Impact of rapid enterovirus polymerase chain reaction testing on management of febrile young infants < 90 days of age with aseptic meningitis

Molecular assays for the diagnosis of sepsis in neonates: a diagnostic test accuracy review

BACKGROUND

Microbial cultures for diagnosis of neonatal sepsis have low sensitivity and reporting delay. Advances in molecular microbiology have fostered new molecular assays that are rapid and may improve neonatal outcomes.

OBJECTIVES

To assess the diagnostic accuracy of various molecular methods for the diagnosis of culture-positive bacterial and fungal sepsis in neonates and to explore heterogeneity among studies by analyzing subgroups classified by gestational age and type of sepsis onset and compare molecular tests with one another.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and trial registries in August 2023. We checked reference lists of included studies and systematic reviews where subject matter related to the intervention or population examined in this review.

SELECTION CRITERIA

We included studies that were prospective or retrospective, cohort or cross-sectional design, which evaluated molecular assays (index test) in neonates with suspected sepsis in comparison with microbial cultures (reference standard).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data and assessed the methodological quality of the studies. We performed meta-analyses using the bivariate model and entered data into Review Manager.

MAIN RESULTS

Seventy-four studies were eligible for inclusion, of which 68 studies provided data for meta-analysis. The total number of participants was 14,309 (1328 infants who were culture-positive and 12,981 infants who were culture-negative) from 68 studies that were included in the meta-analysis. The summary estimate of sensitivity was 0.91 (95% confidence interval (CI) 0.85 to 0.95) and of specificity was 0.88 (95% CI 0.83 to 0.92) (low-certainty evidence). We explored heterogeneity by subgroup analyses of type of test, gestational age, type of sepsis onset and prevalence of sepsis. We found insufficient explanations for the heterogeneity (low- to very low-certainty evidence). Sensitivity analyses including studies that analyzed blood samples, using good methodology and those that did not use multiple samples from the same participant revealed similar results (low-certainty evidence).

AUTHORS' CONCLUSIONS

Molecular assays have the advantage of producing rapid results and have moderate diagnostic accuracy. Molecular assays may prevent overuse of antibiotics in neonates with suspected sepsis. The efficacy and cost-effectiveness of these molecular assays should be evaluated using randomized trials comparing molecular assays as an add-on test versus conventional methods without the add-on test in neonates with suspected sepsis.

Performance of blood enterovirus and parechovirus polymerase chain reaction testing in young febrile infants: a prospective multicentre observational study

OBJECTIVES

To analyse the performance of blood enterovirus and parechovirus PCR testing (ev-PCR) for invasive bacterial infection (IBI) (isolation of a single bacterial pathogen in a blood or cerebrospinal fluid culture) when evaluating well-appearing infants ≤90 days of age with fever without a source (FWS).

METHODS

We describe the well-appearing infants ≤90 days of age with FWS and normal urine dipstick. We performed a prospective, observational multicentre study at five paediatric emergency departments between October 2020 and September 2023.

RESULTS

A total of 656 infants were included, 22 (3.4%) of whom were diagnosed with an IBI (bacteraemia in all of them and associated with meningitis in four). The blood ev-PCR test was positive in 145 (22.1%) infants. One patient with positive blood ev-PCR was diagnosed with an IBI, accounting for 0.7% (95% CI 0.02 to 3.8) compared with 4.1% (95% CI 2.6 to 6.2) in those with a negative test (p=0.04). All four patients with bacterial meningitis had a negative blood ev-PCR result. Infants with a positive blood ev-PCR had a shorter hospital stay (median 3 days, IQR 2-4) compared with 4 days (IQR 2-6) for those with negative blood ev-PCR (p=0.02), as well as shorter duration of antibiotic treatment (median 2 days, IQR 0-4 vs 2.5 days, IQR 0-7, p=0.01).

CONCLUSIONS

Young febrile infants with a positive blood ev-PCR are at a low risk of having an IBI. Incorporating the blood ev-PCR test into clinical decision-making may help to reduce the duration of antibiotic treatments and length of hospital stay.

Non-polio enterovirus aseptic meningitis in infants up to three months of age, the bacterial mask of viral disease: A retrospective cohort study

BACKGROUND

Non-polio enterovirus aseptic meningitis (NPE-AM) is a self-limiting illness that can mimic serious bacterial infection (SBI) in infants during their first months of life.

OBJECTIVES

To compare the clinical features of febrile infants diagnosed with NPE-AM with those of infants who had SBI or non-bacterial infection (NBI).

STUDY DESIGN

A systematic series of febrile infants < 3-months-old hospitalized between 2010 and 2019 with febrile illness in a tertiary hospital. Clinical and laboratory data were compared between the three groups.

