinical information and CSF analysis were used to resolve PCR positive, culture negative samples. Sensitivity and specificity were calculated using resolved data.

RESULTS

There were 138 samples which met the definition of a true positive. Of these culture detected 77 (sensitivity 55.8%) and PCR detected 136 (sensitivity 98.6%). PCR missed two culture positive samples. Upon repeat testing, these CSF samples were found to contain inhibitors.

CONCLUSIONS

The Roche AMPLICOR EV-PCR test was statistically more sensitive than culture (P<0.001) in the detection of enteroviruses in CSF in patients suspected of having enteroviral meningitis. This assay also has the advantage of a rapid turnaround time of 5-6 h compared to 3-5 days for culture.

Evaluation of a commercial DNA enzyme immunoassay for detection of enterovirus reverse transcription-PCR products amplified from cerebrospinal fluid specimens

We evaluated the DiaSorin DNA enzyme immunoassay (DEIA) kit for detection of enteroviral reverse transcription-PCR (RT-PCR) products amplified from cerebrospinal fluid. By use of an optical density of 0.05 as the absorbance cutoff, 35% of 198 specimens were PCR positive, whereas 16% were culture positive. DEIA was rapid and sensitive and can help implement enterovirus RT-PCR in clinical laboratories.

Reverse-transcription polymerase chain reaction detection of the enteroviruses

OBJECTIVE

This review focuses on commercial and in-house-developed reverse-transcription polymerase chain reaction (RT-PCR) assays used for the detection of enteroviral infections. In addition to providing details on the performance of RT-PCR, its specificity, and sensitivity, the clinical utility of this diagnostic method with specific reference to its impact on hospitalization and cost savings is addressed.

DATA SOURCES

MEDLINE was searched for reports relating to RT-PCR detection of the enteroviruses in adults and children. The search was restricted to studies reported in English language journals.

STUDY SELECTION

Reports documenting detailed information regarding the RT-PCR conditions, primers, sensitivity, specificity and, if relevant, clinical impact were selected for analysis.

DATA EXTRACTION

Details regarding method of extraction of the enteroviral genome, the primers used, RT-PCR conditions, and sensitivity and specificity of the assay were extracted from the literature. For reports detailing the use of RT-PCR in the clinical management of enteroviral infections in children, the reduction in duration of hospitalization and health care cost savings were recorded.

DATA SYNTHESIS

Reverse-transcription PCR can increase the yield of detection of enteroviruses from cerebrospinal fluid by a mean of approximately 20% over tissue culture. Reverse-transcription PCR of cerebrospinal fluid has been shown to exhibit sensitivity and specificity values of 86% to 100% and 92% to 100%, respectively. Reductions of 1 to 3 days of hospitalization per patient are predicted if RT-PCR is used to diagnose enteroviral meningitis in children.

CONCLUSIONS

Reverse-transcription PCR detection of enteroviral infections is an extremely rapid, sensitive, and specific diagnostic modality. Both commercial assays and assays developed in-house appear to be equivalent with regard to sensitivity and specificity. Reverse-transcription PCR diagnosis of enteroviral infections in children could reduce the length of hospitalization and result in significant health care cost savings.

Clinical significance of enteroviruses in serious summer febrile illnesses of children

BACKGROUND

Enteroviruses are common causes of aseptic meningitis and nonspecific febrile illnesses in young children. During the summer-fall months, enterovirus-infected children are frequently evaluated in emergency room settings to rule out bacterial sepsis and/or meningitis.

OBJECTIVES

We sought to determine the clinical significance of enterovirus infections in children evaluated for serious febrile illnesses in pediatric emergency rooms during the summer-fall season.

METHODS

Children admitted to emergency rooms at four university teaching hospitals during a single summer-fall season who required blood culture and/or lumbar puncture to rule out bacterial sepsis/meningitis were prospectively studied. An extensive questionnaire was administered, and specimens of cerebrospinal fluid, serum, urine and throat were tested for enteroviruses by viral culture and PCR. Patients were followed to determine the duration, management and outcome of their illnesses.

RESULTS

Of 203 patients studied 173 had no apparent explanation for their illness (e.g. bacterial sepsis, bacterial urinary tract infection, etc.). Of those 173 patients 79 (46%) were infected with enteroviruses, including 33 of 47 (70%) patients with aseptic meningitis, 13 of 25 (52%) patients with nonspecific febrile episodes and 33 of 101 (33%) patients with fever and focal findings (P < 0.0001 for aseptic meningitis vs. fever and focal findings; P = 0.0001 for aseptic meningitis vs. combined nonspecific febrile episodes and fever/focal patients). Among 119 hospitalized patients 65 (55%) were enterovirus-infected. Children < or =90 days of age were more likely to be enterovirus-infected (66 of 122; 54%) than children older than 90 days (13 of 51; 25%) (P = 0.0001). Enterovirus-infected children were more likely to be hospitalized as a result of the current emergency room visit (65 of 79 vs. 54 of 94; P = 0.0005) and were more likely to have had an additional hospitalization for the same illness (10 of 79 vs. 1 of 94; P = 0.003). Enterovirus-infected patients also had a shorter period from illness onset to presentation. Enterovirus-infected children were indistinguishable from those without enterovirus infection in their symptoms at onset, signs at presentation and total duration of illness (>7 days in both groups). Enterovirus-infected children were almost all treated with antibiotics (78 of 79; 99%), with 74 of 79 (94%) receiving parenteral antibiotics for a mean of 3.6 days.

