Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Archimedes
QUESTION 2 Is a lumbar puncture necessary in an afebrile newborn infant with localised skin and soft tissue infection? SCENARIO A 3-week-old previously healthy full-term infant with uncomplicated perinatal course presents to the emergency room with a large perineal abscess. At home, the infant has been afebrile and otherwise well appearing. On physical examination, a 3×3 cm indurated, tender, nodular lesion with central fluctuation and surrounding erythema was noted in the right perineal region, consistent with a right perianal abscess. Initial sepsis evaluation included basic inflammatory markers and blood and urine cultures. Pus was manually expressed and sent for bacterial culture. Arch Dis Child July 2014 Vol 99 No 7
695
Citation
Study group
Infants with soft tissue and skin infection (SSTI) Faden3 9 infants, ≤60 days, with mastitis.
Study type (level of evidence)
Key results
Comments
Case series (5)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
No cases of meningitis 9/9 (100%) had an LP 2/9 infants with abscess had wound cultures, spectrum of organisms include Staphylococcus aureus, group A Streptococcus, Gram-negative bacillus 7/57 (11%) afebrile patients with CSF pleocytosis (pustulosis (4 infants), cellulitis/ abscess (2 infants) invasive (1 infant)). 57/99 (60%) afebrile patients had an LP (55% of pustulosis and 65% of cellulitis/abscesses and 20% of invasive disease). No significant difference of likelihood between the two groups (p=0.3). 73/113 (65%) of gram stains in all patients regardless of fever status were (+) GPC. No cases of meningitis 37/104 (36%) had an LP (0% of pustulosis, 53% of cellulitis, 25% of abscesses) Patients with cellulitis were more likely to have an LP compared to the rest (OR=4.0, 95% CI 1.7 to 9.4, p=0.0013) 25/49 (51%) cultures grew MRSA No cases of meningitis 35/158 (22%) had an LP 13/29 (45%) cultures grew MRSA
Study cohort comprised of children ≤18 years of age with mastitis, including 9 infants under 2 months of age. A total of 6 children had fever and 5 were pretreated with antibiotics; unclear if any infants were among this group. Unclear if CSF was evaluated for pleocytosis. Unclear which microorganisms grew in wound cultures obtained from infants A total of 11 infants had CSF pleocytosis. Four infants were excluded as they presented with fever. None of the 7 infants were treated with antibiotics prior to LP. Late-preterm infants were included CSF pleocytosis defined as >22k WBC/mm3 No association of CSF pleocytosis with severity of local infection, presence of bacteraemia or UTI Expanded cohort from a previous publication in 2006 in Pediatrics
Arch Dis Child July 2014 Vol 99 No 7
Fortunov et al1
99 afebrile neonates, ≤30 days old, with pustulosis (42), cellulitis/abscess (51) and invasive disease (6). Invasive disease defined as infection beyond the skin and soft tissue level
Retrospective review of prospective cohort (3b)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Likelihood of LP by type of skin infection’ ‘Wound organism’
Kharazmi et al2
104 afebrile neonates, ≤ 28 days old, with pustulosis (8), cellulitis (45), and abscess (51)
Retrospective cohort (3b)
‘Prevalence of meningitis’ ‘Performed (LP)’ ‘Likelihood of LP by type of skin infection’ ‘Wound organism’
Vidwan and Geis4
89 afebrile neonantes, ≤60 days old, with cellulitis (49) and abscess (40)
Retrospective cohort (3b)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
Walsh and McIntosh5
(a) 41 infants, ≤5 weeks, with mastitis (b) 119 infants with mastitis
(a) Retrospective cohort (3b) (b) Meta-analysis of case series (5)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
(a) No cases of meningitis (b) 1/119 (0.8%) with culture negative pleocytosis (a) 9/41 (22%) had an LP (b) Not specified in meta-analysis (a) 30/36 (83%) Staphylococcus aureus, rest mixed flora with Staphylococcus epidermidis, alpha streptococcus, GBS, peptostreptococcus (b) 63/119 (53%) Staphylococcus aureus, rest mixed flora with Staphylococcus epidermidis, Gram-negative bacilli
Infants with GBS cellulitis-adenitis syndrome Two afebrile neonates, ≤ 30 days, with GBS Albanyan cellulitis-adenitis syndrome et al7
Case series (5)
Hauger8
Two afebrile neonates, ≤ 60 days, with GBS cellulitis-adenitis syndrome
Case series (5)
Wirth et al6
An 8-day-old afebrile neonate with GBS cellulitis-adenitis syndrome
Case report (5)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’ ‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’ ‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
Both neonates had aseptic pleocytosis 2/2 infants had an LP 2/2 infants grew type III GBS One of two infants diagnosed with meningitis 2/2 infants had an LP” GBS No meningitis LP was performed Blood culture grew GBS
No analysis of CSF pleocytosis. Diagnosis of meningitis was based on CSF culture results. Highest rate of LP performance was associated with presence of cellulitis
The original study cohort was comprised of 158 afebrile neonates with local infection including otitis media and other focal infections besides SSTIs. No analysis of CSF pleocytosis Only a selected number of afebrile patients with skin infection had an LP. Factors associated with performance of LP were not analysed Unclear which patients had fever.