RESULTS

Overall 1278 infants were included; 207 (16.2%) had NPE-AM, 210 (16.4%) SBI and 861 (67.4%) NBI. The median age was 34 (IQR: 21.5-51.7) days. NPE-AM was documented in 25% of infants < 29 days and 9.9% of infants aged 29-90 days. Infants with NPE-AM or SBI had fever >39°C more frequently, 24.2% and 17.1% compared with 10% in infants with NBI (p < 0.001). Fever duration ≥ 2 days was reported in 3.4% of infants with NPE-AM vs 18.6% in SBI and 26.3% in NBI (p < 0001); rash occurred in 37.7% in NPE-AM compared to 4.6% in NBI and 5.7% in SBI (p < 0.001). The mean white blood count, C-reactive protein and absolute neutrophil count were significantly lower in infants with NPE-AM compared to infants with the SBI (p < 0.001) and similar to the means in infants with NBI (p = 0.848, 0.098 and 0.764 respectively). A high proportion of bloody tap 346/784 (53.1%) was detected. Infants with NPE-AM were more likely to be treated with antibiotics than infants with NBIs (88.9% vs 50.7%, p < 0.001), similarly to infants with SBIs (p = 0.571).

CONCLUSIONS

The clinical presentation of infants with NPE-AM that could mimic bacterial infection and the high rate of bloody taps may lead to more hospital admissions and antibiotic prescriptions. Rapid molecular testing for detection of NPE may be of additional value in the evaluation of febrile infants.

The impact of cerebrospinal fluid viral polymerase chain reaction testing on the management of adults with viral meningitis: A multi-center retrospective study

The aim of this study was to evaluate the role of viral polymerase chain reaction (PCR) testing in patients with aseptic meningitis and identify opportunities for improvement in clinical management. All cerebrospinal fluid samples collected in 1 year from four teaching hospitals in Sydney, Australia, were reviewed. Patients with aseptic meningitis were selected, and clinical and diagnostic features, hospital length of stay (LOS), and treatment were analyzed. Identifying a cause by viral PCR did not reduce hospital LOS (median 3 days) or antibiotic use (median 2 days), but the turnaround time of the PCR test correlated with LOS (Rs = 0.3822, p = 0.0003). Forty-one percent of patients received intravenous acyclovir treatment, which was more frequent in patients admitted under neurologists than infectious diseases physicians (56% vs. 24%; p = 0.013). The majority of patients did not have investigations for alternative causes of aseptic meningitis such as human immunodeficiency virus and syphilis if the viral PCR panel was negative. The benefit of PCR testing in aseptic meningitis in adults in reducing LOS and antibiotic use is unclear. The reasons for unnecessary aciclovir use in meningitis syndromes require further assessment.

Detection of enterovirus in cerebrospinal fluids without pleocytosis in febrile infants under 3 months old reduces antibiotherapy duration

Background

Infants under 3 months old with fever often receive empirical antibiotic treatment. Enterovirus is one of the leading causes of infection and aseptic meningitis but is not systematically screened. We aimed to evaluate enterovirus positive RT-PCR proportion in cerebrospinal fluid (CSF) with no pleocytosis and its impact on antibiotic treatment duration.

Methods

During the enterovirus endemic season, from 2015 to 2018, we retrospectively studied infants under 3 months old, consulting for fever without cause, with normal CSF analysis, and receiving empirical antibiotic treatment. Clinical and biological data were analyzed, notably enterovirus RT-PCR results. The primary outcome was the duration of antibiotic therapy.

Results

92 patients were recruited. When tested, 41% of infants were positive for enterovirus, median antibiotic duration was reduced in enterovirus positive in comparison to negative patients with respectively 1.9 [interquartile range (IQR), 1.7-2] vs. 4.1 [IQR, 2-6], p < 0.001. No clinical nor biological features differed according to the enterovirus status.

Conclusion

In this population, enterovirus positive CSF are frequent despite the absence of pleocytosis. However, its research was not guided by clinical or biological presentations. Systematic and routine use of enterovirus RT-PCR during enterovirus season, regardless of CSF cell count, could reduce the prescription of antibiotics in febrile infants under 3 months old without clinical orientation.

Enteroviral Infections in the First Three Months of Life

Enteroviruses (EVs) are an important source of infection in the paediatric age, with most cases concerning the neonatal age and early infancy. Molecular epidemiology is crucial to understand the circulation of main serotypes in a specific area and period due to their extreme epidemiological variability. The diagnosis of EVs infection currently relies on the detection of EVs RNA in biological samples (usually cerebrospinal fluid and plasma, but also throat swabs and feces) through a polymerase chain reaction assay. Although EVs infections usually have a benign course, they sometimes become life threatening, especially when symptoms develop in the first few days of life. Mortality is primarily associated with myocarditis, acute hepatitis, and multi-organ failure. Neurodevelopmental sequelae have been reported following severe infections with central nervous system involvement. Unfortunately, at present, the treatment of EVs infections is mainly supportive. The use of specific antiviral agents in severe neonatal infections has been reported in single cases or studies including few neonates. Therefore, further studies are needed to confirm the efficacy of these drugs in clinical practice.