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caring for these children is unknown. Boston Children’s Hospital and Harvard Medical School, Boston,
Massachusetts; and bDivisions of Hospital Medicine and
Infectious Diseases, Cincinnati Children’s Hospital Medical Center,
WHAT THIS STUDY ADDS: There was a decline in the rate of University of Cincinnati, Cincinnati, Ohio
diagnosis of viral meningitis in US children’s hospitals between
KEY WORDS
2005 and 2011. Most children diagnosed with viral meningitis are viral meningitis, lumbar puncture, resource utilization
treated with antibiotics and are hospitalized, accounting for
ABBREVIATIONS
considerable health care costs. CSF—cerebrospinal fluid
ED—emergency department
ICD-9—International Classification of Disease, Ninth Revision
IQR—interquartile range
LP—lumbar puncture
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TABLE 2 Clinical Management for 7618 Patients With Viral Meningitis Presenting to ED of visits for children with either suspected
Participating US Children’s Hospitals Stratified by Patient Age
viral meningitis or viral meningitis de-
Clinical Management #60 d N = 2830, 61 d–3 y N = 1382, .3 y N = 3406, Overall creased (Table 3). For the children with
n (%) n (%) n (%)
viral meningitis, the proportion of ED
Hospital admission 2822 (99) 1344 (97) 2796 (82) 6962 (91)
rate
visits for children #60 days of age
Length of stay similarly declined during the study
(admitted patients) period. The number and proportion of
1d 364 (13) 205 (15) 954 (34) 1523 (22)
ED visits with an LP performed declined
2d 1344 (48) 586 (44) 995 (36) 2925 (42)
3d 699 (25) 306 (23) 421 (15) 1426 (20) as well as the proportion of those di-
$4 d 415 (15) 247 (18) 426 (15) 1088 (16) agnosed with viral meningitis.
Repeat ED visits 54 (2) 49 (4) 302 (9) 405 (5)
within 3 d Most children diagnosed with viral
Cranial computed 113 (4) 267 (19) 1457 (43) 1837 (24) meningitis in the ED setting were hos-
tomography pitalized (91%). Over the study period,
Parenteral antibiotics 2814 (99) 1329 (96) 2329 (68) 6472 (85)
Acyclovir 1043 (37) 242 (18) 326 (10) 1611 (21)
admission rates declined only slightly
Corticosteroids 35 (1) 58 (4) 248 (7) 341 (4) (94% in 2005 vs 91% in 2011), although
Viral testinga 699 (25) 375 (27) 751 (22) 1825 (24) the test for trend was statistically sig-
a Viral testing included any of the following laboratory codes: viral antibody unspecified; other specified viral culture; other
nificant (odds ratio = 0.89, 95% confi-
specified meningitis bacteria; or viruses, unspecified
dence interval 0.82–0.96). The median
duration of hospital stay for admitted
children , 3 years, P , .001), although a third-generation cephalosporin with patients remained constant (2 days in
we were unable to determine whether ampicillin (n = 2325, 36%), third- 2005, IQR 2–3 vs 2 days in 2011, IQR
the imaging was performed before or generation cephalosporin with vanco- 2–3). After adjusting for health care in-
after the diagnostic LP. Of the 7618 chil- mycin (n = 1496, 23%), and ampicillin flation and hospital location, the me-
dren with viral meningitis, 6472 children with gentamicin (n = 526, 8%). The dian cost for a child hospitalized with
(85%) were treated with parenteral youngest infants were the most likely to viral meningitis remained stable over
antibiotics. Among these patients, the receive acyclovir (37% for #60 days vs the study period (overall cost per child
most commonly prescribed paren- 12% for .60 days of age, P ,.001). Only $5363, IQR $3967–$7444). The median
teral antibiotics were as follows: third- a minority of patients received cortico- cost per child with viral meningitis was
generation cephalosporins (n = 6141, steroids. ∼$4000 higher for hospitalized chil-
95%), ampicillin (n = 2569, 40%), and While the overall number of ED visits dren compared with those discharged
vancomycin (n = 1539, 24%). The most increased from 2005 to 2011, both the from the ED ($1371, IQR $984–$1825 for
frequent antibiotic combinations were absolute number and proportion of ED discharged patients, P , .001). The
TABLE 3 The Number and Proportion of ED Patients Who Had an LP Performed, Suspected Viral Meningitis, and Viral Meningitis Diagnoses Over the
Study Period
2005 2006 2007 2008 2009 2010 2011
All ED visits (n) 1 491 059 1 651 196 2 007 947 2 180 221 2 705 241 2 568 635 2 688 713
No. of hospitals 37 40 41 41 41 41 41
Suspected viral meningitisa
Number of cases 1886 1468 1515 1654 1444 1382 980
Percent of all ED visitsb 0.13 0.09 0.08 0.08 0.05 0.05 0.04
Admissionb 1694 (90) 1325 (90) 1344 (89) 1379 (83) 1188 (82) 1109 (80) 824 (84)
Viral meningitisc
No. of cases 1457 1165 1147 1191 1014 970 674
Percent of all ED visitsb 0.10 0.07 0.06 0.05 0.04 0.04 0.03
Admissionb 1364 (94) 1094 (94) 1073 (94) 1055 (89) 901 (89) 862 (89) 613 (91)
Age #60 db 550 (38) 440 (38) 457 (40) 409 (34) 403 (40) 329 (34) 242 (36)
LPs performed in the ED (n)
No. of cases 17 878 18 052 20 817 19 901 19 538 17 248 16 900
Percent of all ED visits 1.20 1.09 1.04 0.91 0.72 0.67 0.63
Percent with viral meningitis 8.1 6.5 5.5 6.0 5.2 5.6 4.0
a Suspected viral meningitis defined by ICD-9 discharge code.
b Test for linear trend using logistic regression: P , .05.
c Viral meningitis defined by ICD-9 discharge code plus a lumbar puncture performed.