Both infants had elevated I/T ratio and GBS bacteraemia Both infants were pretreated with antibiotics prior to LP Both infants had GBS bacteraemia No pleocytosis but isolated GBS from CSF in infant with meningitis Unclear if CSF was evaluated for pleocytosis
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Outcome
Archimedes
696
Table 1 Summary
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Archimedes Intravenous antibiotic treatment was initiated. The resident taking care of the baby wonders if a lumbar puncture (LP) should be performed as part of the sepsis evaluation to rule out occult meningitis.
STRUCTURED CLINICAL QUESTION In afebrile neonates with localised skin and soft tissue infection (POPULATION), is routine LP necessary (INTERVENTION) to evaluate for occult meningitis? (OUTCOME)
SEARCH Search date: 12 April 2013. Primary source: The PubMed database and Scopus. Secondary source: The Cochrane Library. English language literature sources were searched using either text word (tw) or medical subject subheading (MeSH): (infant, newborn (MeSH) OR neonates (tw) OR neonate (tw) AND (focal infection (MeSH) OR cellulitis (MeSH) OR soft tissue infections (MeSH) OR abscess (MeSH) OR mastitis (MeSH)) OR neonatal mastitis (tw) AND cellulitis adenitis syndrome (tw). Inclusion criteria: English language and human study. Total number of hits: 1157. Of these articles, only eight articles were considered for review.1–8 The remaining 1149 articles were excluded because of the following reasons: not relevant to structured clinical question under consideration, and/or presence of fever at presentation, and/or insufficient or unclear information concerning fever status and performance of lumbar tap for sepsis evaluation.
COMMENTARY Healthcare providers can expect to see more skin and soft tissue infections (SSTI) in the neonatal population due to rising rates of colonisation with methicillin resistant staphylococcus aureus (MRSA) and Panton-Valentine leukocidine (PVL) positive in the community.1 9 While febrile neonates with SSTI will usually undergo a full diagnostic evaluation for serious bacterial infection (SBI), there is controversy about the extent of diagnostic work-up in afebrile and well-appearing neonates presenting with SSTI.2 10 The concern about concomitant bacterial meningitis raises the question if an LP should be incorporated in routine practice. Nearly one-third of neonates with meningitis presents without bacteraemia or suggestive clinical symptoms.11 Therefore, the diagnosis of neonatal meningitis solely relies on CSF findings.11 Exploring this diagnostic dilemma, 107 emergency room (ER) physicians were surveyed regarding their diagnostic approach to a non-toxic 2-week-old infant with localised mastitis.10 Among the 46 respondents, only 4.3% recommended a full sepsis evaluation (including LP) versus 48%, and 47% who opted for a partial (excluding meningitis) and no septic work-up, respectively.10 Variation in diagnostic practice could be due to lack of systematic data on rates of SBI in this population. Therefore, the objective of this literature search was to determine the prevalence of meningitis among afebrile and wellappearing neonates with SSTI and, therefore, whether an LP is necessary. In our literature search, summarised in table 1, no cases of culture-positive meningitis were found in any of the reviewed studies. However, there were seven cases with sterile CSF pleocytosis reported in the study by Fortunov et al.1 Five out of these seven (71%) cases had a mononuclear cell predominance, which is a reported finding in aseptic meningitis, and was attributed to unidentified proinflammatory mediators.12 The presence of sterile CSF pleocytosis was neither associated with severity of SSTI, nor with presence of bacteraemia or UTI. Interestingly, 4/ 7 (57%) afebrile infants with aseptic CSF pleocytosis presented Arch Dis Child July 2014 Vol 99 No 7
