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Zhou RW, Sangam K, Budhram A. Clinical Utility of CSF Correction Factors for Traumatic Lumbar Puncture in Adults. Neurol Clin Pract 2024; 14:e200350. [PMID: 39185100 PMCID: PMC11341082 DOI: 10.1212/cpj.0000000000200350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/26/2024] [Indexed: 08/27/2024]
Abstract
Objectives To identify indicators of false pleocytosis in adults with traumatic lumbar puncture (LP), and determine specificities and sensitivities of commonly used CSF correction factors. Methods Adults who underwent 4-tube CSF collection were reviewed. Study inclusion required elevated tube 1 red blood cell (RBC) count, tube 1 pleocytosis, and normalized tube 4 RBC count. Tube 4 white blood cell (WBC) count served as the reference standard. Specificities and sensitivities of 3 correction factors (1 WBC:500 RBC, 1 WBC:1000 RBC, and 1 WBC:1500 RBC) were calculated. Results One hundred ninety-five adults were included. Among them, 106 (54%) had false tube 1 pleocytosis; these patients had a significantly higher median CSF RBC count and lower median CSF WBC count than those with true tube 1 pleocytosis. Specificities and sensitivities of correction factors ranged from 71.7% to 29.2% and 84.3% to 97.8%, respectively; 1 WBC:500 RBC had highest specificity for pleocytosis, while 1 WBC:1500 RBC had highest sensitivity. Irrespective of correction factor used, false-positive and false-negative determinations of pleocytosis were usually mild (≤20 WBCs/μL). Discussion Indicators of false pleocytosis in adults with traumatic LP include bloodier CSF and milder pleocytosis, suggesting that correction factors are most useful in such cases. Across correction factors, an expected specificity/sensitivity tradeoff is observed. Corrected CSF WBC counts suggesting only mild pleocytosis should be interpreted cautiously.
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Affiliation(s)
- Ryan W Zhou
- Department of Clinical Neurological Sciences (RWZ, KS, AB); and Department of Pathology and Laboratory Medicine (AB), Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Kamala Sangam
- Department of Clinical Neurological Sciences (RWZ, KS, AB); and Department of Pathology and Laboratory Medicine (AB), Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences (RWZ, KS, AB); and Department of Pathology and Laboratory Medicine (AB), Western University, London Health Sciences Centre, London, Ontario, Canada
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Duplessis CT, Colburn Z, Osborne CK, Smith LA, Schunk MP, Sainato LRJ. Pitfalls of Applying Fever Guidelines to Recently Immunized Infants. Clin Pediatr (Phila) 2024:99228241256875. [PMID: 39056353 DOI: 10.1177/00099228241256875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Affiliation(s)
| | - Zachary Colburn
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, WA, USA
| | - Cpt Katey Osborne
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ltc Ashley Smith
- Department of Pediatrics, Madigan Army Medical Center, Tacoma, WA, USA
| | - Maj Paul Schunk
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
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Strunk T, Molloy EJ, Mishra A, Bhutta ZA. Neonatal bacterial sepsis. Lancet 2024; 404:277-293. [PMID: 38944044 DOI: 10.1016/s0140-6736(24)00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 07/01/2024]
Abstract
Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.
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Affiliation(s)
- Tobias Strunk
- Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, Perth, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, University of Dublin and Trinity Research in Childhood Centre, Dublin, Ireland; Children's Health Hospital at Tallaght, Tallaght University Hospital, Dublin, Ireland; Trinity Translational Medicine Institute, St James Hospital, Dublin, Ireland; Neonatology, Children's Health Hospital at Crumlin, Dublin, Ireland; Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Archita Mishra
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute for Global Health and Development, The Aga Khan University South-Central Asia, Karachi, Pakistan
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Sievänen H, Palmu S, Kari J, Soukka H, Lähteenmäki P, Eskola V. Incidence of Traumatic Lumbar Punctures in Neonates and Infants. Am J Perinatol 2024; 41:e103-e108. [PMID: 35523412 DOI: 10.1055/a-1845-2335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The objective of this study is to examine factors accounting for the incidence of traumatic lumbar puncture (TLP) in infants younger than 1 year old. STUDY DESIGN Retrospective analysis of cerebrospinal fluid (CSF) data from 1,240 neonatal (≤28 days) and 399 infant lumbar puncture (LP) procedures was conducted. Data from two successive LP procedures were obtained from 108 patients. Logistic regression analysis was used to assess factors accounting for the incidence of TLP in the second LP procedure. The following categorical variables were entered into the model: whether the first procedure was traumatic according to criteria of ≥500 and ≥10,000 erythrocytes/µL, whether the LP procedures were performed within a week, and whether the patient was neonatal at the first procedure. RESULTS The incidences of TLP were 42.9% in neonates and 22.5% in infants for the criterion of ≥500 erythrocytes/µL, and 16.6 and 10.3% for the criterion of ≥10,000 erythrocytes/µL. Compared with a nontraumatic first LP procedure, if the first procedure was traumatic according to the criterion of ≥10,000 erythrocytes/µL, the odds ratio (OR) of TLP in the second procedure was 5.86 (p = 0.006). Compared with a longer time, if the successive procedures were performed within a week, the OR of TLP was 9.06 (p < 0.0001) according to the criteria of ≥500 erythrocytes/µL and 3.34 (p = 0.045) according to the criteria of ≥10,000 erythrocytes/µL. If the patient was neonatal at the first procedure, the OR of TLP at the second puncture was 0.32 (p = 0.031) according to the criterion of ≥500 erythrocytes/µL. CONCLUSION The incidence of TLP in neonates is twice as high as that in infants. Successive LP procedures performed within a week and a highly blood-contaminated CSF sample in the first procedure each multiplied the odds of TLP in the second procedure, whereas being a neonate at the time of the first procedure reduced the odds of TLP. KEY POINTS · Traumatic LPs increase diagnostic uncertainty.. · Traumatic LPs are twice as common in neonates as in infants.. · Two LPs performed within a week multiplied the odds of traumatic LP.. · Erythrocyte-based criteria for traumatic LP affect the incidence of TLP..
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Affiliation(s)
| | - Sauli Palmu
- Department of Pediatrics, and Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere, Finland
| | | | - Hanna Soukka
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Lähteenmäki
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Vesa Eskola
- Department of Pediatrics, and Tampere University, Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere, Finland
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5
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Dong THK, Donovan J, Ngoc NM, Thu DDA, Nghia HDT, Oanh PKN, Phu NH, Hang VTT, Vinh Chau NV, Thuong Thuong NT, Tan LV, Thwaites GE, Geskus RB. A novel diagnostic model for tuberculous meningitis using Bayesian latent class analysis. BMC Infect Dis 2024; 24:163. [PMID: 38321395 PMCID: PMC10845506 DOI: 10.1186/s12879-024-08992-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/08/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Diagnosis of tuberculous meningitis (TBM) is hampered by the lack of a gold standard. Current microbiological tests lack sensitivity and clinical diagnostic approaches are subjective. We therefore built a diagnostic model that can be used before microbiological test results are known. METHODS We included 659 individuals aged [Formula: see text] years with suspected brain infections from a prospective observational study conducted in Vietnam. We fitted a logistic regression diagnostic model for TBM status, with unknown values estimated via a latent class model on three mycobacterial tests: Ziehl-Neelsen smear, Mycobacterial culture, and GeneXpert. We additionally re-evaluated mycobacterial test performance, estimated individual mycobacillary burden, and quantified the reduction in TBM risk after confirmatory tests were negative. We also fitted a simplified model and developed a scoring table for early screening. All models were compared and validated internally. RESULTS Participants with HIV, miliary TB, long symptom duration, and high cerebrospinal fluid (CSF) lymphocyte count were more likely to have TBM. HIV and higher CSF protein were associated with higher mycobacillary burden. In the simplified model, HIV infection, clinical symptoms with long duration, and clinical or radiological evidence of extra-neural TB were associated with TBM At the cutpoints based on Youden's Index, the sensitivity and specificity in diagnosing TBM for our full and simplified models were 86.0% and 79.0%, and 88.0% and 75.0% respectively. CONCLUSION Our diagnostic model shows reliable performance and can be developed as a decision assistant for clinicians to detect patients at high risk of TBM. Diagnosis of tuberculous meningitis is hampered by the lack of gold standard. We developed a diagnostic model using latent class analysis, combining confirmatory test results and risk factors. Models were accurate, well-calibrated, and can support both clinical practice and research.
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Affiliation(s)
- Trinh Huu Khanh Dong
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
- King's College London, London, UK.
| | - Joseph Donovan
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nghiem My Ngoc
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- the Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Do Dang Anh Thu
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- the Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | | | - Nguyen Hoan Phu
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- School of Medicine, Vietnam National University, Ho Chi Minh City, Vietnam
| | - Vu Thi Ty Hang
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Van Vinh Chau
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- the Hospital of Tropical Diseases, Ho Chi Minh City, Vietnam
- Ho Chi Minh City Department of Health, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Le Van Tan
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Guy E Thwaites
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ronald B Geskus
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Lamb AE, Rent S, Brannon AJ, Greer JL, Ndey-Bongo NP, Cho SH, Greenberg RG, Benjamin DK, Clark RH, Kumar KR. Diagnostic Utility of Cerebrospinal Fluid White Blood Cell Components for the Identification of Bacterial Meningitis in Infants. J Pediatric Infect Dis Soc 2023; 12:S44-S52. [PMID: 38146862 PMCID: PMC10750308 DOI: 10.1093/jpids/piad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/10/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND To evaluate the diagnostic and predictive utility of cerebrospinal fluid (CSF) white blood cell (WBC) components in the diagnosis of bacterial meningitis in infants discharged from the neonatal intensive care unit (NICU). METHODS We identified a cohort of infants discharged from a Pediatrix NICU between 1997 and 2020 who did not have an immunodeficiency, had at least 1 CSF culture collected within the first 120 days of life, and at least 1 CSF laboratory specimen obtained on the day of culture collection. We only included an infant's first CSF culture and excluded cultures from CSF reservoirs and those growing contaminants or nonbacterial organisms. We examined the utility of CSF WBC components to diagnose or predict bacterial meningitis by calculating sensitivity, specificity, positive and negative predictive values, likelihood ratios, and area under the receiver operating curve (AUC) at different cutoff values for each parameter. We performed subgroup analysis excluding infants treated with antibiotics the day before CSF culture collection. RESULTS Of the 20 756 infants that met the study inclusion criteria, 320 (2%) were diagnosed with bacterial meningitis. We found (AUC [95% CI]) CSF WBC count (0.76 [0.73-0.79]), CSF neutrophil count (0.74 [0.70-0.78]), and CSF neutrophil percent (0.71 [0.67-0.75]) had the highest predictive values for bacterial meningitis, even when excluding infants with early antibiotic administration. CONCLUSIONS No single clinical prediction rule had the optimal discriminatory power for predicting culture-proven bacterial meningitis, and clinicians should be cautious when interpreting CSF WBC parameters in infants with suspected meningitis.
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Affiliation(s)
- Ashley E Lamb
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Sharla Rent
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Asia J Brannon
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Stephen H Cho
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, Florida, USA
| | - Karan R Kumar
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
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Abstract
BACKGROUND Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes. OBJECTIVES To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.99, 95% CI 0.88 to 1.12; RD 0.00, 95% CI -0.06 to 0.05; I2 = 47% and 46% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts as specified in this review. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position (I2 = not applicable; 2 studies; 1102 infants; high-certainty evidence; in one of the study median and IQR to report time to perform the lumbar puncture were 8 (5-13) and 8 (5-12) in the lateral and sitting position, respectively, I2 = not applicable; 1 study, 1082 infants; in the other study: mean difference 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review. AUTHORS' CONCLUSIONS When compared to sitting position, lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts as specified in this review. Furthermore, infants in a sitting position likely experience less episodes of bradycardia and oxygen desaturation than in the lateral decubitus, and there may be little to no difference in episodes of apnea. Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.
