Introduction:
Fever among newborns in the first months of life is one of the most common problems in the pediatric healthcare unit. Such newborns are at an increased risk of developing grave life-threatening serious bacterial infections (SBIs), such as urinary tract infections (UTIs), bacteremia, and bacterial meningitis. Around 10 percent of newborns with a fever and 60 days or younger have underlying urinary tract infections, which are more likely to spread to the meninges or covering of the brain. Consequently, newborns with urinary tract infections are at an increased risk for developing bacterial meningitis.
In order to avoid missing even a single case of bacterial meningitis, nearly 400 infants undergo invasive cerebrospinal fluid (CSF) testing by lumbar puncture (LP), hospitalization, and treatment with broad-spectrum antibiotic therapy. Failure to promptly detect meningitis among newborns with urinary tract infections can lead to grave outcomes and complications. In addition, modern urinalyses accurately predict urinary tract infections among newborns. Therefore, the diagnosis of urinary tract infection depends solely on urinalysis results before urine culture results are available.
What Is Meningitis?
Meningitis is an inflammation of the meninges or the tissues covering the brain and spinal cord. The inflammation affects the brain at times. A viral, bacterial, fungal, or parasitic infection can cause it. With early diagnosis and proper treatment, a newborn with meningitis has a reasonable chance of a good recovery. However, certain types of bacterial meningitis have a high risk of complications and can be fatal.
What Are the Symptoms of Meningitis in Newborns?
The typical symptoms of meningitis in newborns include the following:
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Extremely sleepy or irritable.
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High fever.
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Constant crying.
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Hard to comfort.
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Trouble waking up from sleep.
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Not waking to eat.
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Inactive and sleepy.
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Poor feeding.
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Vomiting.
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A bulge in the soft spot on top of the baby's head.
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Body and neck stiffness.
How Are Febrile Meningitis and Positive Urinalysis Related?
Urinary tract infection (UTI) is one of the most common bacterial infections in newborns, occurring in around seven percent of febrile infants of zero to three months. In addition, bacteremia has been associated with UTI in up to 25 percent of cases in infants younger than three months, placing these infants at high risk for bacterial spread to the central nervous system. Feverish infants of 0 to 28 days undergo routine lumbar puncture (LP) during their initial evaluation. Febrile infants of 29 to 90 days are often differentiated according to their clinical examination, complete blood count, and urinalysis to determine their risk of serious bacterial infections before proceeding with a lumbar puncture. According to the Rochester criteria, a feverish infant aged 0 to 60 days with a positive urinalysis should have cerebrospinal fluid (CSF) evaluated for concomitant bacterial meningitis.
The clinical prediction rules for febrile infants less than 60 to 90 days do not include initial CSF testing and recommend lumbar puncture for infants with an abnormal urinalysis. The patterns regarding acquiring the cerebral spinal fluid for culture differ among infants with suspected urinary tract infections.
Aseptic meningitis is common in infants with urinary tract infections. Physicians beginning antibiotic therapy without obtaining the cerebral spinal fluid in infants with suspected urinary tract infections might decide to perform the lumbar puncture in the later part of the treatment for infants with a positive blood culture or change in clinical status. Routine lumbar puncture for all urinary tract infection-suspected infants does not determine whether the increase in the sterile cerebral spinal fluid after antibiotic administration leads to systemic inflammation related to the urinary tract infection or partially treated bacterial meningitis. Several past studies have found that bacterial meningitis associated with urinary tract infection is rare. Young infants outside the neonatal period with urinary tract infections are at a lower risk for bacterial meningitis, and an increase in the cerebrospinal fluid in such infants is not likely to cause bacterial meningitis.
What Did the Studies Conclude?
Several studies have been conducted, and investigators from various institutions conducted a systematic review to assess the prevalence of bacterial meningitis in febrile infants between 29 to 60 days with and without a positive urinalysis result. The primary outcome of the studies was the prevalence of meningitis among infants with positive urinalysis results. A secondary outcome was the prevalence of meningitis among infants with negative urinalysis results. In all, there were 48 studies conducted, including 12,735 infants. The prevalence of bacterial meningitis was 0.44 percent among infants with positive urinalysis results and 0.50 percent among infants with negative urinalysis results. The investigators concluded that the prevalence of bacterial meningitis was no different in infants between 29 to 60 days with or without a positive urinalysis, thereby suggesting that the decision to do a lumbar puncture should not be taken by urinalysis results alone. Instead, the decision of whether to perform a lumbar puncture takes work. While missed bacterial meningitis can prove fatal, the results of multiple studies have shown a low rate of occurrence of bacterial meningitis among young infants with fever. The researchers found that fewer than 1 in 200 patients have bacterial meningitis.
What Are the Characteristics of Febrile Newborns With Urinary Tract Infections?
Among the newborns with urinary tract infections, few have been found to have co-infection with viral meningitis, some had an increase in the cerebrospinal fluid, and an almost negligible percentage had a co-infection with bacterial meningitis. A comparison of the newborns with urinary tract infections and without an increase in the cerebrospinal fluid revealed that younger infants have a lower rate of increase in the cerebrospinal fluid. It has also been found that younger age and early examination correlate with the absence of an increase in the amount of cerebrospinal fluid.
Conclusion:
The development of febrile meningitis in newborns with urinary tract infections is a severe problem in the pediatric ward, which, if not timely diagnosed and treated, can prove fatal. In addition, invasive cerebrospinal fluid testing, hospitalization, and treatment with antibiotics of such febrile newborns older than 28 days with a positive urinalysis result suggest an increased risk of bacterial meningitis. Unfortunately, although fever in newborns is a common clinical problem, there is not much data to determine the actual risk among newborns with positive urinalysis results.