with pustulosis, which in any other study appeared to be the least invasive type of skin infection.1 2 The above reviewed studies have several limitations. Fortunov et al did not clearly stratify the data based on fever status, and lack standard indications for an LP.1 In the case series by Faden, it remains unclear which patients were pretreated with antibiotics, and whether CSF was analysed for pleocytosis.3 The major limitations of the studies by Kharazmi et al and Vidwan and Geis are the low rate of performed LP (22 and 36%) and lack of follow-up data of enrolled infants which bear the potential for missed diagnosis of occult meningitis. No information regarding pleocytosis was provided in either of these studies.2 4 Walsh and McIntosh’s work lacks stratification of data by fever status, and the number of infants that underwent an LP was relatively low (22%), which again raises concerns about missed diagnosis of occult meningitis.5 Cellulitis-adenitis syndrome caused by group B streptococcus (GBS) serotype III is an important differential diagnosis in infants with SSTI. One percent of late-onset manifestations (during 3– 7 weeks of life) are considered to be GBS cellulitis-adenitis syndrome.6 13 14 The pathogenesis involves colonisation of mucus membrane or otitis media and subsequent lymphatic spread, bacteraemia, and SSTI, respectively.6 7 Patients present with systemic signs of infection such as fever, irritability, lethargy, poor feeding and focal findings, such as neck swelling due to lymphadenitis and SSTIs. Up to one-quarter of affected infants with GBS bacteraemia, in part afebrile, have been reported to have concomitant GBS meningitis that is associated with high mortality.6–8 Therefore, clinicians should have a high index of suspicion and bear in mind that the finding of lymphadenitis alters the differential diagnosis and necessity to perform an LP.
Clinical bottom lines ▸ In afebrile, non-toxic infants with non-GBS SSTI, lumbar puncture can be avoided in the absence of any systemic signs of illness (Grade C). ▸ Clinicians should decide on an individual basis, and depending on additional history and physical exam findings whether an LP is indicated (Grade C). ▸ GBS cellulitis-adenitis syndrome is rare but associated with a much higher risk of meningitis and, hence, requires routine LP even in the absence of fever, signs of systemic illness, or toxicity (Grade C).
Rosa Nguyen,1 Ramachandra Bhat,1 Getachew Teshome2 1
Department of Pediatrics, University of Maryland, USA Pediatric Emergency Medicine, University of Maryland, USA
2
Correspondence to Dr Rosa Nguyen, Department of Pediatrics, University of Maryland, 22 S Greene Street, N5W70, Baltimore, MD 21201, USA; [email protected] Contributors RN conducted the initial literature search, prepared the initial manuscript. RB conceptualised the structured clinical question and revised the manuscript. GT performed a critical review and revision of the manuscript. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Received 30 January 2014 Revised 8 March 2014 Accepted 14 March 2014 Published Online First 8 April 2014 697
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Archimedes 6
7
▸ http://dx.doi.org/10.1136/archdischild-2013-305928 ▸ http://dx.doi.org/10.1136/archdischild-2014-306821 Arch Dis Child 2014;99:695–698. doi:10.1136/archdischild-2014-306111
REFERENCES 1
2
3 4
5
698
Fortunov RM, Hulten KG, Hammerman WA, et al. Evaluation and treatment of community-acquired Staphylococcus aureus infections in term and late-preterm previously healthy neonates. Pediatrics 2007;120:937–45. Kharazmi SA, Hirsh DA, Simon HK, et al. Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department. Pediatr Emerg Care 2012;28:1013–6. Faden H. Mastitis in children from birth to 17 years. Pediatr Infect Dis J 2005;24:1113. Vidwan G, Geis GL. Evaluation, management, and outcome of focal bacterial infections (FBIs) in nontoxic infants under two months of age. J Hosp Med Off Publ Soc Hosp Med 2010;5:76–82. Walsh M, McIntosh K. Neonatal mastitis. Clin Pediatr (Phila) 1986;25:395–9.