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Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Glenton Prescott
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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Roehr CC, Marshall AS, Scrivens A, Sadarangani M, Williams R, Yong J, Linsell L, Chiocchia V, Bell JL, Stokes C, Santhanadass P, Nicoll I, Adams E, King A, Murray D, Bowler U, Stanbury K, Juszczak E. Techniques to increase lumbar puncture success in newborn babies: the NeoCLEAR RCT. Health Technol Assess 2023; 27:1-97. [PMID: 38149666 PMCID: PMC11017152 DOI: 10.3310/thjy0671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Background Lumbar puncture is an essential tool for diagnosing meningitis. Neonatal lumbar puncture, although frequently performed, has low success rates (50-60%). Standard technique includes lying infants on their side and removing the stylet 'late', that is, after the needle is thought to have entered the cerebrospinal fluid. Modifications to this technique include holding infants in the sitting position and removing the stylet 'early', that is, following transection of the skin. To the best of our knowledge, modified techniques have not previously been tested in adequately powered trials. Objectives The aim of the Neonatal Champagne Lumbar punctures Every time - An RCT (NeoCLEAR) trial was to compare two modifications to standard lumbar puncture technique, that is, use of the lying position rather than the sitting position and of 'early' rather than 'late' stylet removal, in terms of success rates and short-term clinical, resource and safety outcomes. Methods This was a multicentre 2 × 2 factorial pragmatic non-blinded randomised controlled trial. Infants requiring lumbar puncture (with a working weight ≥ 1000 g and corrected gestational age from 27+0 to 44+0 weeks), and whose parents provided written consent, were randomised by web-based allocation to lumbar puncture (1) in the sitting or lying position and (2) with early or late stylet removal. The trial was powered to detect a 10% absolute risk difference in the primary outcome, that is, the percentage of infants with a successful lumbar puncture (cerebrospinal fluid containing < 10,000 red cells/mm3). The primary outcome was analysed by modified intention to treat. Results Of 1082 infants randomised (sitting with early stylet removal, n = 275; sitting with late stylet removal, n = 271; lying with early stylet removal, n = 274; lying with late stylet removal, n = 262), 1076 were followed up until discharge. Most infants were term born (950/1076, 88.3%) and were aged < 3 days (936/1076, 87.0%) with a working weight > 2.5 kg (971/1076, 90.2%). Baseline characteristics were balanced across groups. In terms of the primary outcome, the sitting position was significantly more successful than lying [346/543 (63.7%) vs. 307/533 (57.6%), adjusted risk ratio 1.10 (95% confidence interval 1.01 to 1.21); p = 0.029; number needed to treat = 16 (95% confidence interval 9 to 134)]. There was no significant difference in the primary outcome between early stylet removal and late stylet removal [338/545 (62.0%) vs. 315/531 (59.3%), adjusted risk ratio 1.04 (95% confidence interval 0.94 to 1.15); p = 0.447]. Resource consumption was similar in all groups, and all techniques were well tolerated and safe. Limitations This trial predominantly recruited term-born infants who were < 3 days old, with working weights > 2.5 kg. The impact of practitioners' seniority and previous experience of different lumbar puncture techniques was not investigated. Limited data on resource use were captured, and parent/practitioner preferences were not assessed. Conclusion Lumbar puncture success rate was higher with infants in the sitting position but was not affected by timing of stylet removal. Lumbar puncture is a safe, well-tolerated and simple technique without additional cost, and is easily learned and applied. The results support a paradigm shift towards sitting technique as the standard position for neonatal lumbar puncture, especially for term-born infants during the first 3 days of life. Future work The superiority of the sitting lumbar puncture technique should be tested in larger populations of premature infants, in those aged > 3 days and outside neonatal care settings. The effect of operators' previous practice and the impact on family experience also require further investigation, alongside in-depth analyses of healthcare resource utilisation. Future studies should also investigate other factors affecting lumbar puncture success, including further modifications to standard technique. Trial registration This trial is registered as ISRCTN14040914 and as Integrated Research Application System registration 223737. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/188/106) and is published in full in Health Technology Assessment; Vol. 27, No. 33. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Charles C Roehr
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Sj Marshall
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Alexandra Scrivens
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Rachel Williams
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jean Yong
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Caz Stokes
- Support for the Sick Newborn And their Parents (SSNAP) Charity, John Radcliffe Hospital, Oxford, UK
| | - Patricia Santhanadass
- Support for the Sick Newborn And their Parents (SSNAP) Charity, John Radcliffe Hospital, Oxford, UK
| | - Ian Nicoll
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Andrew King
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Murray
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
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9
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Pessano S, Bruschettini M, Prescott MG, Romantsik O. Positioning for lumbar puncture in newborn infants. Cochrane Database Syst Rev 2023; 10:CD015592. [PMID: 37870133 PMCID: PMC10591282 DOI: 10.1002/14651858.cd015592.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes. OBJECTIVES To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.93, 95% CI 0.85 to 1.02; RD -0.04, 95% CI -0.09 to 0.01; I2 = 70% and 72% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). The evidence is very uncertain regarding the effect of lateral decubitus position on time to perform the lumbar puncture (MD 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants, very low-certainty evidence). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review. AUTHORS' CONCLUSIONS When compared to sitting position, lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts. Furthermore, infants in a lateral decubitus position likely experience more episodes of bradycardia and oxygen desaturation, and there may be little to no difference in episodes of apnea. The evidence is very uncertain regarding time to perform lumbar puncture. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.
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Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Glenton Prescott
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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10
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Cheng J, Dang C, Li X, Wang J, Huang X, Li Y, Cui X. The participation of clinical pharmacists in the treatment of patients with central nervous system infection can improve the effectiveness and appropriateness of anti-infective treatments: a retrospective cohort study. Front Pharmacol 2023; 14:1226333. [PMID: 37745082 PMCID: PMC10512419 DOI: 10.3389/fphar.2023.1226333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background: Central nervous system infection (CNSI) treatment in hospital neurosurgery emphasizes the importance of optimizing antimicrobial therapy. Timely and appropriate empiric antibiotic treatment is critical for managing patients with bacterial meningitis. Objectives: To evaluate the activities of clinical pharmacists in the anti-infective treatment of patients with CNSI in neurosurgery. Method: A single-center retrospective cohort study was carried out from January 2021 to March 2023 at a tertiary teaching hospital in China. The study sample included a group that received pharmacy services and a group that did not. In the pharmacy services group, the anti-infective treatment plan was led and developed by pharmacists. Pharmaceutical care, including medication therapy and all CNSI treatment regimens, was administered in daily unit rounds by pharmacists. Baseline demographics, treatment outcomes, and rational use of antibiotics were compared between the two groups, and the impact of a antimicrobial stewardship (AMS) program was evaluated. Results: Of the 306 patients assessed according to the inclusion and exclusion criteria, 151 patients were included, and 155 patients were excluded due to abnormal data and missing information on antibiotic costs or antimicrobial use. Eventually, 73 were included in the pharmacy services group and 78 in the group without pharmacist participation. The antibiotic use density (AUD) of the pharmacy services group decreased from 167.68 to 127.63 compared to the group without pharmacist participation. After the pharmacist services, the AUD for linezolid decreased from 9.15% to 5.23% and that for miscellaneous agents decreased from 17.91% to 6.72%. The pharmacy services group had better improvement (p < 0.05) and a significantly higher score for the rational use of antibiotics (p < 0.05) than the group without pharmacist participation. Conclusion: The clinical pharmacist services evaluation results demonstrated an essential role of clinical pharmacist-led AMS programs in the effective and appropriate use of anti-infective treatments in neurosurgery with patients with CNSI.
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Affiliation(s)
- Jie Cheng
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
- Department of Clinical Pharmacy, The First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - ChuanDong Dang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Xiao Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - JianJun Wang
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yan Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - XueYan Cui
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
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11
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Gurley AL, Fukuda M, Sharma A, Lee E, Junqueira E, Kang M, Kim TY. Validation of a Clinical Prediction Rule for Distinguishing Bacterial and Aseptic Meningitis in Pediatric Patients. Cureus 2023; 15:e45829. [PMID: 37881396 PMCID: PMC10593592 DOI: 10.7759/cureus.45829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/27/2023] Open
Abstract
Introduction The treatments and prognosis of bacterial meningitis differ greatly from those of aseptic meningitis, making early identification and differentiation essential. Several different clinical prediction rules have been developed to distinguish bacterial meningitis from aseptic meningitis. We sought to validate one clinical prediction rule for pediatric patients utilizing a centralized data warehouse that collects daily data from 184 hospitals across the United States. Methods We retrospectively collected data on all patients aged 29 days to 14 years who presented to Hospital Corporation of America (HCA) Healthcare hospitals from January 1, 2016, to May 31, 2021, with a diagnosis of meningitis. Our study replicated the original study of the meningitis score for emergencies (MSE) for the pediatric clinical prediction rule and assigned 3 points for procalcitonin (PCT) >1.2 ng/dL, 2 points for CSF protein >80 mg/dL, and 1 point for each of the other variables of C-reactive protein (CRP) >40 mg/L and CSF absolute neutrophil count >1000 cells per mm3. Patients were categorized either as having bacterial or aseptic meningitis. Using the clinical prediction rule, a calculation of the sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic (ROC) curve was performed. Results The optimum test characteristic was found to have a score of ≥ 3, showing a sensitivity of 92.86% (95% CI, 83.3-100), a specificity of 65.22% (95% CI, 51.5-79), a positive predictive value of 61.90% (95% CI, 47.2-76.6), and a negative predictive value of 93.75% (95% CI, 85.4-100). The ROC curve from this study showed an area under the curve (AUC) of 0.7892 (95% CI, 0.681-0.897). Conclusion Our study validated a high sensitivity for distinguishing bacterial meningitis from aseptic meningitis, suggesting the clinical prediction rule has clinical utility as a predictive screening tool. Although the original MSE advised a cutoff score of ≥1, our study suggests that a score ≥3 would give the best test performance.
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Affiliation(s)
- Amelia L Gurley
- Emergency Medicine, Hospital Corporation of America (HCA) Healthcare, Riverside Community Hospital, Riverside, USA
| | - Matt Fukuda
- Emergency Medicine, Hospital Corporation of America (HCA) Healthcare, Riverside Community Hospital, Riverside, USA
| | - Ashwin Sharma
- Emergency Medicine, University of California (UC) Riverside School of Medicine, Riverside, USA
| | - Ethan Lee
- Emergency Medicine, School of Medicine, Loma Linda University, Riverside, USA
| | - Erica Junqueira
- Emergency Medicine, Hospital Corporation of America (HCA) Houston Healthcare, Houston, USA
| | - Michael Kang
- Emergency Medicine, Hospital Corporation of America (HCA) Healthcare, Riverside Community Hospital, Riverside, USA
| | - Tommy Y Kim
- Emergency Medicine, Hospital Corporation of America (HCA) Healthcare, Riverside Community Hospital, Riverside, USA
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12
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Orman A, Aydın H. Do Spinal Needle Sizes Affect the Development of Traumatic CSF in Neonatal LP Procedures? CHILDREN 2023; 10:children10030509. [PMID: 36980067 PMCID: PMC10047216 DOI: 10.3390/children10030509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023]
Abstract
Lumbar puncture (LP) is widely employed to evaluate infectious, neurological and metabolic diseases in the newborn. Neonatal LP is a difficult procedure with 45–54% success rates. Although there are studies examining traumatic LP failure, studies on the effects of needle sizes are limited. This study was intended to investigate the effect of needle sizes on LP traumatization. Term and premature babies who underwent LP in the neonatal intensive care unit between 30 November 2017 and 30 July 2019 were included in the study by retrospective file scanning. LP was performed by a pediatric or neonatal specialist using a 22 Gauge pen (G) or 25 G pen spinal needle in all cases, with all patients being placed in the lateral decubitus position. The primary outcome was to evaluate the effect of needle sizes used in LP on traumatization. The secondary outcome was to evaluate traumatization rates and complications. A statistically significant difference was determined in the rate of traumatized LP and desaturation development between needle sizes and CSF microscopic findings (p = 0.031, p = 0.005, and p = 0.006, respectively). The study data show that 25 G pen-tip spinal needles cause less traumatic LP in neonates than 22 G pen-tip spinal needles.
