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PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1181-1186

To Tap or Not to Tap: High Likelihood of Meningitis Without Sepsis Among Very Low Birth Weight Infants

Barbara J. Stoll, MD^*, Nellie Hansen, MPH, Avroy A. Fanaroff, MD, Linda L. Wright, MD^||, Waldemar A. Carlo, MD^¶, Richard A. Ehrenkranz, MD^#, James A. Lemons, MD^**, Edward F. Donovan, MD, Ann R. Stark, MD, Jon E. Tyson, MD, MPH^||||, William Oh, MD^¶¶, Charles R. Bauer, MD^##, Sheldon B. Korones, MD^***, Seetha Shankaran, MD, Abbot R. Laptook, MD, David K. Stevenson, MD^||||||, Lu-Ann Papile, MD^¶¶¶ and W. Kenneth Poole, PhD

^* Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
Research Triangle Institute, Research Triangle Park, North Carolina
Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
^|| National Institute of Child Health and Human Development, Bethesda, Maryland
^¶ Department of Pediatrics, University of Alabama, Birmingham, Alabama
^# Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
^** Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
Joint Program in Neonatology, Harvard University, Children’s Hospital Boston, Boston, Massachusetts
^|||| Center for Clinical Research and Evidence Based Medicine, University of Texas Health Science Center at Houston Medical School, Houston, Texas
^¶¶ Department of Pediatrics, Brown University, Providence, Rhode Island
^## Department of Pediatrics, University of Miami, Miami, Florida
^*** The Newborn Center, University of Tennessee, Memphis, Tennessee
Division of Neonatal and Perinatal Medicine, Wayne State University, Detroit, Michigan
Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
^|||||| Division of Neonatology, Stanford University Medical Center, Palo Alto, California
^¶¶¶ Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, New Mexico

Context. Neonatal meningitis is associated with significant morbidity and mortality. We speculated that meningitis may be underdiagnosed among very low birth weight (VLBW) infants because of the failure to perform lumbar punctures (LPs) in infants with suspected sepsis.

Objective. This study was undertaken to review the epidemiology of late-onset meningitis in VLBW (401–1500 g) infants and to evaluate the concordance of cerebrospinal fluid (CSF) and blood culture (BC) results.

Methods. VLBW infants (excluding those with intraventricular shunts) born at centers of the National Institute of Child Health and Human Development Neonatal Research Network from September 1, 1998, through December 31, 2001, were studied. Late-onset meningitis was defined by culture-based criteria and classified as meningitis with or without associated sepsis. Unadjusted comparisons were made using ² tests and adjusted comparisons using regression models.

Results. Of 9641 VLBW infants who survived >3 days, 2877 (30%) had 1 LPs, and 6056 (63%) had 1 BC performed after day 3. One hundred thirty-four infants had late-onset meningitis (1.4% of all patients; 5% of those with an LP). Pathogens associated with meningitis were similar to those associated with sepsis. One third (45 of 134) of the infants with meningitis had negative BCs. Lower gestational age and prior sepsis increased risk for meningitis. Compared with uninfected infants, those with meningitis had a longer time on mechanical ventilation (28 vs 18 days), had longer hospitalizations (91 vs 79 days), were more likely to have seizures (25% vs 2%), and were more likely to die (23% vs 2%).

Conclusions. Meningitis is a serious complication among VLBW infants, associated with increased severity of illness and risk of death. Of note, one third of the infants with meningitis had meningitis in the absence of sepsis. Because CSF cultures were performed only half as often as BCs, this discordance in blood and CSF culture results suggests that meningitis may be underdiagnosed among VLBW infants.

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Key Words: meningitis • sepsis • lumbar puncture • very low birth weight infants

Abbreviations: LP, lumbar puncture • VLBW, very low birth weight • LOM, late-onset meningitis • NICHD, National Institute of Child Health and Human Development • BC, blood culture • CSF, cerebrospinal fluid • CONS, coagulase-negative staphylococcus • GA, gestational age • IVH, intraventricular hemorrhage • PVL, periventricular leukomalacia • NEC, necrotizing enterocolitis • OR, odds ratio • CI, confidence interval

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Received for publication Jul 24, 2003; Accepted Oct 1, 2003.

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