8 9 10 11
12
13
14
Wirth J, Raymond J, Lapillonne A. Unusual report of diaper rash in a premature infant with group B streptococcal infection. Pediatr Infect Dis J 2006;25: 750–1. Albanyan EA, Baker CJ. Is lumbar puncture necessary to exclude meningitis in neonates and young infants: lessons from the group B streptococcus cellulitisadenitis syndrome. Pediatrics 1998;102:985–6. Hauger SB. Facial cellulitis: an early indicator of group B streptococcal bacteremia. Pediatrics 1981;67:376–7. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med 2007;357:380–90. Al Ruwaili N, Scolnik D. Neonatal mastitis: controversies in management. J Clin Neonatol 2012;1:207–10. Garges HP, Moody MA, Cotten CM, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics 2006;117:1094–100. Amir J, Harel L, Frydman M, et al. Shift of cerebrospinal polymorphonuclear cell percentage in the early stage of aseptic meningitis. J Pediatr 1991;119: 938–41. Lachenauer C, Wessels M. Group B Streptococcus. In: Kliegman R, Behrman R, Jenson H, et al., eds. Nelson Textbook of Pediatrics. Philadelphia: WB Saunders, 2011;925–8. Peters TR, Edwards KM. Cervical lymphadenopathy and adenitis. Pediatr Rev Am Acad Pediatr 2000;21:399–405.
Arch Dis Child July 2014 Vol 99 No 7
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Question 2: Is a lumbar puncture necessary in an afebrile newborn infant with localised skin and soft tissue infection? Rosa Nguyen, Ramachandra Bhat and Getachew Teshome Arch Dis Child 2014 99: 695-698 originally published online April 8, 2014
doi: 10.1136/archdischild-2014-306111
Updated information and services can be found at: http://adc.bmj.com/content/99/7/695.full.html
These include:
References
This article cites 13 articles, 4 of which can be accessed free at: http://adc.bmj.com/content/99/7/695.full.html#ref-list-1
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Archimedes
QUESTION 2 Is a lumbar puncture necessary in an afebrile newborn infant with localised skin and soft tissue infection? SCENARIO A 3-week-old previously healthy full-term infant with uncomplicated perinatal course presents to the emergency room with a large perineal abscess. At home, the infant has been afebrile and otherwise well appearing. On physical examination, a 3×3 cm indurated, tender, nodular lesion with central fluctuation and surrounding erythema was noted in the right perineal region, consistent with a right perianal abscess. Initial sepsis evaluation included basic inflammatory markers and blood and urine cultures. Pus was manually expressed and sent for bacterial culture. Arch Dis Child July 2014 Vol 99 No 7
695
Citation
Study group
Infants with soft tissue and skin infection (SSTI) Faden3 9 infants, ≤60 days, with mastitis.
Study type (level of evidence)
Key results
Comments
Case series (5)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
No cases of meningitis 9/9 (100%) had an LP 2/9 infants with abscess had wound cultures, spectrum of organisms include Staphylococcus aureus, group A Streptococcus, Gram-negative bacillus 7/57 (11%) afebrile patients with CSF pleocytosis (pustulosis (4 infants), cellulitis/ abscess (2 infants) invasive (1 infant)). 57/99 (60%) afebrile patients had an LP (55% of pustulosis and 65% of cellulitis/abscesses and 20% of invasive disease). No significant difference of likelihood between the two groups (p=0.3). 73/113 (65%) of gram stains in all patients regardless of fever status were (+) GPC. No cases of meningitis 37/104 (36%) had an LP (0% of pustulosis, 53% of cellulitis, 25% of abscesses) Patients with cellulitis were more likely to have an LP compared to the rest (OR=4.0, 95% CI 1.7 to 9.4, p=0.0013) 25/49 (51%) cultures grew MRSA No cases of meningitis 35/158 (22%) had an LP 13/29 (45%) cultures grew MRSA
Study cohort comprised of children ≤18 years of age with mastitis, including 9 infants under 2 months of age. A total of 6 children had fever and 5 were pretreated with antibiotics; unclear if any infants were among this group. Unclear if CSF was evaluated for pleocytosis. Unclear which microorganisms grew in wound cultures obtained from infants A total of 11 infants had CSF pleocytosis. Four infants were excluded as they presented with fever. None of the 7 infants were treated with antibiotics prior to LP. Late-preterm infants were included CSF pleocytosis defined as >22k WBC/mm3 No association of CSF pleocytosis with severity of local infection, presence of bacteraemia or UTI Expanded cohort from a previous publication in 2006 in Pediatrics