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Affiliation(s)
- Aysen Orman
- Departments of Neonatology, School of Medicine, Mersin University, Mersin 33110, Turkey
- Correspondence: ; Tel.: +90-3242412264
| | - Hilal Aydın
- Departments of Pediatric Neurology, School of Medicine, Balikesir University, Balikesir 10145, Turkey
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13
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Marshall ASJ, Scrivens A, Bell JL, Linsell L, Hardy P, Yong J, Williams R, Adams E, Sadarangani M, Juszczak E, Roehr CC. Assessment of infant position and timing of stylet removal to improve lumbar puncture success in neonates (NeoCLEAR): an open-label, 2 × 2 factorial, randomised, controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:91-100. [PMID: 36460015 DOI: 10.1016/s2352-4642(22)00343-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Newborn infants are the highest-risk age group for bacterial meningitis. Lumbar punctures are therefore frequently performed in neonates, but success rates are low (50-60%). In Neonatal Champagne Lumbar punctures Every time-A Randomised Controlled Trial (NeoCLEAR), we sought to optimise infant lumbar puncture by evaluating two modifications to traditional technique: sitting position versus lying down and early stylet removal (stylet removal after transecting the subcutaneous tissue) versus late stylet removal. METHODS NeoCLEAR was an open-label, 2 × 2 factorial, randomised, controlled trial, conducted in 21 UK neonatal and maternity units. Infants requiring lumbar puncture at 27+0 to 44+0 weeks corrected gestational age and weighing 1000 g or more were randomly assigned (1:1:1:1) to sitting position and early stylet removal, sitting position and late stylet removal, lying position and early stylet removal, or lying position and late stylet removal using a 24/7, web-based, secure, central randomisation system. Block randomisation was stratified within site by corrected gestational age (27+0 to 31+6 weeks, 32+0 to 36+6 weeks, 37+0 to 40+6 weeks, or 41+0 to 44+0 weeks), using variable block sizes of four and eight with equal frequency. Laboratory staff were masked to allocation. The primary outcome was successful first lumbar puncture, defined as obtaining a cerebrospinal fluid sample with a red blood cell count of less than 10 000 cells per μL. The primary and secondary (including safety) outcomes were analysed by the groups to which infants were assigned regardless of deviation from the protocol or allocation received, but with exclusion of infants who were withdrawn before data collection or who did not undergo lumbar puncture (modified intention-to-treat analysis). This study is registered with ISRCTN, ISRCTN14040914. FINDINGS Between Aug 3, 2018, and Aug 31, 2020, 1082 infants were randomly assigned to sitting (n=546) or lying (n=536), and early (n=549) or late (n=533) stylet removal. 1076 infants were followed-up until discharge and included in the modified intention-to-treat analysis. 961 (89%) infants were term, and 936 (87%) were younger than 3 days. Successful first lumbar puncture was more frequently observed in sitting than in lying position (346 [63·7%] of 543 vs 307 [57·6%] of 533; adjusted risk ratio 1·10 [95% CI 1·01 to 1·21], p=0·029; number needed to treat=16). Timing of stylet removal had no discernible effect on the primary outcome (338 [62·0%] of 545 infants in the early stylet removal group and 315 [59·3%] of 531 in the late stylet removal group had a successful first lumbar puncture; adjusted risk ratio 1·04 [95% CI 0·94-1·15], p=0·45). Sitting was associated with fewer desaturations than was lying (median lowest oxygen saturations during first lumbar puncture 93% [IQR 89-96] vs 90% [85-94]; median difference 3·0% [2·1-3·9], p<0·0001). One infant from the sitting plus late stylet removal group developed a scrotal haematoma 2 days after lumbar puncture, which was deemed to be possibly related to lumbar puncture. INTERPRETATION NeoCLEAR is the largest trial investigating paediatric lumbar puncture so far. Success rates were improved when sitting rather than lying. Sitting lumbar puncture is safe, cost neutral, and well tolerated. We predominantly recruited term neonates younger than 3 days; other populations warrant further study. Neonatal lumbar puncture is commonly performed worldwide; these results therefore strongly support the widespread adoption of sitting technique for neonatal lumbar puncture. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Andrew S J Marshall
- Department of Paediatrics, Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexandra Scrivens
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jean Yong
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachel Williams
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada; Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Charles C Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Paediatrics, Faculty of Health Sciences, University of Bristol, Bristol, UK; Neonatal Unit, Southmead Hospital, North Bristol Trust, Bristol, UK.
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14
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Affiliation(s)
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden; Lund Sweden
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
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15
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Gunti S, Nair V, Kannan Loganathan P. Reference range for cerebrospinal fluid values in neonates: 5-year retrospective study. J Matern Fetal Neonatal Med 2022; 35:10584-10590. [PMID: 36310086 DOI: 10.1080/14767058.2022.2139172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cerebro spinal fluid (CSF) parameters (white blood cell count, protein, glucose) in the diagnosis of neonatal bacterial meningitis. OBJECTIVES To report the reference range of CSF parameters (white blood cell count, protein, glucose) in both term and preterm infants. METHODS This was a single center retrospective study over a period of 5 years (2015-2020). We included infants aged 0-3 months admitted to the neonatal unit and infants ≤28 days attending pediatric acute care and who underwent Lumbar Puncture. We excluded infants with evidence of CSF bacteremia, viral infection and traumatic lumbar puncture defined as CSF Red Blood Cell >500 cells/µL. Clinical, demographic, and microbiological data were collected from the hospital database. The study was approved by ethics committee. RESULTS We identified a total of 518 CSF samples, with 232 CSF samples available for final analysis. 54% of excluded samples were traumatic. Median birth gestation and birth weight of the study cohort were 38 (IQR 35-40) weeks and 3030 (IQR 1965-3565) grams respectively. Median RBC, WBC count, protein and glucose were 15 (IQR 3-85)/µL, 3(IQR 0-8.5)/µL, 0.72 (0.53-1.06) g/L and 2.8 (2.4-3.3) mmol/L respectively. There was no difference in CSF WBC cell count between preterm and term infants. Higher CSF protein content was noted in preterm infants and infants in the first 7 days of life. Use of antibiotics prior to LP was associated with higher CSF protein. Presence of any CSF RBC (including <500 cells/µL) influenced the CSF WBC count and protein content. CONCLUSION We have provided a reference range of CSF parameters in neonates without meningitis. CSF WBC count between preterm and term infants were similar with higher CSF protein content in preterm infants and for infants in the first seven days of life. Presence of any CSF RBC influenced CSF parameters.
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Affiliation(s)
- Swathi Gunti
- Neonatal Unit, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Vrinda Nair
- Neonatal Unit, James Cook University Hospital, Middlesbrough, United Kingdom.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Prakash Kannan Loganathan
- Neonatal Unit, James Cook University Hospital, Middlesbrough, United Kingdom.,Clinical Academic office, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Department of Physics, University of Durham, Durham, United Kingdom
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16
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Brumbaugh JE, Bell EF, Do BT, Greenberg RG, Stoll BJ, DeMauro SB, Harmon HM, Hintz SR, Das A, Puopolo KM. Incidence of and Neurodevelopmental Outcomes After Late-Onset Meningitis Among Children Born Extremely Preterm. JAMA Netw Open 2022; 5:e2245826. [PMID: 36480199 PMCID: PMC9856224 DOI: 10.1001/jamanetworkopen.2022.45826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Importance Late-onset meningitis (LOM) has been associated with adverse neurodevelopmental outcomes in children born extremely preterm. Objective To report the incidence of LOM during birth hospitalization and neurodevelopmental outcomes at 18 to 26 months' corrected age. Design, Setting, and Participants This cohort study is a secondary analysis of a multicenter prospective cohort of children born at 22 to 26 weeks' gestation between 2003 and 2017 with follow-up from 2004 to 2021. The study was conducted at 25 Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers. Exposures Culture-confirmed LOM. Main Outcomes and Measures Incidence and microbiology of LOM (2003-2017); lumbar puncture (LP) performance in late-onset sepsis (LOS) evaluations (2011-2017); composite outcome of death or neurodevelopmental impairment (NDI; 2004-2021). Results Among 13 372 infants (median [IQR] gestational age, 25.4 [24.4-26.1] weeks; 6864 [51%] boys), LOM was diagnosed in 167 (1%); LOS without LOM in 4564 (34%); and neither LOS nor LOM in 8641 (65%). The observed incidence of LOM decreased from 2% (95% CI, 1%-3%) in 2003 to 0.4% (95% CI, 0.7%-1.0%) in 2017 (P < .001). LP performance in LOS evaluations decreased from 36% (95% CI, 33%-40%) in 2011 to 24% (95% CI, 21%-27%) in 2017 (P < .001). Among infants with culture-confirmed LOS, LP performance decreased from 58% (95% CI, 51%-65%) to 45% (95% CI, 38%-51%; P = .008). LP performance varied by center among all LOS evaluations (10%-59%, P < .001) and among those with culture-confirmed LOS (23%-79%, P < .001). LOM occurred in the absence of concurrent LOS in 27 of 167 cases (16%). The most common LOM isolates were coagulase-negative Staphylococcus (98 [59%]), Candida albicans (38 [23%]), and Escherichia coli (27 [16%]). Death or NDI occurred in 22 of 46 children (48%) with LOM due to coagulase-negative Staphylococcus, 43 of 67 (64%) due to all other bacterial pathogens, and 26 of 33 (79%) due to fungal pathogens. The adjusted relative risk of death or NDI was increased among children with LOM (aOR, 1.53; 95% CI, 1.04-2.25) and among those with LOS without LOM (aOR, 1.41; 95% CI, 1.29-1.54) compared with children with neither infection. Conclusions and Relevance In this cohort study, LP was performed with decreasing frequency, and the observed incidence of LOM also decreased. Both LOM and LOS were associated with increased risk of death or NDI; risk varied by LOM pathogen. The full association of LOM with outcomes of children born extremely preterm may be underestimated by current diagnostic practices.
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Affiliation(s)
- Jane E. Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Barbara T. Do
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | | | - Barbara J. Stoll
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, Georgia
- McGovern Medical School of UTHealth, Houston, Texas
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Karen M. Puopolo
- Department of Pediatrics, University of Pennsylvania, Philadelphia
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17
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García-De la Rosa G, De Las Heras-Flórez S, Rodríguez-Afonso J, Carretero-Pérez M. Interpretation of white blood cell counts in the cerebrospinal fluid of neonates with traumatic lumbar puncture: a retrospective cohort study. BMC Pediatr 2022; 22:488. [PMID: 35971102 PMCID: PMC9380374 DOI: 10.1186/s12887-022-03548-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Difficulty in interpreting white blood cell (WBC) counts in cerebrospinal fluid (CSF) complicates the diagnosis of neonatal meningitis in traumatic lumbar punctures (LP). The aim of our study was to determine the correction factor for WBC counts in traumatic LP that offers the greatest diagnostic efficacy in meningitis. METHODS We conducted a retrospective observational study of LP in neonates between January 2014 and December 2020. Traumatic LP was defined as a red blood cell (RBC) count ≥ 1,000 cells/mm3 CSF and pleocytosis as WBCs ≥ 20 cells/mm3 CSF. The CSF RBC:WBC ratio was analyzed by linear regression to determine a new correction factor. Cell count adjustments were also studied using the 500:1, the 1,000:1 ratio method, and the peripheral blood RBC:WBC ratio, using ROC curves and studies of accuracy (sensitivity and specificity). RESULTS Overall, 41.0% of the 1,053 LPs included in the study were traumatic. The best results for effective WBC correction were the method based on the peripheral blood ratio (sensitivity = 1.0 and specificity = 0.9 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.9 for viral meningitis) and the 400:1 ratio (sensitivity = 1.0 and specificity = 0.8 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.8 for viral meningitis) obtained from linear regression (95% CI 381.7-427.4; R2 = 0.7). CONCLUSION Both the peripheral blood correction and the 400:1 correction reduce the number of neonates classified with pleocytosis who were not eventually diagnosed with meningitis. Both methods might be a useful tool to clarify the neonatal meningitis diagnosis, offering neonatologists the possibility to assess the WBC count in traumatic LP.
