Comparing the Use of, and Considering the Need for, Lumbar Puncture in Children With Influenza or Other Respiratory Virus Infections

Gulam Khandaker; Leon Heron; Harunor Rashid; Jean Li-Kim-Moy; David Lester-Smith; Alison Kesson; Mary McCaskill; Cheryl Jones; Yvonne Zurynski; Elizabeth J. Elliott; Dominic E. Dwyer; Robert Booy

Disclosures

Influenza Resp Viruses. 2013;7(6):932-937. 

In This Article

Abstract and Introduction

Abstract

Background The clinical presentation of influenza in infancy may be similar to serious bacterial infection and be investigated with invasive procedures like lumbar puncture (LP), despite very limited evidence that influenza occurs concomitantly with bacterial meningitis, perhaps because the diagnosis of influenza is very often not established when the decision to perform LP is being considered.

Methods A retrospective medical record review was undertaken in all children presenting to the Children's Hospital at Westmead, Sydney, Australia, in one winter season with laboratory-confirmed influenza or other respiratory virus infections (ORVIs) but excluding respiratory syncytial virus, to compare the use of, and reflect on the need for, the performance of invasive diagnostic procedures, principally LP, but also blood culture, in influenza and non-influenza cases. We also determined the rate of concomitant bacterial meningitis or bacteraemia.

Findings Of 294 children, 51% had laboratory-confirmed influenza and 49% had ORVIs such as parainfluenza viruses (34%) and adenoviruses (15%). Of those with influenza, 18% had a LP and 71% had a blood culture performed compared with 6·3% and 55·5% in the ORVI group (for both P < 0·01). In multivariate analysis, diagnosis of influenza was a strong independent predictor of both LP (P = 0·02) and blood culture (P = 0·05) being performed, and, in comparison with ORVIs, influenza cases were almost three times more likely to have a LP performed on presentation to hospital. One child with influenza (0·9%) had bacteraemia and none had meningitis.

Interpretation Children with influenza were more likely to undergo LP on presentation to hospital compared with those presenting with ORVIs. If influenza is confirmed on admission by near-patient testing, clinicians may be reassured and less inclined to perform LP, although if meningitis is clinically suspected, the clinician should act accordingly. We found that the risk of bacterial meningitis and bacteraemia was very low in hospitalised children with influenza and ORVIs. A systematic review should be performed to investigate this across a large number of settings.

Introduction

Influenza in children poses a significant burden to healthcare services and often requires escalated medical care.[1,2] A large proportion of the children with influenza admitted to hospital receive antibiotics for suspected bacterial infection and undergo multiple invasive procedures. For instance, during the winter of 2006, among children aged <5 years admitted to the Children's Hospital at Westmead (CHW) with laboratory-confirmed influenza, 68% received intravenous antibiotics and 23% underwent lumbar puncture (LP).[3] The following year, 2007, similar proportions of hospitalised children with confirmed influenza were given antibiotics (67%) and underwent LP (23%).[1]

Pneumonia and secondary bacterial infections are recognised to follow influenza infection in children.[4] However, studies have shown that concomitant serious bacterial infections (SBI), especially meningitis, occur rarely in infants during the course of infection with respiratory viruses, including influenza and respiratory syncytial virus (RSV).[5–8] Lumbar puncture is now not specifically recommended in infants presenting with RSV bronchiolitis, the policy having evolved in recent years.[9,10] Although comparisons have been made between the clinical characteristics of influenza and RSV,[11] there are few studies that compare the use of invasive diagnostic procedures, especially LP, in children with influenza with respiratory viral infections other than RSV (ORVIs); the rates of concomitant bacterial infection are also uncommonly reported. To this end, we have compared the clinical characteristics, the rates of invasive diagnostic procedures, particularly LP, and the incidence of bacterial meningitis and bacteraemia in children presenting with influenza or with ORVIs at the CHW, a tertiary paediatric hospital in Greater Sydney, Australia.

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