Arch Dis Child July 2014 Vol 99 No 7
Fortunov et al1
99 afebrile neonates, ≤30 days old, with pustulosis (42), cellulitis/abscess (51) and invasive disease (6). Invasive disease defined as infection beyond the skin and soft tissue level
Retrospective review of prospective cohort (3b)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Likelihood of LP by type of skin infection’ ‘Wound organism’
Kharazmi et al2
104 afebrile neonates, ≤ 28 days old, with pustulosis (8), cellulitis (45), and abscess (51)
Retrospective cohort (3b)
‘Prevalence of meningitis’ ‘Performed (LP)’ ‘Likelihood of LP by type of skin infection’ ‘Wound organism’
Vidwan and Geis4
89 afebrile neonantes, ≤60 days old, with cellulitis (49) and abscess (40)
Retrospective cohort (3b)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
Walsh and McIntosh5
(a) 41 infants, ≤5 weeks, with mastitis (b) 119 infants with mastitis
(a) Retrospective cohort (3b) (b) Meta-analysis of case series (5)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
(a) No cases of meningitis (b) 1/119 (0.8%) with culture negative pleocytosis (a) 9/41 (22%) had an LP (b) Not specified in meta-analysis (a) 30/36 (83%) Staphylococcus aureus, rest mixed flora with Staphylococcus epidermidis, alpha streptococcus, GBS, peptostreptococcus (b) 63/119 (53%) Staphylococcus aureus, rest mixed flora with Staphylococcus epidermidis, Gram-negative bacilli
Infants with GBS cellulitis-adenitis syndrome Two afebrile neonates, ≤ 30 days, with GBS Albanyan cellulitis-adenitis syndrome et al7
Case series (5)
Hauger8
Two afebrile neonates, ≤ 60 days, with GBS cellulitis-adenitis syndrome
Case series (5)
Wirth et al6
An 8-day-old afebrile neonate with GBS cellulitis-adenitis syndrome
Case report (5)
‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’ ‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’ ‘Prevalence of meningitis’ ‘Performed LP’ ‘Wound organism’
Both neonates had aseptic pleocytosis 2/2 infants had an LP 2/2 infants grew type III GBS One of two infants diagnosed with meningitis 2/2 infants had an LP” GBS No meningitis LP was performed Blood culture grew GBS
No analysis of CSF pleocytosis. Diagnosis of meningitis was based on CSF culture results. Highest rate of LP performance was associated with presence of cellulitis
The original study cohort was comprised of 158 afebrile neonates with local infection including otitis media and other focal infections besides SSTIs. No analysis of CSF pleocytosis Only a selected number of afebrile patients with skin infection had an LP. Factors associated with performance of LP were not analysed Unclear which patients had fever.
Both infants had elevated I/T ratio and GBS bacteraemia Both infants were pretreated with antibiotics prior to LP Both infants had GBS bacteraemia No pleocytosis but isolated GBS from CSF in infant with meningitis Unclear if CSF was evaluated for pleocytosis
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Outcome
Archimedes
696
Table 1 Summary
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Archimedes Intravenous antibiotic treatment was initiated. The resident taking care of the baby wonders if a lumbar puncture (LP) should be performed as part of the sepsis evaluation to rule out occult meningitis.
STRUCTURED CLINICAL QUESTION In afebrile neonates with localised skin and soft tissue infection (POPULATION), is routine LP necessary (INTERVENTION) to evaluate for occult meningitis? (OUTCOME)
SEARCH Search date: 12 April 2013. Primary source: The PubMed database and Scopus. Secondary source: The Cochrane Library. English language literature sources were searched using either text word (tw) or medical subject subheading (MeSH): (infant, newborn (MeSH) OR neonates (tw) OR neonate (tw) AND (focal infection (MeSH) OR cellulitis (MeSH) OR soft tissue infections (MeSH) OR abscess (MeSH) OR mastitis (MeSH)) OR neonatal mastitis (tw) AND cellulitis adenitis syndrome (tw). Inclusion criteria: English language and human study. Total number of hits: 1157. Of these articles, only eight articles were considered for review.1–8 The remaining 1149 articles were excluded because of the following reasons: not relevant to structured clinical question under consideration, and/or presence of fever at presentation, and/or insufficient or unclear information concerning fever status and performance of lumbar tap for sepsis evaluation.
