DOI: 10.1542/peds.2012-3077; originally published online March 25, 2013; 2013;131;670Pediatrics

NeumanLise E. Nigrovic, Andrew M. Fine, Michael C. Monuteaux, Samir S. Shah and Mark I.

HospitalsTrends in the Management of Viral Meningitis at United States Children's

  

  http://pediatrics.aappublications.org/content/131/4/670.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Trends in the Management of Viral Meningitis at UnitedStates Children’s Hospitals

WHAT’S KNOWN ON THIS SUBJECT: In the era of widespreadconjugate vaccine use, the prevalence of bacterial meningitis hasdeclined. However, the impact of this decline on the rate ofemergency department visits for viral meningitis and cost ofcaring for these children is unknown.

WHAT THIS STUDY ADDS: There was a decline in the rate ofdiagnosis of viral meningitis in US children’s hospitals between2005 and 2011. Most children diagnosed with viral meningitis aretreated with antibiotics and are hospitalized, accounting forconsiderable health care costs.

abstractOBJECTIVE: To determine trends in the diagnosis and management ofchildren with viral meningitis at US children’s hospitals.

METHODS: We performed a multicenter cross sectional study of chil-dren presenting to the emergency department (ED) across the 41 pe-diatric tertiary-care hospitals participating in the Pediatric HealthInformation System between January 1, 2005, and December 31,2011. A case of viral meningitis was defined by InternationalClassification of Diseases, Ninth Revision, discharge diagnosis, andrequired performance of a lumbar puncture. We examined trends indiagnosis, antibiotic use, and resource utilization for children with viralmeningitis over the study period.

RESULTS: We identified 7618 children with viral meningitis (0.05% of EDvisits during the study period). Fifty-two percent of patients were ,1year of age, and 43% were female. The absolute number and theproportion of ED visits for children with viral meningitis declined from0.98 cases per 1000 ED visits in 2005 to 0.25 cases in 2011 (P , .001).Most children with viral meningitis received a parenteral antibiotic(85%), and were hospitalized (91%). Overall costs for children forchildren with viral meningitis remain substantial (median cost percase $5056, interquartile range $3572–$7141).

CONCLUSIONS: Between 2005 and 2011, viral meningitis diagnoses atUS children’s hospitals declined. However, most of these children arehospitalized, and the cost for caring for these children remains con-siderable. Pediatrics 2013;131:670–676

AUTHORS: Lise E. Nigrovic, MD, MPH,a Andrew M. Fine, MD,MPH,a Michael C. Monuteaux, ScD,a Samir S. Shah, MD,MSCE,b and Mark I. Neuman, MD, MPHa

aDivision of Emergency Medicine, Department of Medicine,Boston Children’s Hospital and Harvard Medical School, Boston,Massachusetts; and bDivisions of Hospital Medicine andInfectious Diseases, Cincinnati Children’s Hospital Medical Center,University of Cincinnati, Cincinnati, Ohio

KEY WORDSviral meningitis, lumbar puncture, resource utilization

ABBREVIATIONSCSF—cerebrospinal fluidED—emergency departmentICD-9—International Classification of Disease, Ninth RevisionIQR—interquartile rangeLP—lumbar puncturePHIS—Pediatric Health Information System

Dr Nigrovic conceived and designed the study, interpreted thedata, and drafted the manuscript; Drs Fine, Shah, and Neumanconceived and designed the study, interpreted the data, andcritically reviewed the manuscript; and Dr Monuteaux acquireddata, conducted the data analysis, interpreted the data, andcritically reviewed the manuscript.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3077

doi:10.1542/peds.2012-3077

Accepted for publication Nov 29, 2012

Address correspondence to Lise E. Nigrovic, MD, MPH, Division ofEmergency Medicine, Boston Children’s Hospital, 300 LongwoodAve, Boston, MA 02115. E-mail: lise.nigrovic@childrens.harvard.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

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In the era of widespread conjugatevaccines,most childrenwithmeningitishave a viral rather than a bacterialinfection.1–3 Although children withbacterial meningitis require promptinitiation of parenteral antibiotics andhospitalization, those with viral men-ingitis, a self-limited condition, requireonly supportive care. Until recently,a reliable and accurate method todistinguish children with viral frombacterial meningitis based on clinicaland laboratory predictors availableat presentation was not available. TheBacterial Meningitis Score, a vali-dated clinical prediction rule, accu-rately identifies children at low riskfor bacterial meningitis.4,5 However,the impact of this clinical decision-making tool on the diagnosis andmanagement of children with viralmeningitis in the setting of a sub-stantial decline in the prevalence ofbacterial meningitis2 has not beenevaluated.