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performed and were diagnosed with code and either an LP procedure code required interventions such as in-
viral meningitis also declined. We hy- or a CSF culture. Although we may not travenous hydration or pain control.
pothesize that this reflects changes in have identified all potential patients, Future studies should investigate pa-
referral patterns as well as discharge we also identified children with sus- tient management decisions to inform
diagnosis coding. Pediatricians and pected meningitis based on discharge the development of effective clinical
community hospitals may now feel diagnosis alone. The trends in diag- practice guidelines for children with
more comfortable managing children nosis and management in children viral meningitis.
with suspected viral meningitis and with suspected viral meningitis and
may refer fewer of these children to viral meningitis were similar. Third, we
pediatric centers for evaluation. Addi- were unable to obtain specific clinical CONCLUSIONS
tionally visits for suspected meningitis and laboratory information because Bacterial meningitis has become a
may be coded as viral illness rather the PHIS database relies primarily rare disease, especially for pediatric
than meningitis, particularly when the on administrative data. Therefore, we patients.2 Over the 7-year study period,
LP is not performed. were unable to exclude children who the number and the proportion of
Our study has the following limitations. were pretreated with antibiotics, which children diagnosed with viral menin-
First, because we were limited to ED may require hospitalization because gitis and suspected viral meningitis at
visits to children’s hospitals included in bacterial cultures may be falsely neg- US children’s hospitals has declined.
the PHIS database, we are unable to ative and CSF profiles affected.23,24 However, admission rates, antibiotic
make population based estimates Fourth, we only captured return visits use, and costs for caring for children
about the overall burden of viral men- to PHIS hospitals. However, we believe diagnosed with viral meningitis remain
ingitis in children. However, our direct that the majority of meningitis follow- high. Evidence-based clinical guide-
rather than proportional sampling up care occurred at the institution lines for the management of children
allowed us to make more precise con- where the patient had the LP per- with meningitis should be developed
clusions about the care each child re- formed. Last, we were unable to de- to guide clinical decision-making by
ceived. Second, we selected a specific termine the reason some children with safely reducing hospitalization and
viral meningitis case definition that viral meningitis were hospitalized; antibiotic use for children with viral
required both a discharge diagnosis presumably, some children may have meningitis.
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BOUTIQUE WORMING: When I see the word “boutique,” I tend to think of a small
shop that sells fashionable (and usually expensive) clothes or jewelry. Rarely do I
associate the word with the digestive powers of earthworms. However, I may
need to change my thinking. As reported in The New York Times (Science: De-
cember 31, 2012), earthworm farming can be big business. The worms’ value lies
in their ability to reduce an incredible array of rotting organic material (including
manure) into a wonder supplement for plants. The product of worm digestion,
called vermicompost, helps plants mature faster and assists in preventing
a variety of plant diseases. Vermicompost production most often begins with
mounds of composted cow manure. This initial composting step generates heat
that kills seeds and unwanted bacteria (such as Escherichia coli) in the manure.
Next, in a controlled environment, thousands of worms (most often Eisenia fetida)
are added to the composted manure. Over the next six months, the worms turn
the cow manure into a fine loose material that resembles peat moss and is
teeming with valuable microorganisms. Scientists believe that the bacteria from
the worms’ digestive systems help generate nitrogen for the growing plants and
prevent disease by other virulent organisms. Many growers swear by the product –
which costs far more than usual soil additives. Vermicompost has a wide variety
of uses and can restore richness to soil depleted by synthetic fertilizers and
pesticides. Interestingly, some plants seem to respond better to different types of
vermicompost. For example, some plants respond best to vermicompost made
from dairy manure, while others respond better to vermicompost made from
food waste or cardboard. Vermicompost made from cardboard seems particu-
larly good for nut and stone fruit farmers and helps control nutgall, a fungal
disease that afflicts walnut trees. This has led to the development of “boutique”
vermiculture producers that specialize in vermicompost for specific types of
plants or trees. While I doubt we will eventually see the same number of “bou-
tiques” as we do at the local shopping mall, the process seems fantastic. Not only
do the worms help get rid of mounds of waste, but the end product of the
breakdown improves the environment.
Noted by WVR, MD
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Trends in the Management of Viral Meningitis at United States Children's
Hospitals
Lise E. Nigrovic, Andrew M. Fine, Michael C. Monuteaux, Samir S. Shah and Mark I.
Neuman
Pediatrics 2013;131;670
DOI: 10.1542/peds.2012-3077 originally published online March 25, 2013;
Updated Information & including high resolution figures, can be found at:
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References This article cites 21 articles, 7 of which you can access for free at:
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .