2
tests and adjusted comparisons using regression models.
NeoNotes
Journal Club
Andrew B. Kairalla MD, Editor
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LPs in VLBW Infants
To Tap or Not to Tap: High Likelihood of Meningitis Without Sepsis Among Very Low Birth Weight Infants. Stoll BJ, Hansen N, Fanaroff AA, et al. PEDIATRICS (May 2004); 113: 1181-6.
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.
Comment. If you only do lumbar punctures in VLBW infants in the setting of positive blood cultures, then you are missing (and possibly undertreating) many cases of meningitis. On the other hand, lumbar punctures may not be benign procedures in sick VLBW infants. The procedure itself may increase the risk of cardiopulmonary decompensation or IVH. We need to develop additional indicators (besides positive blood cultures) that are associated with an increased incidence of meningitis in this population. ABK.
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