Suboptimal management of central nervous system infections in children: a multi-centre retrospective study.

Christine Kelly,Aman Sohal,Benedict D Michael,Andrew Riordan,Rachel Kneen,Tom Solomon

doi:10.1186/1471-2431-12-145

Abstract

ObjectiveWe aimed to audit the regional management of central nervous system (CNS) infection in children.MethodsThe study was undertaken in five district general hospitals and one tertiary paediatric hospital in the Mersey region of the UK. Children admitted to hospital with a suspected CNS infection over a three month period were identified. Children were aged between 4 weeks and 16 years old. Details were recorded from the case notes and electronic records. We measured the appropriateness of management pathways as outlined by national and local guidelines.ResultsSixty-five children were identified with a median age of 6 months (range 1 month to 15 years). Ten had a CNS infection: 4 aseptic meningitis, 3 purulent meningitis, 3 encephalitis [2 with herpes simplex virus (HSV) type 1]. A lumbar puncture (LP) was attempted in 50 (77%) cases but only 43 had cerebrospinal fluid (CSF) available for analysis. Of these 24 (57%) had a complete standard set of tests performed. Fifty eight (89%) received a third generation cephalosporin. Seventeen (26%) also received aciclovir with no obvious indication in 9 (53%). Only 11 (65%) of those receiving aciclovir had CSF herpes virus PCR. Seventeen had cranial imaging and it was the first management step in 14. Treatment lengths of both antibiotics and aciclovir were highly variable: one child with HSV encephalitis was only treated with aciclovir for 7 days.ConclusionsThe clinical management of children with suspected CNS infections across the Mersey region is heterogeneous and often sub-optimal, particularly for the investigation and treatment of viral encephalitis. National guidelines for the management of viral encephalitis are needed.

Highlights

Infections of the central nervous system (CNS) can present with a wide variety of clinical symptoms and signs which are often non-specific, especially in infants and children
This current study aims to audit the management of children with suspected CNS infection in all hospitals admitting children across the region, including the original tertiary hospital
Case inclusion To identify children in whom a CNS infection might have been suspected we screened doctors ward round registers, electronic laboratory records to identify patients who had cerebrospinal fluid (CSF) analysis and electronic pharmacy records to identify patients who had received an intravenous third generation cephalosporin, intravenous aciclovir or a combination of both medications

Summary

Introduction

Infections of the central nervous system (CNS) can present with a wide variety of clinical symptoms and signs which are often non-specific, especially in infants and children. Both meningitis and viral encephalitis are neurological emergencies requiring urgent investigation and treatment; [1] especially as distinguishing between the syndromes of meningitis and encephalitis and Guidelines for the management of bacterial meningitis and meningococcal disease have been introduced[5,6] but the management of viral CNS infections has been relatively neglected. An earlier study of children with suspected encephalitis in a tertiary paediatric hospital in our region found that the management was often haphazard [9]. As far as the authors are aware, this is the first comparative study in children examining the incidence, clinical features and management of acute bacterial and viral CNS infections in a single population

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Conclusion