Patients with viral meningitis arecommonly hospitalized to receive an-timicrobial therapy while awaitingresults of bacterial cultures.5,6 How-ever, recent information regardingrates of hospitalization for childrenwith viral meningitis are limited. Al-though the number of emergencydepartment (ED) visits for mening-itis in children and adults combinedremained stable over the past de-cade,7 the rate of hospitalizations forpneumococcal meningitis decreasedsubstantially.8

We sought to determine whether therate of diagnosis and managementof children with viral meningitis atchildren’s hospitals has changed inrecent years. We examined patientspresenting to the ED of a PediatricHealth Information System (PHIS)participating children’s hospital be-tween 2005 and 2011 to examinetrends in diagnosis and managementof viral meningitis.

METHODS

Setting

Data for this study were obtainedfrom PHIS, an administrative databasethat contains inpatient, ED, ambulatorysurgery, and observation data fromtertiary care pediatric hospitals in theUnited States. These hospitals are af-filiated with the Children’s HospitalAssociation (Overland Park, KS). Thedata warehouse function for the PHISdatabase is managed by Truven HealthAnalytics (Ann Arbor, MI). For the pur-poses of external benchmarking, par-ticipating hospitals provide discharge/encounter data including demographics,diagnoses, and procedures as well asresource utilization data (eg, pharma-ceuticals, imaging, laboratory). Data aredeidentified at the time of submissionand are subjected to a number of re-liability and validity checks before beingincluded in the database. We excluded 2PHIS hospitals due to incomplete ED visitdata. For this study, the number of hos-pitals contributing complete ED data in-creased from 37 to 41 over the studyperiod. This study was approved by theInstitutional Review Board at BostonChildren’s Hospital.

Study Population

Children ,18 years of age who pre-sented to the pediatric ED of a partici-pating PHIS institution between January1, 2005, and December 31, 2011, withviral meningitis were eligible for in-clusion. Using a previously reportedclassification scheme, children wereexcluded if they were transferred to thereceiving institution, had a chroniccomorbid condition (eg, cystic fibrosis,malignancy, sickle cell disease, epilepsy,cerebral palsy), or a diagnosis of cere-brospinal fluid (CSF) ventricular shunt.9

Classification of viral meningitis

Patients with “suspected” viral menin-gitis were defined by the following 6

International Classification of Diseases,Ninth Revision (ICD-9) discharge di-agnosis codes: meningitis due to Cox-sackie viruses (047.0), meningitis due toechoviruses (047.1), meningitis due toother specified enteroviruses (047.8),unspecified viral meningitis (047.9),meningitis due to adenovirus (049.1),and meningitis due to viruses not else-where classified (321.2). We used di-agnosis codes similar to those used byprevious investigators, although wechose to not include herpes infections inour case definition.6 Among a subset ofpatients with suspected viral meningitis,we considered a patient to have viralmeningitis if he or shehad 1 of the 6 ICD-9diagnosis codes and also had a lumbarpuncture (LP) performed. We definedan LP by the presence of either an LPprocedure code or a billing code fora CSF culture on the day of hospitalpresentation.

Measured Exposures andOutcomes

We evaluated diagnostic testing, re-source utilization, and costs for childrenwith viral meningitis. Diagnostic andlaboratory testing were identified byusing clinical tabular codes. We identi-fied the performance of an LP usingthese codes and medication deliveryusingtheNationalDrugCodeDirectory.10

We evaluated admission rate and hos-pital length of stay for children whowere hospitalized. The admission rateincluded inpatient hospitalization oradmission to “observation status” toaccount for the variable use of obser-vation status, “virtual” inpatient admis-sion, and availability of inpatient bedsamong institutions.11,12 For patientsdischarged from the ED with viralmeningitis, we identified all return visitsto the ED within 3 days of index visit, aswell as return visits resulting in ad-mission.

Costswere based on the ratio of cost-to-charges submitted by the hospitals ontheir respective Medicare cost reports

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and were adjusted by the Centers forMedicare and Medicaid price/wageindex. We further adjusted all patientcosts to 2011 dollars by using the an-nual Consumer Price Index inflationrate for the “Hospital and related serv-ices” expenditure category as publishedby the US Department of Labor.

