Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis

Laura Simone,Mark D Lyttle,Suzanne Schuh,Damian Roland,Derek Stephens

doi:10.1136/emermed-2018-208000

Abstract

BackgroundSerious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and...

Highlights

Bronchiolitis represents the most common cause for infant hospitalization and a common reason for Emergency Department (ED) visits.[1, 2] Fever constitutes a common clinical sign of bronchiolitis, yet in very young infants the fever poses a dilemma for clinicians: is the fever a consequence of the bronchiolitis, or a superimposed serious bacterial infection (SBI)?(1-3) These infants are not vaccinated and are susceptible to perinatally acquired pathogens.[3]
The aforementioned practice needs to be evaluated in the context of potential utility and possible adverse effects of this procedure in bronchiolitis.[8, 9] A recent international study found large variation in practice patterns of bronchiolitis management between EDs.[10]. It is possible that clinicians looking after febrile newborns with bronchiolitis in different geographic global regions may adopt different diagnostic approaches
The primary objective of this multi-national survey of two pediatric emergency research networks in Canada and the United Kingdom/Ireland which are part of a large international collaborative pediatric emergency research network was to compare the proportions of emergency physicians who would be very likely/likely to perform an lumbar puncture (LP) in a febrile, well-appearing full-term 21-day-old infant with a typical presentation of mild bronchiolitis and without perinatal sepsis-associated risk factors

Summary

INTRODUCTION

Bronchiolitis represents the most common cause for infant hospitalization and a common reason for Emergency Department (ED) visits.[1, 2] Fever constitutes a common clinical sign of bronchiolitis, yet in very young infants the fever poses a dilemma for clinicians: is the fever a consequence of the bronchiolitis, or a superimposed serious bacterial infection (SBI)?(1-3) These infants are not vaccinated and are susceptible to perinatally acquired pathogens.[3] Clinical practice guidelines recommend routine comprehensive screening for SBI in febrile infants under 1 month of age without a clear source of infection.[4, 5] Since the incidence of concurrent SBI in febrile infants with bronchiolitis is less than 2%, leading bronchiolitis clinical practice guidelines (CPG) do not endorse routine laboratory investigations.[1,2,3] there is currently no guidance on the management of febrile infants with bronchiolitis in the first month of life Many such children routinely undergo a full sepsis work up, including a lumbar puncture (LP), despite published evidence that meningitis occurs in less than 1% of these infants.[3, 6, 7] given the rarity of bacterial meningitis in young infants with fever and bronchiolitis, a major limitation of the available evidence is lack of optimal power for accurate risk assessment of this outcome. We hypothesized there would be a significant difference in this outcome between the networks

METHODS

Probability of Management in Febrile Newborns with Bronchiolitis in Study

Findings

Antibiotics with