COMMENTARY Healthcare providers can expect to see more skin and soft tissue infections (SSTI) in the neonatal population due to rising rates of colonisation with methicillin resistant staphylococcus aureus (MRSA) and Panton-Valentine leukocidine (PVL) positive in the community.1 9 While febrile neonates with SSTI will usually undergo a full diagnostic evaluation for serious bacterial infection (SBI), there is controversy about the extent of diagnostic work-up in afebrile and well-appearing neonates presenting with SSTI.2 10 The concern about concomitant bacterial meningitis raises the question if an LP should be incorporated in routine practice. Nearly one-third of neonates with meningitis presents without bacteraemia or suggestive clinical symptoms.11 Therefore, the diagnosis of neonatal meningitis solely relies on CSF findings.11 Exploring this diagnostic dilemma, 107 emergency room (ER) physicians were surveyed regarding their diagnostic approach to a non-toxic 2-week-old infant with localised mastitis.10 Among the 46 respondents, only 4.3% recommended a full sepsis evaluation (including LP) versus 48%, and 47% who opted for a partial (excluding meningitis) and no septic work-up, respectively.10 Variation in diagnostic practice could be due to lack of systematic data on rates of SBI in this population. Therefore, the objective of this literature search was to determine the prevalence of meningitis among afebrile and wellappearing neonates with SSTI and, therefore, whether an LP is necessary. In our literature search, summarised in table 1, no cases of culture-positive meningitis were found in any of the reviewed studies. However, there were seven cases with sterile CSF pleocytosis reported in the study by Fortunov et al.1 Five out of these seven (71%) cases had a mononuclear cell predominance, which is a reported finding in aseptic meningitis, and was attributed to unidentified proinflammatory mediators.12 The presence of sterile CSF pleocytosis was neither associated with severity of SSTI, nor with presence of bacteraemia or UTI. Interestingly, 4/ 7 (57%) afebrile infants with aseptic CSF pleocytosis presented Arch Dis Child July 2014 Vol 99 No 7
with pustulosis, which in any other study appeared to be the least invasive type of skin infection.1 2 The above reviewed studies have several limitations. Fortunov et al did not clearly stratify the data based on fever status, and lack standard indications for an LP.1 In the case series by Faden, it remains unclear which patients were pretreated with antibiotics, and whether CSF was analysed for pleocytosis.3 The major limitations of the studies by Kharazmi et al and Vidwan and Geis are the low rate of performed LP (22 and 36%) and lack of follow-up data of enrolled infants which bear the potential for missed diagnosis of occult meningitis. No information regarding pleocytosis was provided in either of these studies.2 4 Walsh and McIntosh’s work lacks stratification of data by fever status, and the number of infants that underwent an LP was relatively low (22%), which again raises concerns about missed diagnosis of occult meningitis.5 Cellulitis-adenitis syndrome caused by group B streptococcus (GBS) serotype III is an important differential diagnosis in infants with SSTI. One percent of late-onset manifestations (during 3– 7 weeks of life) are considered to be GBS cellulitis-adenitis syndrome.6 13 14 The pathogenesis involves colonisation of mucus membrane or otitis media and subsequent lymphatic spread, bacteraemia, and SSTI, respectively.6 7 Patients present with systemic signs of infection such as fever, irritability, lethargy, poor feeding and focal findings, such as neck swelling due to lymphadenitis and SSTIs. Up to one-quarter of affected infants with GBS bacteraemia, in part afebrile, have been reported to have concomitant GBS meningitis that is associated with high mortality.6–8 Therefore, clinicians should have a high index of suspicion and bear in mind that the finding of lymphadenitis alters the differential diagnosis and necessity to perform an LP.