CONCLUSIONS

During the summer-fall months, 39% (79 of 203) of children for whom blood cultures and/or lumbar punctures were performed for suspected bacterial infection had enterovirus infection identified as the only explanation for their illness. Of those patients with no alternative diagnosis, enterovirus infection was confirmed in 46% (79 of 179). The majority of those patients requiring hospitalization were infected with enteroviruses. The use of PCR increases the number of children for whom a specific etiology of illness can be determined and may in the future reduce the hospitalization and use of unnecessary antibiotics in patients with enterovirus infections.

Clinical utility of polymerase chain reaction testing for enteroviral meningitis

BACKGROUND

During summer enteroviral meningitis is a common cause of febrile illness in children, who are typically hospitalized for 2 to 3 days if bacterial infection is suspected. It has been hypothesized that a sensitive polymerase chain reaction (PCR) assay could quickly confirm the diagnosis and subsequently decrease hospitalization costs. However, to have maximum impact results should be available within 24 h. This necessitates daily assays on small numbers of samples.

METHODS

We examined the clinical utility of a PCR assay during two summers, comparing length of stay and charges. Only during the second summer were results reported to clinicians. Case controls were patients with negative PCR assay results but uncomplicated, presumed viral infections. We determined the cost per case identified with and without pleocytosis as a screen for PCR testing.

RESULTS

During the first summer 25% (5/20) of patients with positive PCR assay results remained hospitalized for >2 days. During the second summer 10.2% (6 of 59) of children with positive enteroviral PCR assay results but 37.9% (25 of 66) of case controls remained hospitalized for >2 days. The mean length of hospitalization was significantly (P < 0.05) shorter for patients with positive PCR test results than for case controls. The material cost was approximately $238 per case identified.

CONCLUSIONS

PCR testing has clinical utility for diagnosis of enteroviral meningitis. Although the demands for daily testing make the test expensive, it appears to be cost-effective with savings related to shorter hospital stays.

A polymerase chain reaction-based epidemiologic investigation of the incidence of nonpolio enteroviral infections in febrile and afebrile infants 90 days and younger

OBJECTIVE

Enteroviruses are important pathogens in infants, but their true contribution to febrile illness in infants </=90 days old is unknown. The purpose of this study was to use the polymerase chain reaction (PCR) for diagnosis of enteroviral (EV) infection in febrile and afebrile infants </=90 days of age to improve the understanding of the epidemiology of EV infection in this population.

METHODS

Patients included all unimmunized, febrile infants </=90 days of age admitted to Primary Children's Medical Center (Salt Lake City, UT) for sepsis evaluation from December 1996 to December 1997. Blood, urine, cerebrospinal fluid, and throat swabs were tested for enteroviruses using a PCR assay (Roche Molecular Systems, Branchburg, NJ). Alternate PCR assays separated polio and nonpolio enteroviruses. Results of bacterial cultures, outcome, and hospital charges were obtained. Blood from afebrile, control infants </=90 days old was tested for enteroviruses.

RESULTS

A total of 345 febrile infants were enrolled; 89 (25.8%) were positive for enterovirus. The incidence of EV infection ranged from 3.2% in January to 50% in August and October. Five EV-positive, febrile infants (5.6%) had concomitant urinary tract infections, and 1 (1. 1%) had concomitant bacteremia. Infants with confirmed EV infection were significantly less likely to have bacterial infection than those who were EV-negative. All infants infected with an enterovirus recovered. Average length of stay was 3 days, average charges were nearly $4500. Eighty-six afebrile, control infants were enrolled; 6 (6.9%) were positive for enterovirus; 3 had received oral polio vaccine.

CONCLUSIONS

Nonpolio EV infections commonly cause fever in infants </=90 days of age. Rates of EV positivity are low in afebrile, unimmunized infants. The use of PCR to identify febrile infants with nonpolio EV infections may decrease length of hospital stay, unnecessary antibiotic administration, and charges.

Fever without apparent source on clinical examination, lower respiratory infections in children, and other infectious diseases

This section focuses on issues in infectious disease that are commonly encountered in pediatric office practice. Paul McCarthy discusses recent literature regarding the evaluation and management of acute fevers without apparent source on clinical examination in infants and children and the evaluation of children with prolonged fevers of unknown origin. Jean Klig reviews recent literature about lower respiratory tract infection in children. Finally, Jeffrey Kahn discusses recent developments concerning rotavirus vaccine.