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Affiliation(s)
- Gema García-De la Rosa
- Department of Clinical Analysis Laboratory, Hospital Universitario Nuestra Señora de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain.
| | - Silvia De Las Heras-Flórez
- Department of Clinical Analysis Laboratory, Hospital Universitario Nuestra Señora de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Jorge Rodríguez-Afonso
- Department of Clinical Analysis Laboratory, Hospital Universitario Nuestra Señora de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Mercedes Carretero-Pérez
- Department of Clinical Analysis Laboratory, Hospital Universitario Nuestra Señora de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
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18
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Cheng X, Zhang Q, Fu Z, Shi Z, Xia P, Zhang Y, Mao F, Xu Q, Yan X, Wang L. Establishment of a predictive model for purulent meningitis in preterm infants. Transl Pediatr 2022; 11:1018-1027. [PMID: 35800267 PMCID: PMC9253939 DOI: 10.21037/tp-22-236] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Purulent meningitis (PM) is an important cause of mortality and morbidity in the newborn population throughout the world. The subtle of specific clinical signs and low success rates of lumbar puncture make diagnosis of PM more difficult in preterm than in older children. The objective of this study was to establish a predict model for preterm PM in hopes of helping clinicians develop new diagnostic and treatment strategies. METHODS Premature infants who were admitted to The First Affiliated Hospital of Zhengzhou University from September 2017 to March 2020 were enrolled in this study. All the patients underwent lumbar puncture. We collected data encompassing maternal diseases and neonatal clinical features. Cerebrospinal fluid (CSF) culture is the gold standard for diagnosing meningitis. The PM was diagnosed according to the diagnostic criteria. All statistical analyses were performed using R 3.63 (https://www.r-project.org/). Logistic regression and least absolute shrinkage and selection operator (LASSO) regression analyses were used to establish a risk prediction model of PM. The Brier score, calibration slope, and concordance (C)-index were used to verify the accuracy of prediction model. RESULTS A total of 168 preterm infants were enrolled in this study, 80 boys and 88 girls, the gestational age (GA) was 26.43-36.86 weeks (32.45±2.79 weeks), the birth weight (BW) was 700-3,400 g (1,814.05±568.84 g). There were 77 preterm infants with PM while 91 without. We identified seven variables as independent risk factors for PM in preterm infants by LASSO analysis [the optimal λ was 0.080960, and log(λ) = -2.5138], including procalcitonin (PCT) on the 1st day after birth, prenatal glucocorticoid use, albumin, the 1-minute Apgar score, the use of non-invasive biphasic positive airway pressure, hemoglobin, and sex. These were used to construct a risk prediction nomogram and verified its accuracy. The Brier score was 0.17, the calibration slope was 0.966, and the concordance index was 0.82018. CONCLUSIONS Our prediction model could predict the risk of PM in preterm infants. Using this prediction model, it may be able to provide reference to determine whether lumbar puncture is performed and whether antibiotics are applied as soon as possible.
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Affiliation(s)
- Xinru Cheng
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Treatment and Follow-Up Center for High-Risk Newborns of Henan Province, Zhengzhou, China.,Zhengzhou Key Laboratory for the Prevention and Control of Developmental Disorders, Zhengzhou, China
| | - Qian Zhang
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Treatment and Follow-Up Center for High-Risk Newborns of Henan Province, Zhengzhou, China.,Zhengzhou Key Laboratory for the Prevention and Control of Developmental Disorders, Zhengzhou, China
| | - Zhaoqin Fu
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Treatment and Follow-Up Center for High-Risk Newborns of Henan Province, Zhengzhou, China
| | - Zanyang Shi
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Treatment and Follow-Up Center for High-Risk Newborns of Henan Province, Zhengzhou, China.,Zhengzhou Key Laboratory for the Prevention and Control of Developmental Disorders, Zhengzhou, China
| | - Peige Xia
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Treatment and Follow-Up Center for High-Risk Newborns of Henan Province, Zhengzhou, China
| | - Yanan Zhang
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fengxia Mao
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qianya Xu
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaomin Yan
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Wang
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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19
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Ekambaram M, Nabower A, Rajbhandari P, Eisenberg J, Goodrich N, Ampofo K, Gollehon NS, Martin KC, Lyden E, Snowden J. Evaluation of Discordant Results Between FilmArray Meningitis/Encephalitis Panel and Conventional Testing in Pediatric Patients: A Multisite Retrospective Cohort Study. J Pediatric Infect Dis Soc 2022; 11:134-141. [PMID: 35020927 DOI: 10.1093/jpids/piab126] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Maheswari Ekambaram
- Department of Pediatrics, Baylor Scott and White Medical Center, Round Rock, Texas, USA
| | - Aleisha Nabower
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Prabi Rajbhandari
- Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio, USA
| | - Jaclyn Eisenberg
- Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Nathaniel Goodrich
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Krow Ampofo
- Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Nathan S Gollehon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kimberly C Martin
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, USA
| | - Elizabeth Lyden
- Department of Biostatistics, University of Nebraska College of Public Health, Omaha, Nebraska, USA
| | - Jessica Snowden
- Department of Pediatrics, University of Arkansas Medical Center, Little Rock, Arkansas, USA
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20
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Retrospective study comparing success rates of lumbar puncture positions in infants. Am J Emerg Med 2022; 56:228-231. [PMID: 35462151 DOI: 10.1016/j.ajem.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/06/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A lumbar puncture (LP) is performed in the emergency room for diagnostic purposes; unsuccessful or traumatic LPs can complicate decision making. The sitting position has a larger interspinous process compared to lateral recumbent and is safer in sick neonates at risk for cardiac and respiratory instability. PURPOSE Our study aims to determine which position (lateral recumbent or sitting) is associated with a greater likelihood of successful lumbar puncture in infants <3 months when performed in the emergency room. BASIC PROCEDURES This is a retrospective chart review in infants aged <3 months who had a LP performed in a pediatric emergency room. The primary outcome was the rate of successful LPs, defined as obtaining adequate CSF to send for all studies. The secondary outcome was the proportion of atraumatic LPs by position, defined as <500 RBCs or < 10,000 RBCs. MAIN FINDINGS A total of 557 charts were reviewed with 116 in the sitting position and 441 in the lateral recumbent position. The primary outcome of adequate CSF fluid collection was not significantly different between groups (63% sitting position versus 58% lateral recumbent position; p = 0.22). In addition, the proportion of atraumatic LPs showed no significant difference regardless of RBC cutoff (<500 RBCs p = 0.83, <10,000 RBCs p = 0.60). PRINCIPLE CONCLUSIONS This study found no evidence that there is a difference in rate of LP success nor the proportion of traumatic LP in infants less than 3 months of age when positioned in the sitting position compared to the lateral recumbent position.
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21
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Nagaraj M, Bandiya P, Jagannatha B, Shivanna N, Benakappa N, Bandyopadhyay T. Diagnostic Utility of Cerebrospinal Fluid Procalcitonin in Neonatal Meningitis. J Trop Pediatr 2022; 68:6601309. [PMID: 35657202 DOI: 10.1093/tropej/fmac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We aimed to study the diagnostic utility of cerebrospinal fluid (CSF) procalcitonin (PCT) in neonates with meningitis. All the neonates with sepsis who qualified for lumbar puncture were prospectively evaluated. The neonates were classified into Meningitis and No meningitis group based on predefined criteria. CSF PCT was estimated in these neonates along with cytological and biochemical parameters. A total of 113 neonates were included in the study with 29 in the meningitis group and 84 in the no meningitis group. The median PCT levels were higher in babies with meningitis as compared to those without meningitis [0.194 (0.034-0.534) in meningitis group vs. 0.012 (0.012-0.012) ng/ml in no meningitis group, p < 0.001]. The area under curve for CSF PCT was 0.867 (0.77-0.95) and at a cut-off level of 0.120 ng/ml CSF PCT had a sensitivity of 83%, specificity of 84% and positive and negative predictive likelihood ratios of 5.35 and 0.20, respectively for the diagnosis of meningitis. CSF PCT has a good diagnostic accuracy similar to other parameters in the diagnosis of neonatal meningitis and can be considered as an additional diagnostic marker particularly when CSF culture is negative and cytochemical analysis is inconclusive.
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Affiliation(s)
- Meghana Nagaraj
- Department of Pediatrics, Mysore Medical College and Research Centre, Mysore 570001, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bangalore 560029, India
| | - Bhavana Jagannatha
- Department of Microbiology, Indira Gandhi Institute of Child Health, Bangalore 560029, India
| | - Niranjan Shivanna
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bangalore 560029, India
| | - Naveen Benakappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bangalore 560029, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi 110001, India
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22
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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23
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Accuracy of Clinical and Cerebrospinal Fluid Indicators in the Diagnosis of Bacterial Meningitis in Infants <90 Days of Age in Luanda, Angola. Pediatr Infect Dis J 2021; 40:e462-e465. [PMID: 34561386 DOI: 10.1097/inf.0000000000003305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnosis of bacterial meningitis (BM) is problematic in young infants, as clinical features may be nonspecific or even absent. Cerebrospinal fluid (CSF) analysis usually confirms the diagnosis, but the CSF parameters can be normal also in culture-proven BM. Our objective was to identify the clinical and CSF indices, that quickly and without laboratory likely lead to the diagnosis of confirmed of probable BM in young infants in Angola. METHODS We conducted a prospective, observational, single-site study from February 2016 to October 2017 in the Pediatric Hospital of Luanda. All assessed infants showed symptoms and signs compatible of BM or neonatal sepsis and were <90 days of age. RESULTS Of the 1088 infants, 212 (19%) showed bacteria in CSF, while 88 (8%) had probable BM. Independent clinical indicators of BM were not-clear CSF, seizures, weight <2500 g and illness >7 days. In infants with BM, CSF leukocytes were >10 × 106/L in 46%, CSF glucose <25 mg/dL in 43% and CSF protein >120 mg/dL in 58%. All measured parameters were in normal range in 25% of patients. In 515 infants with normal CSF parameters, bacteria were found in 74 (14%). In these infants, illness >7 days, weight <2500 g and malnutrition increased the probability of BM. CONCLUSIONS Our study confirms and underlines the problems in diagnosing BM in young infants. While the CSF parameters were normal in 25% of infants, the easily recognizable unclear appearance of CSF was the single strongest predictor of BM.
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24
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Rogers S, Gravel J, Anderson G, Papenburg J, Quach C, Burstein B. Clinical utility of correction factors for febrile young infants with traumatic lumbar punctures. Paediatr Child Health 2021; 26:e258-e264. [PMID: 34676015 DOI: 10.1093/pch/pxaa114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Objectives Correction factors have been proposed for traumatic lumbar punctures (LPs) in febrile young infants. However, no studies have assessed their diagnostic utility. We sought to determine the proportion of traumatic LPs safely reclassified as low risk for bacterial meningitis using recently derived white blood cell (WBC) and protein correction factors. Methods We retrospectively analyzed traumatic LPs among all febrile infants ≤60 days old at two tertiary paediatric hospitals from 2006 through 2018. Traumatic LPs were defined as ≥10,000 RBCs/mm3. Abnormal cerebrospinal fluid (CSF) WBCs and protein were adjusted downward using a newly derived correction factor (877 red blood cells [RBCs]: 1 WBC), three commonly used correction factors (500 WBCs: 1 RBC; 1,000 WBCs: 1 WBC; peripheral RBCs: WBCs), and a newly derived protein correction factor (1,000 RBCs: 0.011 g/L protein). Results There were 437 traumatic LPs including 357 (82%) with pleocytosis and 4 (0.9%) with bacterial meningitis. Overall, fewer infants were classified as having CSF pleocytosis using 877:1 and 1,000:1 ratios (38% and 43%, respectively), with 100% sensitivity and negative predictive value, and improved specificity (63% for 877:1, 58% for 1,000:1 ratios versus 19% for uncorrected counts). Among infants with pleocytosis, 877:1 and 1,000:1 ratios reclassified 191 (54%) and 171 (48%) as normal with no misclassified bacterial meningitis cases. Ratios of 500:1 and peripheral RBC:WBC misclassified 1 infant that had bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity but did not add diagnostic value following WBC-based correction. Conclusions Correction ratios of 877:1 and 1,000:1 safely reclassified half of all febrile infants ≤60 days. These corrections should be considered when interpreting CSF results of traumatic LPs.
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Affiliation(s)
- Sarah Rogers
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montreal, Quebec
| | - Gregory Anderson
- Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - Jesse Papenburg
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec.,Division of Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montreal, Quebec.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec
| | - Caroline Quach
- Department of Microbiology, Infectious Diseases, and Immunology, Université de Montréal, Montreal, Quebec.,Infection Prevention and Control, Clinical Department of Laboratory Medicine, CHU Sainte-Justine, Montreal, Quebec
| | - Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec
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25
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Stephens C, Reynolds C, Cremin M, Barry R, Morley U, Gibson L, De Gascun CF, Felsenstein S. Parent-administered Neurodevelopmental Follow up in Children After Picornavirus CNS Infections. Pediatr Infect Dis J 2021; 40:867-872. [PMID: 34260497 DOI: 10.1097/inf.0000000000003192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data on the neurodevelopment of children who experienced central nervous system (CNS) infections with enteroviruses (EV) or parechoviruses (hPeV) is scarce and mostly limited to follow up of short-term outcomes. METHODS Parents of children who presented between 2014 and 2019, underwent a lumbar puncture and whose cerebrospinal fluid was polymerase chain reaction positive for EV or hPeV, were asked to complete a care-giver-administered neurodevelopmental assessment tool (The Ages and Stages Instrument [ASQ3]). Clinical data of the infective episode were collected from patient notes. RESULTS Of 101 children, 43 (10 hPeV+, 33 EV+) submitted ASQ3 results. Median age at assessment was 38.9 months (interquartile range, 15.4-54.8), the follow-up interval 3 years (median 37 months; interquartile range, 13.9-53.1). Age, inflammatory markers, and cerebrospinal fluid pleocytosis during the infective event were not associated with ASQ3 scores. In 23 children (17 EV+, 6 hPeV+), no neurodevelopmental concerns were reported. Two more had preexisting developmental delay and were excluded. Of the remaining, 18/41 (43.9%) reported ASQ3 scores indicating need for monitoring or professional review in at least 1 category, not differing by pathogen (EV 14/31, 45.2%; hPeV 4/10, 40%; P = 0.71). Seven children will require formal review, scoring ≥2 SD below the mean in at least 1 category (6/31 EV+, 1/10 hPeV+, P = 0.7), 3 scored ≥2 SD below the mean in more than 1 area. CONCLUSIONS Parent-administered developmental assessment of children with a history of early picornavirus infection of the CNS identified a subgroup that requires formal neurodevelopmental review. Wider application of community-based developmental screening will complement our understanding of the impact of CNS infections in early childhood.
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Affiliation(s)
- Carol Stephens
- From the Department of Pediatrics, Cork University Hospital, Wilton, Cork, Republic of Ireland
| | - Clare Reynolds
- From the Department of Pediatrics, Cork University Hospital, Wilton, Cork, Republic of Ireland
| | - Molly Cremin
- From the Department of Pediatrics, Cork University Hospital, Wilton, Cork, Republic of Ireland
| | - Rachel Barry
- Department of Microbiology, Cork University Hospital, Wilton, Cork, Republic of Ireland
| | - Ursula Morley
- National Virus Reference Laboratory, University College Dublin, Dublin, Republic of Ireland
| | - Louise Gibson
- From the Department of Pediatrics, Cork University Hospital, Wilton, Cork, Republic of Ireland
| | - Cillian F De Gascun
- National Virus Reference Laboratory, University College Dublin, Dublin, Republic of Ireland
| | - Susana Felsenstein
- Department of Infectious Diseases, Alder Hey Children's Hospital NHS Trust, East Prescot Road, Liverpool, Great Britain
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26
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Mukherjee G, Waris R, Rechler W, Kudelka M, McCracken C, Kirpalani A, Hames N. Determining Normative Values for Cerebrospinal Fluid Profiles in Infants. Hosp Pediatr 2021; 11:930-936. [PMID: 34344692 DOI: 10.1542/hpeds.2020-005512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Previous studies of reference values for cerebrospinal fluid (CSF) profiles have been limited by small sample size and few exclusion criteria. OBJECTIVE To determine age-specific normative CSF white blood cell count (WBC), glucose, and protein values in infants ≤90 days old. METHODS Performed a retrospective cross-sectional study of infants ≤90 days old who had a diagnostic lumbar puncture between 2008 and 2016. Infants with bacterial meningitis, bacteremia, UTI, positive CSF herpes simplex virus polymerase chain reaction (PCR) result, traumatic lumbar puncture, ventriculoperitoneal shunt, prematurity, recent seizure, previous antibiotic use, and history of a complex chronic condition were excluded for calculations to determine normative values. Data on demographics and CSF values (WBC with differential, protein, glucose, enterovirus PCR) were collected. CSF values were compared by age and by enterovirus PCR results using Kruskal-Wallis and Wilcoxon rank tests. RESULTS A total of 1029 out of 2000 patients were included and divided into 3 age groups: 0 to 28 days, 29 to 60 days, 61 to 90 days. CSF WBC values were significantly greater for 0- to 28-day old infants (median: 3, 95th percentile: 14) than for 29- to 60-day and 61- to 90-day old infants (median: 2 and 2; 95th percentile: 7 and 11, respectively) (P < .001). With each month of life, the median CSF protein significantly decreased and glucose significantly increased. In the CSF WBC differential, monocytes were found to be prevalent. CONCLUSION We determined age-specific normative components for CSF profile values for infants 0 to 90 days.
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Affiliation(s)
- Gargi Mukherjee
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Willi Rechler
- UCLA Mattel Children's Hospital, Los Angeles, California
| | | | | | - Anjali Kirpalani
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nicole Hames
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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27
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Blood Procalcitonin Level as a Diagnostic Marker of Pediatric Bacterial Meningitis: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11050846. [PMID: 34066811 PMCID: PMC8151301 DOI: 10.3390/diagnostics11050846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022] Open
Abstract
Early diagnosis and treatment of bacterial meningitis in children are essential, due to the high mortality and morbidity rates. However, lumbar puncture is often difficult, and cerebrospinal fluid (CSF) culture takes time. This meta-analysis aims to determine the diagnostic accuracy of blood procalcitonin for detecting bacterial meningitis in children. We conducted a systematic search on electronic databases to identify relevant studies. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated, and a hierarchical summary receiver operating characteristic curve and area under the curve (AUC) were determined. Eighteen studies with 1462 children were included in the analysis. The pooled sensitivity, specificity, and the DOR of blood procalcitonin for detecting bacterial meningitis were 0.87 (95% confidence interval (CI): 0.78–0.93); 0.85 (95% CI: 0.75–0.91), and 35.85 (95% CI: 10.68–120.28), respectively. The AUC for blood procalcitonin was 0.921. Blood procalcitonin also showed higher diagnostic accuracy for detecting bacterial meningitis than other conventional biomarkers, including serum C-reactive protein and leukocyte count, CSF leukocyte and neutrophil count, and CSF protein and glucose levels. Blood procalcitonin can be a good supplemental biomarker with high diagnostic accuracy in detecting bacterial meningitis in children.
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28
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Emergency physician performed ultrasound-assisted lumbar puncture in children: A randomized controlled trial. Am J Emerg Med 2021; 43:158-163. [DOI: 10.1016/j.ajem.2020.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/19/2022] Open
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Sievänen H, Kari J, Halonen S, Elomaa T, Tammela O, Soukka H, Eskola V. Real-time detection of cerebrospinal fluid with bioimpedance needle in paediatric lumbar puncture. Clin Physiol Funct Imaging 2021; 41:303-309. [PMID: 33682245 PMCID: PMC8251608 DOI: 10.1111/cpf.12697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
Background Lumbar puncture is a common clinical procedure that can occasionally be difficult. Various needle guidance methods can facilitate performing this procedure, but at the expense of special expertise, equipment and facility. In the present study, we evaluated the clinical feasibility of a novel bioimpedance needle system regarding its ability to detect cerebrospinal fluid (CSF) in paediatric lumbar punctures. Methods We performed 40 lumbar puncture procedures using the bioimpedance needle system in 37 paediatric patients, aged from 0 days to 17 months, as a part of their prescribed examinations in two university hospitals. The bioimpedance needle is similar to a conventional 22G cutting‐edge spinal needle with a stylet, except the needle and stylet are configured as a bipolar electrode with high spatial resolution. The system measures in real‐time when the needle tip reaches the subarachnoid space containing CSF. The procedure was considered successful when the erythrocyte count was determined from the obtained CSF sample. Results Subarachnoid space was verifiably reached in 28 out of 40 procedures (70%). Bioimpedance needle system detected CSF in 23 out of these 28 successful procedures (82%) while failed in 3 out of 28 procedures (11%). No adverse events were reported. Conclusion Bioimpedance spinal needle system was found clinically feasible in paediatric lumbar punctures, and it may offer an objective and simple means to detect the time point when the needle tip is in contact with the cerebrospinal fluid.
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Affiliation(s)
| | | | | | | | - Outi Tammela
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,Tampere Center for Child Health Research, Tampere University, Tampere, Finland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Vesa Eskola
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,Tampere Center for Child Health Research, Tampere University, Tampere, Finland
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Relevance of Biomarkers Currently in Use or Research for Practical Diagnosis Approach of Neonatal Early-Onset Sepsis. CHILDREN-BASEL 2020; 7:children7120309. [PMID: 33419284 PMCID: PMC7767026 DOI: 10.3390/children7120309] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023]
Abstract
Neonatal early-onset sepsis (EOS) is defined as an invasive infection that occurs in the first 72 h of life. The incidence of EOS varies from 0.5–2% live births in developed countries, up to 9.8% live births in low resource settings, generating a high mortality rate, especially in extremely low birth weight neonates. Clinical signs are nonspecific, leading to a late diagnosis and high mortality. Currently, there are several markers used for sepsis evaluation, such as hematological indices, acute phase reactants, cytokines, which by themselves do not show acceptable sensitivity and specificity for the diagnosis of EOS in neonates. Newer and more selective markers have surfaced recently, such as presepsin and endocan, but they are currently only in the experimental research stages. This comprehensive review article is based on the role of biomarkers currently in use or in the research phase from a basic, translational, and clinical viewpoint that helps us to improve the quality of neonatal early-onset sepsis diagnosis and management.
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Boula A, Senghore M, Ngoh R, Tassadjo F, Fonkoua MC, Nzouankeu A, Njiki MK, Musi J, Bebey S, Ngo Baleba M, Nkembe A, Médjina S, Ndow PS, Worwui A, Kobela M, Nimpa M, Mwenda JM, N'diaye A, Kwambana-Adams BA, Antonio M. Hospital-based Surveillance Provides Insights Into the Etiology of Pediatric Bacterial Meningitis in Yaoundé, Cameroon, in the Post-Vaccine Era. Clin Infect Dis 2020; 69:S148-S155. [PMID: 31505633 PMCID: PMC6761319 DOI: 10.1093/cid/ciz506] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Meningitis is endemic to regions of Cameroon outside the meningitis belt including the capital city, Yaoundé. Through surveillance, we studied the etiology and molecular epidemiology of pediatric bacterial meningitis in Yaoundé from 2010 to 2016. Methods Lumbar puncture was performed on 5958 suspected meningitis cases; 765 specimens were further tested by culture, latex agglutination, and/or polymerase chain reaction (PCR). Serotyping/grouping, antimicrobial susceptibility testing, and/or whole genome sequencing were performed where applicable. Results The leading pathogens detected among the 126 confirmed cases were Streptococcus pneumoniae (93 [73.8%]), Haemophilus influenzae (18 [14.3%]), and Neisseria meningitidis (15 [11.9%]). We identified more vaccine serotypes (19 [61%]) than nonvaccine serotypes (12 [39%]); however, in the latter years non–pneumococcal conjugate vaccine serotypes were more common. Whole genome data on 29 S. pneumoniae isolates identified related strains (<30 single-nucleotide polymorphism difference). All but 1 of the genomes harbored a resistance genotype to at least 1 antibiotic, and vaccine serotypes harbored more resistance genes than nonvaccine serotypes (P < .05). Of 9 cases of H. influenzae, 8 were type b (Hib) and 1 was type f. However, the cases of Hib were either in unvaccinated individuals or children who had not yet received all 3 doses. We were unable to serogroup the N. meningitidis cases by PCR. Conclusions Streptococcus pneumoniae remains a leading cause of pediatric bacterial meningitis, and nonvaccine serotypes may play a bigger role in disease etiology in the postvaccine era. There is evidence of Hib disease among children in Cameroon, which warrants further investigation.
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Affiliation(s)
- Angeline Boula
- Centre Mere et Enfant de la Fondation, Yaoundé, Cameroon
| | - Madikay Senghore
- World Health Organization (WHO) Collaborating Centre for New Vaccines Surveillance, West Africa Partnerships and Strategy, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Rose Ngoh
- Centre Mere et Enfant de la Fondation, Yaoundé, Cameroon
| | | | | | | | | | | | - Sandrine Bebey
- Centre Mere et Enfant de la Fondation, Yaoundé, Cameroon
| | | | | | | | - Peter S Ndow
- World Health Organization (WHO) Collaborating Centre for New Vaccines Surveillance, West Africa Partnerships and Strategy, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Archibald Worwui
- World Health Organization (WHO) Collaborating Centre for New Vaccines Surveillance, West Africa Partnerships and Strategy, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | | | - Jason M Mwenda
- WHO Regional Office for Africa, Brazzaville, Republic of Congo
| | | | - Brenda A Kwambana-Adams
- World Health Organization (WHO) Collaborating Centre for New Vaccines Surveillance, West Africa Partnerships and Strategy, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Martin Antonio
- World Health Organization (WHO) Collaborating Centre for New Vaccines Surveillance, West Africa Partnerships and Strategy, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia.,Microbiology and Infection Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
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Li H, Xiao R, Javed R, Li K, Ye W, Zhou W, Liang H. Evaluation of cerebrospinal fluid and blood parameters finding in early diagnosis and drug therapy of suspected bacterial meningitis in neonates. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:77. [PMID: 33088314 PMCID: PMC7554534 DOI: 10.4103/jrms.jrms_470_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 11/26/2019] [Accepted: 04/18/2020] [Indexed: 11/17/2022]
Abstract
Background: Whether early lumbar puncture (LP) and blood indicators are suitable as diagnostic criteria and helpful to treatment strategies for newborns remains to be solved. The study was to evaluate the value of cerebrospinal fluid (CSF) at the first LP and blood indicators at the similar time in the early diagnosis and the drug therapy of neonatal bacterial meningitis. Materials and Methods: We conducted a retrospective observational study of 997 infants with suspected bacterial meningitis between June 2012 and June 2018. CSF and blood parameters were evaluated by three stepwise logistic models to assess their ability: to distinguish bacterial meningitis from nonbacterial meningitis, to distinguish positive CSF culture from negative, and to distinguish Gram-positive bacteria from negative. Results: Of the 997 neonates, 236 (23.67%) were later diagnosed as bacterial meningitis. Of the neonates with meningitis, 54 (22.88%) had positive CSF culture results. And of neonates with positive CSF culture, 27 (50%) had Gram-positive results. One or more CSF indicators were added to the three models. Only blood hypersensitive C-reactive protein and blood lactate dehydrogenase were added to the first model, while no blood parameters was added to the other two models. The areas under the effect-time curves of the three models were 0.91 (95% confidence interval [CI]: 0.89–0.92, P < 0.001), 0.69 (95% CI: 0.63–0.75, P < 0.001), and 0.86 (95% CI: 0.74–0.94, P < 0.001), respectively. Conclusion: LP was irreplaceable predictor of bacterial meningitis, and comprehensive analysis of CSF indicators can predict the offending organism, which enables refinement of therapy.
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Affiliation(s)
- Huixian Li
- Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Rui Xiao
- Department of Respiration, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Ruheena Javed
- Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Kuanrong Li
- Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Weitao Ye
- Public Health School, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wei Zhou
- Guangzhou Women and Children's Medical Center, Neonatal Intensive Care Unit, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Huiying Liang
- Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, Guangdong, China
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Podkovik S, Kashyap S, Wiginton J, Kang C, Mo K, Goodrich M, Wolberg A, Wacker MR, Miulli DE. Comparison of Ventricular and Lumbar Cerebrospinal Fluid Composition. Cureus 2020; 12:e9315. [PMID: 32850195 PMCID: PMC7444742 DOI: 10.7759/cureus.9315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022] Open
Abstract
Objective Cerebrospinal fluid (CSF) analysis is a common diagnostic tool used to evaluate diseases of the central nervous system (CNS). We sought to determine whether there is a difference between the composition of CSF sampled from an external ventricular drain (EVD) and lumbar drain (LD) and whether this made a difference in guiding therapeutic decisions. Patients and Methods This study was a retrospective analysis from a single neurosurgery service between the dates of January 2011 and April 2019. A total of 12,134 patients were screened. Inclusion criteria were ages 18-80 and the presence of both an EVD and LD. Exclusion criteria were not having both routes of CSF sampling and the inability to determine which samples originated from which compartment. Results Six patients underwent simultaneous spinal and ventricular routine CSF sampling <24 hours apart and were analyzed for their compositions. There were 42 samples, but only 20 paired EVD-LD samples that could be analyzed. When comparing the EVD and LD sample compositions, there were statistically significant differences in white blood cells (WBCs; p = 0.040), total protein (p = 0.042), and glucose (p = 0.043). Red blood cells (RBCs; p = 0.104) and polymorphonuclear leukocytes (PMN; p = 0.544) were not statistically significant. We found a statistically significant correlation between cranial and spinal CSF WBC (r = 0.944, p < 0.001), protein (r = 0.679, p = 0.001), and glucose (r = 0.805, p < 0.001). We also found that there was a significant correlation between CSF and serum glucose (r = 0.502, p = 0.040). There was no statistically significant correlation between RBCs (r = 0.276, p = 0.252). Conclusion Our results demonstrate a correlation between the cranial and spinal CSF samples, except for RBCs, with statistically significant differences in WBC, glucose, and protein values between the two sites. This confirms that sampling CSF via lumbar puncture, which carries less risk than a ventriculostomy and provides accurate data to help establish a diagnosis for intracranial pathologies.
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Affiliation(s)
- Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Christine Kang
- Neurosurgery, Touro University College of Osteopathic Medicine California, Vallejo, USA
| | - Kevin Mo
- Medicine, Western University of Health Sciences, Pomona, USA
| | | | - Adam Wolberg
- Surgery, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | | | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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Spinal needle size and traumatic neonatal lumbar puncture: an observational study (neo-LP). Eur J Pediatr 2020; 179:939-945. [PMID: 32002614 DOI: 10.1007/s00431-020-03580-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/30/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
The incidence of 'traumatic' lumbar puncture (LP; CSF red cells > 500/mm) has been reported to be 35-46% in the neonatal period. A traumatic LP incurs challenges in diagnosis and management of the underlying condition and increases the risk of complications. We aimed to assess the benefits of a smaller outer diameter, larger gauge 25G needle in reducing the incidence of traumatic LPs compared with the standard 22G LP needle. This prospective observational study compared data from two consecutive epochs. Epoch 1 (Control, April 2016-October 2016), 22G needle for LP as standard practice. Epoch 2 (Intervention, November 2016-October 2017) 25G needle used for LP. Primary outcome was the incidence of traumatic LP. Multiple logistic regression analyses were conducted adjusting for corrected gestational age (CGA) at LP, proceduralist experience and need for ventilation as an indicator of illness. There were 240 LPs during the study period involving 361 attempts (22G, n = 228; 25G, n = 133). Median gestation at birth (P = 0.617) and CGA at LP (P = 0.163) were comparable. Multivariate analysis revealed lower incidence of traumatic LP using 25G needle (P < 0.001). Incidence of obtaining a successful CSF sample was similar between groups (P = 0.944). Proceduralist experience (P = 0.189) and neonatal illness (P = 0.801) were not significant factors.Conclusion: Our results showed that traumatic LPs were ~ 50% less common with 25G vs 22G needles while retaining a comparable success rate. Dry taps were more likely among the 25G group.What is Known:• The incidence of neonatal 'traumatic' lumbar puncture (CSF red cells > 500/mm) has been reported to be 35-46%.• A traumatic lumbar puncture incurs challenges in diagnosis and management of the underlying condition and increases the risk of complications.What is New:• Multivariate analysis revealed lower incidence of traumatic lumbar puncture using 25G needle (vs 22G).• Incidence of obtaining a successful CSF sample was similar between groups.
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Pathogen or Bystander: Clinical Significance of Detecting Human Herpesvirus 6 in Pediatric Cerebrospinal Fluid. J Clin Microbiol 2020; 58:JCM.00313-20. [PMID: 32102858 DOI: 10.1128/jcm.00313-20] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 02/08/2023] Open
Abstract
Human herpesvirus 6 (HHV-6) is an important cause of meningitis and meningoencephalitis. As testing for HHV-6 in cerebrospinal fluid (CSF) is more readily available using the FilmArray Meningitis/Encephalitis panel (FA-ME; BioFire Diagnostics, Salt Lake City, UT), we aimed to determine the clinical significance of detecting HHV-6 in order to identify true infections and to ensure appropriate antiviral initiation. Chart review on 25 patients positive for HHV-6 by FA-ME was performed to determine clinical presentation, comorbidity, treatment, and outcome. The presence of chromosomally integrated HHV-6 (ciHHV-6) DNA was also investigated. Of 1,005 children tested by FA-ME, HHV-6 was detected in 25 (2.5%). Five patients were diagnosed with either HHV-6 meningitis or meningoencephalitis based on HHV-6 detection in CSF, clinical presentation, and radiographic findings. Detection of HHV-6 by FA-ME led to discontinuation of acyclovir within 12.0 h in all 12 patients empirically treated with acyclovir. Six of the 12 patients were started on ganciclovir therapy within 6.8 h; 4 of these were treated specifically for HHV-6 infection, whereas therapy was discontinued in the remaining 2 patients. CSF parameters were not generally predictive of HHV-6 positivity. The presence of ciHHV-6 was confirmed in 3 of 18 patients who could be tested. Five of the 25 patients included in the study were diagnosed with HHV-6 meningitis/meningoencephalitis. FA-ME results led to discontinuation of empirical antiviral treatment in 12 patients and appropriate initiation of ganciclovir in 4 patients. In our institution, detection of HHV-6 using FA-ME led to faster establishment of disease etiology and optimization of antimicrobial therapy.
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Marshall ASJ, Sadarangani M, Scrivens A, Williams R, Yong J, Bowler U, Linsell L, Chiocchia V, Bell JL, Stokes C, Santhanadass P, Adams E, Juszczak E, Roehr CC. Study protocol: NeoCLEAR: Neonatal Champagne Lumbar punctures Every time - An RCT: a multicentre, randomised controlled 2 × 2 factorial trial to investigate techniques to increase lumbar puncture success. BMC Pediatr 2020; 20:165. [PMID: 32295554 PMCID: PMC7160994 DOI: 10.1186/s12887-020-02050-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
Background The neonatal period carries the highest risk of bacterial meningitis (~ 1 in 5000 births), bearing high mortality (~ 10%) and morbidity (20–50%) rates. Lumbar puncture (LP) remains essential to the diagnosis of meningitis. Though LP is a common procedure in neonates, success rates are lower (50–60%) than in other patient populations. None of the currently-practised neonatal LP techniques are supported by evidence from adequately-powered, randomised controlled trials (RCTs). NeoCLEAR aims to compare two modifications to the traditional technique which are free, accessible, and commonly practised: sitting (as opposed to lying) position, and ‘early’ (as opposed to ‘late’) stylet removal. Methods/design Written parental informed consent permitting, infants in neonatal/maternity wards, of 27+ 0 to 44+ 0 weeks corrected gestational age and weighing ≥1000 g, who require an LP, will be randomly allocated to sitting or lying position, and to early or late stylet removal. The co-primary objectives are to compare success rates (the proportion of infants with cerebrospinal fluid red cell count < 10,000/mm3 on first LP procedure) in 1020 infants between the two positions, and between the two methods of stylet removal. Secondary outcomes relate to LP procedures, complications, diagnoses of meningitis, duration of antibiotics and hospital stay. A modified intention-to-treat analysis will be conducted. Discussion Two modifications to the traditional LP technique (sitting vs lying position; and early vs late stylet removal) will be simultaneously investigated in an efficient and appropriately-powered 2 × 2 factorial RCT design. Analysis will identify the optimal techniques (in terms of obtaining easily-interpretable cerebrospinal fluid), as well as the impact on infants, parents and healthcare systems whilst providing robust safety data. Using a pragmatic RCT design, all practitioners will be trained in all LP techniques, but there will inevitably be variation between unit practice guidelines and other aspects of individual care. An improved LP technique would result in: • Fewer uninterpretable samples, repeated attempts and procedures • Reduced distress for infants and families • Decreased antibiotic use and risk of antibiotic resistance • Reduced healthcare costs due to fewer procedures, reduced length of stay, shorter antibiotic courses, and minimised antibiotic-associated complications Trial registration ISRCTN14040914. Date assigned: 26/06/2018.