Clinical bottom lines ▸ In afebrile, non-toxic infants with non-GBS SSTI, lumbar puncture can be avoided in the absence of any systemic signs of illness (Grade C). ▸ Clinicians should decide on an individual basis, and depending on additional history and physical exam findings whether an LP is indicated (Grade C). ▸ GBS cellulitis-adenitis syndrome is rare but associated with a much higher risk of meningitis and, hence, requires routine LP even in the absence of fever, signs of systemic illness, or toxicity (Grade C).
Rosa Nguyen,1 Ramachandra Bhat,1 Getachew Teshome2 1
Department of Pediatrics, University of Maryland, USA Pediatric Emergency Medicine, University of Maryland, USA
2
Correspondence to Dr Rosa Nguyen, Department of Pediatrics, University of Maryland, 22 S Greene Street, N5W70, Baltimore, MD 21201, USA; [email protected] Contributors RN conducted the initial literature search, prepared the initial manuscript. RB conceptualised the structured clinical question and revised the manuscript. GT performed a critical review and revision of the manuscript. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Received 30 January 2014 Revised 8 March 2014 Accepted 14 March 2014 Published Online First 8 April 2014 697
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Archimedes 6
7
▸ http://dx.doi.org/10.1136/archdischild-2013-305928 ▸ http://dx.doi.org/10.1136/archdischild-2014-306821 Arch Dis Child 2014;99:695–698. doi:10.1136/archdischild-2014-306111
REFERENCES 1
2
3 4
5
698
Fortunov RM, Hulten KG, Hammerman WA, et al. Evaluation and treatment of community-acquired Staphylococcus aureus infections in term and late-preterm previously healthy neonates. Pediatrics 2007;120:937–45. Kharazmi SA, Hirsh DA, Simon HK, et al. Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department. Pediatr Emerg Care 2012;28:1013–6. Faden H. Mastitis in children from birth to 17 years. Pediatr Infect Dis J 2005;24:1113. Vidwan G, Geis GL. Evaluation, management, and outcome of focal bacterial infections (FBIs) in nontoxic infants under two months of age. J Hosp Med Off Publ Soc Hosp Med 2010;5:76–82. Walsh M, McIntosh K. Neonatal mastitis. Clin Pediatr (Phila) 1986;25:395–9.
8 9 10 11
12
13
14
Wirth J, Raymond J, Lapillonne A. Unusual report of diaper rash in a premature infant with group B streptococcal infection. Pediatr Infect Dis J 2006;25: 750–1. Albanyan EA, Baker CJ. Is lumbar puncture necessary to exclude meningitis in neonates and young infants: lessons from the group B streptococcus cellulitisadenitis syndrome. Pediatrics 1998;102:985–6. Hauger SB. Facial cellulitis: an early indicator of group B streptococcal bacteremia. Pediatrics 1981;67:376–7. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med 2007;357:380–90. Al Ruwaili N, Scolnik D. Neonatal mastitis: controversies in management. J Clin Neonatol 2012;1:207–10. Garges HP, Moody MA, Cotten CM, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics 2006;117:1094–100. Amir J, Harel L, Frydman M, et al. Shift of cerebrospinal polymorphonuclear cell percentage in the early stage of aseptic meningitis. J Pediatr 1991;119: 938–41. Lachenauer C, Wessels M. Group B Streptococcus. In: Kliegman R, Behrman R, Jenson H, et al., eds. Nelson Textbook of Pediatrics. Philadelphia: WB Saunders, 2011;925–8. Peters TR, Edwards KM. Cervical lymphadenopathy and adenitis. Pediatr Rev Am Acad Pediatr 2000;21:399–405.
Arch Dis Child July 2014 Vol 99 No 7
Downloaded from adc.bmj.com on July 3, 2014 - Published by group.bmj.com
Question 2: Is a lumbar puncture necessary in an afebrile newborn infant with localised skin and soft tissue infection? Rosa Nguyen, Ramachandra Bhat and Getachew Teshome Arch Dis Child 2014 99: 695-698 originally published online April 8, 2014
doi: 10.1136/archdischild-2014-306111
Updated information and services can be found at: http://adc.bmj.com/content/99/7/695.full.html
These include:
References
This article cites 13 articles, 4 of which can be accessed free at: http://adc.bmj.com/content/99/7/695.full.html#ref-list-1
Email alerting service
Topic Collections
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