SGEM #387 Lumbar Punctures in Febrile Infants with Positive Urinalysis-It’s Just Overkill

Date: Dec 15, 2022 Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Dr. Brian Lee Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Guest Authors: Dr. Prashant Mahajan Dr. Prashant Mahajan is a Professor of Emergency Medicine and Pediatrics at the University of Michigan Department of Emergency Medicine in Ann Arbor, Michigan. He is the Vice-Chair for the Department of Emergency medicine and Section chief for Pediatric Emergency Medicine in CS Mott Children’s Hospital. Currently, he is the founding chair of Emergency Medicine Education and Research by Global Experts (EMERGE), a global emergency research network across 17 countries and 23 emergency departments. Dr. Nathan Kuppermann is a Distinguished Professor of Emergency Medicine and Pediatrics, and the Bo Tomas Brofeldt Endowed Chair of the Department of Emergency Medicine at UC Davis and Associate Dean for Global Health at UC Davis Health. He chaired the first US research network in Pediatric Emergency Medicine (the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics) then became founding chair of the Pediatric Emergency Care Applied Research Network (PECARN). He also recently completed a term as Chair of the Executive Committee of the global Pediatric Emergency Research Network (PERN). Dr. Nathan Kuppermann Both of our guests have received federal funding for their research and played huge roles in establishing multicenter research networks dedicated to improving the care of children across the world. Case: A 6-week-old girl is brought into the emergency department (ED) for fever of 38.5°C that started four hours prior to presentation. Her parents noted that she has been fussier today and has had feeding a little less than normal, but she’s had no other symptoms. She is otherwise healthy, full-term female who had no pre- or postnatal complications. On exam she is well-appearing, and there are no focal signs of infection. You decide to start by obtaining blood and catheterized urine for testing. The urinalysis shows 15 WBCs, 2+ leukocyte esterase and positive nitrites. While waiting for the results of the blood tests, you tell the family the news that their child likely has a urinary tract infection. The family asks you, “does this mean we found the source of her fever? Our son also had a fever when he was very young, and he had to get a lumbar puncture? Do we need to do a lumbar puncture for her today?” Background: Febrile infants ≤ 60 days are at higher risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. While UTIs tend to be the most common, we really do not want to miss those infants with bacteremia and meningitis, termed invasive bacterial infections (IBI). Multiple groups have worked to risk stratify these infants and have listed positive urinalysis as a risk factor for IBI. The SGEM covered the Step-by-Step Approach on SGEM #171 and PECARN Clinical Prediction Rule for Low Risk Febrile Infants on SGEM #296. Recently, the American Academy of Pediatrics (AAP) published guidelines for the management of febrile infants 8-60 days old covered in SGEM #241. In infants 22 days and older, the AAP guidelines state that lumbar puncture may be performed (rather than should) in those with positive urinalysis but normal inflammatory markers. There is wide practice variability in evaluation febrile infants [1-2]. Prior studies have demonstrated low prevalence of meningitis in infants with positive urinalysis [3,4].  Infants between 29-60 days of age are at a comparatively lower risk, with studies estimating their risk to be 0.