Statistical Analysis

We summarized demographic charac-teristics among patients with “sus-pected” viral meningitis and the subsetmeeting our case definition of viralmeningitis. We then stratified our caseseries by age and compared theresulting groups on clinical manage-ment and outcome factors using a se-ries of logistic regression models. Totest for changes over time in the ratesof viral meningitis cases, we conducteda test for trend using a logistic re-gression with case status as the de-pendent variable and time in calendaryear as the independent variable. Totest for changes over time in patientcosts, we conducted a test for trendusing a Poisson regression model.Given that our data were taken fromseveral hospitals, the assumption ofindependent observations may nothold. To accommodate these data, ourregression models used clusteredsandwich standard error estimates,which allow for intrahospital correla-tion, relaxing the assumption thatobservations from the same hospitalare independent.

Because the decision to hospitalizea child with viral meningitis mightbe balanced against return visits,we tested the correlation betweenhospital-specific rate of admission and72-hour return ED visit rate resulting inadmission. Using the Spearman’s corre-lation coefficient, we measured thehospital-specific correlation betweeninitial admission rate and the rate ofreturn visits to the ED resulting in ad-mission within 3 days weighted by the

hospital-specific number of meningitisvisits.

All analyses were performed by usingStata 12.1 (College Station, TX). All sta-tistical tests were 2-tailed, and a wasset at .05.

RESULTS

Over the study period, 15 293 012 chil-dren were seen in the EDs of the 41participating study institutions. Afterapplying the exclusion criteria, weidentified 130 334 children (0.85% of allED visits) who had an LP performed. Ofthese, we identified 10 329 visits forsuspected viral meningitis (0.07% of EDvisits) and 7618 with viral meningitis(0.05% of ED visits). The median pro-portion of visits for viral meningitisamong all ED visits across the partici-pating institutions was 0.05% (range0.01%–0.57%), and the median hospitaladmission rate was 94% (range 64%–100%). Institutionswith loweradmissionrates for children with viral meningitisdid not have higher rates of ED returnvisits within 3 days resulting in ad-mission (P = .10).

The demographic characteristics ofpatients with suspected viral meningi-tis and those with viral meningitis are

presented in Table 1. A greater pro-portion of children with viral meningi-tis than suspected viral meningitiswere ,1 year of age, implying thatyounger children were more likely tohave an LP performed for suspectedviral meningitis. A similar proportionof children with suspected viral men-ingitis and viral meningitis presentedduring the peak enteroviral season(June 1 through October 31).

Clinical management differed by pa-tient age (Table 2). Of the children#60days of age, the most common ED ad-mitting diagnosis was fever (22%) fol-lowed by unspecified viral meningitis(17%). Of the children.60 days of age,the most common ED admitting wasunspecified viral meningitis (29%) fol-lowed by headache (19%). Older chil-dren with viral meningitis had a loweradmission rate (82% for children $3years of age vs 99% for children ,3years, P , .001) as well as shorterlength of stay (median 2 days inter-quartile range [IQR] 1–3 days for chil-dren$3 years of age vs median 2 daysIQR 2–3 days for children ,3 years ofage, P = .01). Older children were morelikely to have a cranial CT performed aspart of their diagnostic evaluation(43% for children $3 years vs 9% for

TABLE 1 Demographic Characteristics of Patients With Suspected Viral Meningitis Presenting tothe ED of Participating US Children’s Hospitals From 2005 Through 2011

Demographic Characteristic Suspected Viral Meningitisa n = 10 329 Viral Meningitisb n = 7618

Gender (female) 4391 (43) 3266 (43)Age,1 y 4743 (46) 3984 (52)$1 y 5586 (54) 3634 (48)

Census regionNortheast 1288 (12) 899 (12)South 4636 (45) 3516 (46)Midwest 2291 (22) 1644 (22)West 2114 (20) 1559 (20)

Enteroviral seasonc 6831 (66%) 5034 (66%)Insurance payerPrivate 3407 (33) 2539 (33)Public 5081 (49) 3704 (49)Other 1715 (17) 1267 (17)Missing 126 (1) 108 (1)

a Suspected viral meningitis defined by ICD-9 discharge code.b Viral meningitis defined by ICD-9 discharge code plus an LP performed.c Enteroviral season defined as June 1 through October 31.