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Affiliation(s)
- Andrew S J Marshall
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, V5Z 4H4, Canada.,Department of Pediatrics, University of British Columbia, 4480 Oak St, Vancouver, BC, V6H 0B3, Canada
| | - Alexandra Scrivens
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.,National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Rachel Williams
- National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Jean Yong
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Caz Stokes
- Support for the Sick Newborn And their Parents (SSNAP) Charity, Level 2, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Patricia Santhanadass
- Support for the Sick Newborn And their Parents (SSNAP) Charity, Level 2, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Charles C Roehr
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.,National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
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Cerebrospinal Fluid Findings Are Poor Predictors of Appropriate FilmArray Meningitis/Encephalitis Panel Utilization in Pediatric Patients. J Clin Microbiol 2020; 58:JCM.01592-19. [PMID: 31852767 DOI: 10.1128/jcm.01592-19] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/17/2019] [Indexed: 01/06/2023] Open
Abstract
Molecular testing of cerebrospinal fluid (CSF) using the BioFire FilmArray meningitis/encephalitis (FA-M/E) panel permits rapid, simultaneous pathogen detection. Due to the broad spectrum of targeted organisms, FA-M/E testing may be restricted to patients with abnormal CSF findings. We sought to determine if restriction is appropriate in our previously healthy and/or immunocompromised pediatric patients. FA-M/E was ordered on 1,025 CSF samples from 948 patients; 121 (11.8%) specimens were FA-M/E positive. Of these, 89 (73.6%) were virus positive, and 30 (24.8%) were bacterium positive. The most common targets detected were enterovirus (n = 38), human herpesvirus 6 (HHV-6) (n = 30), and Streptococcus pneumoniae (n = 14). Pleocytosis with white blood cell (WBC) levels of ≥5 cells/mm3 and ≥10 cells/mm3 were found in 33.1% and 24.3% of all specimens, respectively. Using WBC levels of ≥5 cells/mm3, 63.4% (59/93) of positive specimens exhibited pleocytosis, compared to 29.5% (233/789) of negative specimens. Among positive specimens, 54.4% (37/68) of viral and 87% (20/23) of bacterial cases had pleocytosis. The use of a pleocytosis cutoff of ≥10 cells/mm3 would have missed an additional enterovirus, one cytomegalovirus (CMV), and two HHV-6 diagnoses. CSF glucose and protein levels were normal for 83/116 (75.2%) and 51/116 (44%) positive specimens. Abnormal glucose in combination with WBC levels of ≥10 cells/mm3 showed high specificity (94.5%) and was a better predictor of FA-M/E positivity than abnormal protein. Sensitivity and positive predictive values were <90% for all biomarkers. CSF pleocytosis and abnormal glucose/protein were poor predictors of FA-M/E. Restricting FA-M/E orders based on pleocytosis or other abnormal parameters would have resulted in missed diagnostic opportunities, particularly for the detection of viruses in both previously healthy and immunocompromised patients.
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Szánthó E, Kárai B, Ivády G, Baráth S, Száraz-Széles M, Kappelmayer J, Hevessy Z. Evaluation of Sample Quality As Preanalytical Error in Flow Cytometry Analysis in Childhood Acute Lymphoblastic Leukemia. EJIFCC 2019; 30:385-395. [PMID: 31814813 PMCID: PMC6893891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL) is the most common cancer among children. The intensity of chemotherapy and further therapeutic decisions depend on several prognostic factors, including response to initial treatment by examining peripheral blood (PB), bone marrow (BM) and cerebrospinal fluid (CSF) samples at certain time points. (e.g. day 15 BM). Sample quality is crucial for the correct risk assessment. PATIENTS AND METHODS We aimed to explore the rate of inadequate samples as a source of preanalytical error. We retrospectively analyzed flow cytometry results of BM (day 15 and day 33) and CSF samples from children with ALL in different cohorts focusing on PB contamination and viable cell ratio among nucleated cells. We also compared viable cell percentages in native and stabilized CSF samples. RESULTS Due to PB contamination (erythroid precursors < 2%) 12.5% of day 15 and 14% of day 33 BM samples were inadequate for flow cytometry risk stratification. Significantly fewer CSF samples had to be considered inadequate for analysis (defined as viable cells < 30%) in the subgroup of stabilized samples compared to native samples. Four of the CSF samples from children with ALL had identifiable malignant cell population despite the low viable cell percentage. DISCUSSION Poor sample quality can hamper risk stratification and further therapeutic decision in childhood ALL. Despite low viable cell count malignant cell populations may still be identified in a CSF sample, therefore establishing a certain cutoff point for viable cells is difficult.
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Affiliation(s)
| | | | | | | | | | | | - Zsuzsanna Hevessy
- Corresponding author: Zsuzsanna Hevessy M.D., Ph.D. Department of Laboratory Medicine Faculty of Medicine University of Debrecen Nagyerdei krt. 98 Debrecen, H-4032 Hungary Phone: +36 52 340 006 Fax: +36 52 417 631 E-mail:
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Liu Z, Jia D, Dai J, Zhou X, Qin Z, Chen L, Zhang J, Chen G, He X, Wan R, Ye X. Age-specific reference values for cerebrospinal fluid protein concentrations in children in southern China. Medicine (Baltimore) 2019; 98:e17500. [PMID: 31593118 PMCID: PMC6799853 DOI: 10.1097/md.0000000000017500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cerebrospinal fluid (CSF) protein values decline over the first few months of life as the infant's blood-CSF barrier matures. However, published studies have not reported CSF protein reference values of Chinese infants and differ in the reported rate, timing, and magnitude of this decline. The objective of this study was to determine reference intervals for CSF protein using available data of children in southern China. This retrospective study included infants who had a lumbar puncture (LP) performed in the Department of Pediatrics of Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan of an urban tertiary care children's hospital between January 1, 2008 and May 31, 2018. Infants with conditions suspected or known to cause elevated CSF protein concentrations were excluded. Of 3712 infants undergoing LP, 1043 (28.1%) met inclusion criteria. Results showed that there is an age-related decline in CSF protein concentration. The median CSF protein value was 62 mg/dL [interquartile range (IQR): 47-81 mg/dL] in infants aged 0 to 56 days (group 1). The 95th percentile values were 116 mg/dL for infants 0 to 28 days and 80 mg/dL for infants 29 to 56 days. The 95th percentile values by age category were as follows: ages 0 to 14 days, 117 mg/dL; ages 15 to 28 days, 107 mg/dL; ages 29 to 42 days, 96 mg/dL; and ages 43 to 56 days, 74 mg/dL. The median CSF protein value was 21 mg/dL (IQR: 16-31 mg/dL) in infants aged 2 months to <3 years (group 2). The 95th percentile values were 57 mg/dL for infants 2 to <6 months and 34 mg/dL for infants 6 to ≤24 months. The 95th percentile values by age category were as follows: ages 2 to <3 months, 66 mg/dL; ages 3 to <4 months, 52 mg/dL; ages 4 to <5 months, 53 mg/dL; and ages 5 to <6 months, 42 mg/dL. We quantify the age-related decline in CSF protein concentrations among infants 2 years of age and younger and provide age-specific reference values. The values reported here can be used to interpret the results of LP in infants ≤2 years of age.
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Kitsommart R, Wongsinin T, Swasee U, Paes B. Accuracy of Using a Point-of-Care Glucometer for Cerebrospinal Fluid Glucose Screening in Resource-Limited Countries. Hosp Pediatr 2019; 9:665-672. [PMID: 31434686 DOI: 10.1542/hpeds.2019-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To explore the accuracy of using a point-of-care (POC) glucometer for cerebrospinal fluid (CSF) glucose screening. METHODS A cross-sectional study was conducted. A glucose analysis of CSF samples collected from infants <90 days with suspected meningitis was paired between tests by using a POC glucometer (POC-CSF glucose) and a laboratory glucose analysis (laboratory-CSF glucose). Accuracy and limits of agreement were compared, as well as the glucometer performance to detect a laboratory-CSF glucose level <45 and 60 mg/dL. RESULTS Seventy-three CSF samples were analyzed. Subjects' mean gestational age was 32.2 (SD 4.0) weeks, the mean weight was 1947.7 (SD 814.5) g, and the median age was 8 (interquartile range: 2 to 19.5) days. POC-CSF glucose levels ranged from 26 to 126 mg/dL. The mean (±1.96 SD) difference between POC-CSF and laboratory-CSF glucose levels was -1.6 (interquartile range: -12.6 to 9.4) mg/dL. A POC-CSF glucose level <45 mg/dL has a sensitivity and negative predictive value (NPV) to detect a laboratory-CSF glucose level <45 mg/dL of 82% and 94%, respectively. For a laboratory-CSF glucose level <60 mg/dL, a POC glucose level <60 mg/dL provides a sensitivity and NPV of 96% and 90%, respectively, whereas sensitivity and NPV reach 100% at a POC glucose level <70 mg/dL. CONCLUSIONS A POC glucometer for CSF glucose can detect a potential abnormal glucose level with an appropriate cutoff level. This may facilitate rapid decisions for empirical antibiotics in suspected meningitis, pending laboratory results in limited-resource settings, but requires robust validation in future studies before implementation.
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Affiliation(s)
- Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Thananjit Wongsinin
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Pediatrics, Bhumibol Hospital, Bangkok, Thailand; and
| | - Uraporn Swasee
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Abstract
Introduction of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has led to a substantial reduction in cases of acute bacterial meningitis in countries with high routine childhood immunization coverage. The majority of children hospitalized with meningitis in high-income countries have viral or aseptic meningitis and do not require antibiotic treatment. Cerebrospinal fluid analysis is irreplaceable in appropriately diagnosing and treating bacterial meningitis and avoiding unnecessary antibiotics and prolonged hospitalizations in children with viral meningitis. New diagnostic tests have improved detection of bacterial and viral pathogens in cerebrospinal fluid, underscoring the importance of promptly performing lumbar puncture when meningitis is suspected. This article provides an overview of acute bacterial and viral meningitis in children, focusing on the changing epidemiology, the advantages and limitations of conventional and newer diagnostic methods, and considerations for clinical practice.
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Aleem S, Greenberg RG. When to Include a Lumbar Puncture in the Evaluation for Neonatal Sepsis. Neoreviews 2019; 20:e124-e134. [PMID: 31261050 DOI: 10.1542/neo.20-3-e124] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Meningitis is a devastating infection in infants and is linked to adverse long-term outcomes. The prevalence of meningitis is variable and depends on gestational age, postnatal age, and clinical setting. Early diagnosis and treatment with appropriate antibiotics are crucial to decrease the risk of morbidity and mortality. Lumbar punctures are essential for the diagnosis of meningitis, but clinicians may defer lumbar puncture if the risk for meningitis is low or if there are substantial concerns regarding the risk associated with the procedure. Awareness of the epidemiology and microbiology of meningitis in infants, as well as valid contraindications to performing a lumbar puncture, is necessary to avoid missed diagnoses and procedure-related adverse effects.
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Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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Krishnamurthy V, Nabil N, Reddy SM, Doreswamy SM. Dilemma in Diagnosis of Pyogenic Meningitis in Cerebrospinal Fluid Contaminated with Blood: Does Leucocyte Esterase Test Help? J Cytol 2019; 36:44-47. [PMID: 30745739 PMCID: PMC6343398 DOI: 10.4103/joc.joc_75_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Context: Pyogenic meningitis is often a devastating condition which is diagnosed by analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP). CSF thus obtained can get contaminated with peripheral blood leucocytes during LP which renders it unusable for cytological analysis. Leucocyte esterase strips are available for identifying leucocyte esterase activity in urine and other body fluids which suggest inflammation. We conducted this experiment to see whether the leucocyte esterase strip can differentiate between neutrophils invited at the inflammatory site and circulating neutrophils in CSF. Aim: To compare the diagnostic ability of the leucocyte esterase test between pyogenic meningitis and CSF contaminated with circulating neutrophils. Setting and Design: Prospective analytical study conducted in a tertiary care hospital. Materials and Methods: The CSF samples of pyogenic meningitis patients were analyzed for leucocyte esterase activity. The other group was normal CSF which was deliberately contaminated with buffy coat preparation, and leukocyte esterase activity was determined. Statistical Analysis: Diagnostic ability of a test in terms of sensitivity and specificity. Results: Overall sensitivity of the dipsticks in diagnosing pyogenic meningitis is 81% and specificity is 99%. When compared with experimentally contaminated CSF sample, a reading of 2+ on the strip had a sensitivity of 70% and specificity of 100% for pyogenic meningitis. Conclusion: Leucocyte esterase strip is specific for pyogenic meningitis (activated neutrophils), and hence can differentiate from CSF contaminated with blood.
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Affiliation(s)
- Vani Krishnamurthy
- Department of Pathology, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Nidha Nabil
- Department of Pathology, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Swathi Muni Reddy
- Department of Pathology, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Srinivasa Murthy Doreswamy
- Department of Pediatrics, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
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Puopolo KM, Benitz WE, Zaoutis TE, Cummings J, Juul S, Hand I, Eichenwald E, Poindexter B, Stewart DL, Aucott SW, Goldsmith JP, Watterberg K, Byington CL, Maldonado YA, Banerjee R, Barnett ED, Campbell JD, Gerber JS, Lynfield R, Munoz FM, Nolt D, Nyquist AC, O’Leary ST, Rathore MH, Sawyer MH, Steinbach WJ, Tan TQ. Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics 2018; 142:peds.2018-2894. [PMID: 30455342 DOI: 10.1542/peds.2018-2894] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The incidence of neonatal early-onset sepsis (EOS) has declined substantially over the last 2 decades, primarily because of the implementation of evidence-based intrapartum antimicrobial therapy. However, EOS remains a serious and potentially fatal illness. Laboratory tests alone are neither sensitive nor specific enough to guide EOS management decisions. Maternal and infant clinical characteristics can help identify newborn infants who are at risk and guide the administration of empirical antibiotic therapy. The incidence of EOS, the prevalence and implications of established risk factors, the predictive value of commonly used laboratory tests, and the uncertainties in the risk/benefit balance of antibiotic exposures all vary significantly with gestational age at birth. Our purpose in this clinical report is to provide a summary of the current epidemiology of neonatal sepsis among infants born at ≥35 0/7 weeks' gestation and a framework for the development of evidence-based approaches to sepsis risk assessment among these infants.
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Affiliation(s)
- Karen M. Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia, and
| | - William E. Benitz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Theoklis E. Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Roberts Center for Pediatric Research, Philadelphia, Pennsylvania; and
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Clinical Characteristics and Risk Factors for Poor Outcome in Infants Less Than 90 Days of Age With Bacterial Meningitis in the United Kingdom and Ireland. Pediatr Infect Dis J 2018; 37:837-843. [PMID: 29384979 DOI: 10.1097/inf.0000000000001917] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To describe the clinical characteristics and risk factors associated with poor outcome in infants <90 days of age with bacterial meningitis. METHODS Prospective, enhanced, national population-based active surveillance for infants <90 days of age with bacterial meningitis in the United Kingdom and Ireland between July 2010 and July 2011. Infants were identified through the British Paediatric Surveillance Unit, laboratory surveillance and meningitis charities. RESULTS Clinical details was available for 263 of 298 (88%) infants where a bacterium was identified, 184 (70%) were born at term. Fever was reported in 143 (54%), seizures in 73 (28%), bulging fontanelle in 58 (22%), coma in 15 (6%) and neck stiffness in 7 (3%). Twenty-three (9%) died and 56/240 (23%) of the survivors had serious central nervous system complications at discharge. Temperature instability [odds ratio (OR), 2.99; 95% confidence interval (CI): 1.21-7.41], seizures (OR, 7.06; 95% CI: 2.80-17.81), cerebrospinal fluid protein greater than the median concentration (2275 mg/dL; OR, 2.62; 95% CI: 1.13-6.10) and pneumococcal meningitis (OR, 4.83; 95% CI: 1.33-17.58) were independently associated with serious central nervous system complications while prematurity (OR, 5.84; 95% CI: 2.02-16.85), low birthweight (OR, 8.48; 95% CI: 2.60-27.69), coma at presentation (OR, 31.85; 95% CI: 8.46-119.81) and pneumococcal meningitis (OR, 4.62; 95% CI: 1.19-17.91) were independently associated with death. CONCLUSIONS The classic features of meningitis were uncommon. The presentation in young infants is often nonspecific, and only half of cases presented with fever. A number of clinical and laboratory factors were associated with poor outcomes; further research is required to determine how knowledge of these risk factors might improve clinical management and outcomes.
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46
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Goldfinch CD, Korman T, Kotsanas D, Burgner DP, Tan K. C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis. J Paediatr Child Health 2018; 54:848-854. [PMID: 29602260 DOI: 10.1111/jpc.13890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 01/02/2018] [Accepted: 01/23/2018] [Indexed: 11/27/2022]
Abstract
AIM Meningitis may complicate neonatal sepsis, but there is scant evidence to inform the decision to perform a lumbar puncture (LP) and considerable variation in practice. We investigated whether inflammatory markers - C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR) - were predictive of meningitis or significant cerebrospinal fluid (CSF) pleocytosis and useful in guiding the decision to perform a LP. METHODS We studied all inpatients in a single tertiary neonatal unit who were <6 months of age who had a LP performed between March 2011 and October 2014. We categorised CSF results as follows: (i) culture-positive meningitis; (ii) probable culture-negative meningitis but meeting a priori criteria for significant CSF leucocytosis; or (iii) no evidence of meningitis. CRP and ITR obtained within 48 h of LP were analysed. We assessed the test performance of CRP and ITR by area under receiver operating characteristic curves. RESULTS A total of 757 (male 471, 62.2%) infants were included. The median (interquartile range) gestational age was 38.4 weeks (30-40.3), and birthweight was 2940 g (1330-3560). Ten (1.3%) infants had culture-positive meningitis; 71 (9.4%) were classified as probable culture-negative meningitis and 676 (89.3%) as non-meningitis. The area under receiver operating characteristic curve for culture-positive and probable culture-negative meningitis was 0.43 for CRP (95% confidence interval 0.36-0.51) and 0.58 for ITR (0.51-0.65). At a CRP threshold of 30 mg/L, there was a positive likelihood ratio (LR) of 0.77 and a negative LR of 1.44. CONCLUSIONS CRP and ITR perform poorly in identifying infants with confirmed or probable meningitis. The decision to perform an LP should be more focused on clinical grounds and/or a positive blood culture and less on inflammatory or haematological markers in isolation.
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Affiliation(s)
| | - Tony Korman
- Department of Infectious Diseases, Monash Health, Melbourne, Victoria, Australia
| | - Despina Kotsanas
- Department of Infectious Diseases, Monash Health, Melbourne, Victoria, Australia
| | - David P Burgner
- Paediatric Infectious Diseases, Monash Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Kenneth Tan
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, PHI-Monash Institute of Medical Research, Melbourne, Victoria, Australia
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Nazir M, Wani WA, Kawoosa K, Dar SA, Malik M, Mir NY, Ahmad I, Bhat RA, Bhat JI, Ahmad QI, Charoo BA, Ali SW. The Diagnostic Dilemma of Traumatic Lumbar Puncture: Current Standing of Cerebrospinal Fluid Leukocyte Corrections and Our Experience With Cerebrospinal Fluid Biomarkers. J Child Neurol 2018; 33:441-448. [PMID: 29627993 DOI: 10.1177/0883073818761719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess the diagnostic efficiency of cerebrospinal fluid markers of procalcitonin, lactate, and cerebrospinal fluid/serum lactate ratio for detecting bacterial meningitis during traumatic lumbar puncture, and to compare these markers with routinely used uncorrected and corrected leukocyte measurements. METHODS Infants aged ≤90 days with traumatic lumbar puncture were prospectively studied. The diagnostic characteristics of cerebrospinal fluid assays of uncorrected and corrected leukocyte count, procalcitonin, lactate, and lactate ratio were described and compared. RESULTS Considering the area under the curve (95% CI) analysis and standard cutoff values, the lactate-ratio (0.985 [0.964-0.989] at cutoff 1.2) had the best test indexes for identifying meningitis, followed by lactate (0.964 [0.945-0.984] at cutoff 2.2 mmol/L) and procalcitonin (0.939 [0.891-0.986] at cutoff 0.33 ng/mL) measurement, whereas the corrected total leukocyte count assay (0.906 [0.850-0.962] at cutoff 350 cells/mm3) had diagnostic properties moderately superior to uncorrected total leukocyte count measurement (0.870 [0.798-0.943] at cutoff 430 cells/mm3). CONCLUSION Cerebrospinal fluid levels of procalcitonin, lactate, and lactate-ratio are reliable markers to diagnose bacterial meningitis in blood-contaminated cerebrospinal fluid.
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Affiliation(s)
- Mudasir Nazir
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Wasim Ahmad Wani
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Khalid Kawoosa
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Sheeraz Ahmad Dar
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Muzaffar Malik
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Naseer Yousuf Mir
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Ikhlas Ahmad
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Rais Ahmad Bhat
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Javeed Iqbal Bhat
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Qazi Iqbal Ahmad
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Bashir Ahmad Charoo
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
| | - Syed Wajid Ali
- 1 Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, Jammu & Kashmir, India
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Lee JH, Boning DS, Anthony BW. Measuring the Absolute Concentration of Microparticles in Suspension Using High-Frequency B-Mode Ultrasound Imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1086-1099. [PMID: 29482889 DOI: 10.1016/j.ultrasmedbio.2018.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/06/2018] [Accepted: 01/13/2018] [Indexed: 06/08/2023]
Abstract
Concentration measurement of particles in suspension is an important procedure performed in biological and clinical laboratories. Existing methods based on instruments such as hemocytometers, Coulter counters and flow cytometers are often laborious, destructive and incapable of in vivo measurements. On the other hand, an ultrasound-based method can be non-destructive and non-invasive and have the potential for in vivo measurement. In this work, a method is presented that estimates absolute particle concentration from high-frequency B-mode ultrasound images of a sample. The method is based on the detection and characterization of the echoes from individual particles to estimate the effective slice thickness of the image. Calibration using a reference sample is not required because the estimation is entirely image based. The particle type differential is also performed by using the backscatter coefficient of each detected echoes. The method is demonstrated by measuring microsphere suspensions as well as human T-cell suspensions. The proposed method has a wide range of potential clinical applications including non-invasive measurement of cell concentration in biological fluids such as cerebrospinal fluid.
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Affiliation(s)
- John H Lee
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
| | - Duane S Boning
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Brian W Anthony
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts USA
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One Year in the Life of a Rapid Syndromic Panel for Meningitis/Encephalitis: a Pediatric Tertiary Care Facility's Experience. J Clin Microbiol 2018. [PMID: 29540454 DOI: 10.1128/jcm.01940-17] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Early establishment of infectious processes allows for expedited clinical management of meningitis and encephalitis. The FilmArray meningitis/encephalitis (FA-M/E) panel provides rapid detection of potential pathogens associated with encephalitis/meningitis in both immunocompetent and compromised patients. Here, we conducted a 1-year review of the performance of the FA-M/E panel at a tertiary care children's hospital. Two hundred sixty-five samples from 251 patients were tested. We found 87.25% (219/251) were negative, 9.96% (25/251) were positive for viral analytes, and 3.19% (8/251) were positive for bacterial analytes. When possible, positive results were confirmed by alternate testing; 4/6 available bacterial positives and 17/20 available viral positives were confirmed by retrospective culture or molecular testing.
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50
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Epidemiology of Sepsis-like Illness in Young Infants: Major Role of Enterovirus and Human Parechovirus. Pediatr Infect Dis J 2018; 37:113-118. [PMID: 28763426 DOI: 10.1097/inf.0000000000001718] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sepsis-like illness is a main cause for hospital admission in young infants. Our aim was to investigate incidence, epidemiology and clinical characteristics of enterovirus (EV) and human parechovirus (HPeV) infections in young infants with sepsis-like illness. METHODS This is a prospective observational cohort study in which infants younger than 90 days of age, presenting with sepsis-like symptoms in a secondary care children's hospital, underwent a full sepsis work-up. Clinical signs and infectious indices were recorded. EV or HPeV RNA was detected by polymerase chain reaction in plasma and/or cerebrospinal fluid (CSF). RESULTS Infants were diagnosed with EV, HPeV, fever of unknown origin or severe infection. EV and HPeV were detected in 132 of 353 (37%) and 52 of 353 (15%) of cases, respectively. EV and HPeV have distinct seasonability. Some differences in clinical signs and symptoms occurred between children with EV and HPeV infection but were of limited clinical value. CSF pleocytosis occurred in 44% of EV positive infants, and only in 13% of those with HPeV infection. CONCLUSIONS EV and HPeV infections are major causes of sepsis-like illness in infants < 90 days of age. Neither clinical characteristics nor laboratory indices were predictive for EV/HPeV infection. CSF pleocytosis occurs, but not in all patients. Testing for EV and HPeV in all young infants with sepsis-like illness is strongly advised.
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