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children, 3 years, P, .001), althoughwe were unable to determine whetherthe imaging was performed before orafter the diagnostic LP. Of the 7618 chil-dren with viral meningitis, 6472 children(85%) were treated with parenteralantibiotics. Among these patients, themost commonly prescribed paren-teral antibiotics were as follows: third-generation cephalosporins (n = 6141,95%), ampicillin (n = 2569, 40%), andvancomycin (n = 1539, 24%). The mostfrequent antibiotic combinations were

a third-generation cephalosporin withampicillin (n = 2325, 36%), third-generation cephalosporin with vanco-mycin (n = 1496, 23%), and ampicillinwith gentamicin (n = 526, 8%). Theyoungest infants were the most likely toreceive acyclovir (37% for #60 days vs12% for.60 days of age, P,.001). Onlya minority of patients received cortico-steroids.

While the overall number of ED visitsincreased from 2005 to 2011, both theabsolute number and proportion of ED

visits for childrenwith either suspectedviral meningitis or viral meningitis de-creased (Table 3). For the children withviral meningitis, the proportion of EDvisits for children #60 days of agesimilarly declined during the studyperiod. The number and proportion ofED visits with an LP performed declinedas well as the proportion of those di-agnosed with viral meningitis.

Most children diagnosed with viralmeningitis in the ED setting were hos-pitalized (91%). Over the study period,admission rates declined only slightly(94% in 2005 vs 91% in 2011), althoughthe test for trend was statistically sig-nificant (odds ratio = 0.89, 95% confi-dence interval 0.82–0.96). The medianduration of hospital stay for admittedpatients remained constant (2 days in2005, IQR 2–3 vs 2 days in 2011, IQR2–3). After adjusting for health care in-flation and hospital location, the me-dian cost for a child hospitalized withviral meningitis remained stable overthe study period (overall cost per child$5363, IQR $3967–$7444). The mediancost per child with viral meningitis was∼$4000 higher for hospitalized chil-dren compared with those dischargedfrom the ED ($1371, IQR $984–$1825 fordischarged patients, P , .001). The

TABLE 2 Clinical Management for 7618 Patients With Viral Meningitis Presenting to ED ofParticipating US Children’s Hospitals Stratified by Patient Age

Clinical Management #60 d N = 2830,n (%)

61 d–3 y N = 1382,n (%)

.3 y N = 3406,n (%)

Overall

Hospital admissionrate

2822 (99) 1344 (97) 2796 (82) 6962 (91)

Length of stay(admitted patients)1 d 364 (13) 205 (15) 954 (34) 1523 (22)2 d 1344 (48) 586 (44) 995 (36) 2925 (42)3 d 699 (25) 306 (23) 421 (15) 1426 (20)$4 d 415 (15) 247 (18) 426 (15) 1088 (16)

Repeat ED visitswithin 3 d

54 (2) 49 (4) 302 (9) 405 (5)

Cranial computedtomography

113 (4) 267 (19) 1457 (43) 1837 (24)

Parenteral antibiotics 2814 (99) 1329 (96) 2329 (68) 6472 (85)Acyclovir 1043 (37) 242 (18) 326 (10) 1611 (21)Corticosteroids 35 (1) 58 (4) 248 (7) 341 (4)Viral testinga 699 (25) 375 (27) 751 (22) 1825 (24)a Viral testing included any of the following laboratory codes: viral antibody unspecified; other specified viral culture; otherspecified meningitis bacteria; or viruses, unspecified

TABLE 3 The Number and Proportion of ED Patients Who Had an LP Performed, Suspected Viral Meningitis, and Viral Meningitis Diagnoses Over theStudy 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 713No. of hospitals 37 40 41 41 41 41 41

Suspected viral meningitisa

Number of cases 1886 1468 1515 1654 1444 1382 980Percent of all ED visitsb 0.13 0.09 0.08 0.08 0.05 0.05 0.04Admissionb 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 674Percent of all ED visitsb 0.10 0.07 0.06 0.05 0.04 0.04 0.03Admissionb 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 900Percent of all ED visits 1.20 1.09 1.04 0.91 0.72 0.67 0.63Percent 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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total costs for children,3 years of agewere higher than those $3 years ofage (median of $5429, IQR $4050–$7377for ,3 years of age vs $4536, IQR$2748–$6771 for .3 years, P = .03).

DISCUSSION

Weobserved that theabsolute ratesandrelative proportions of children withviral meningitis presenting to an EDdecreased from 2005 to 2011. Despitethe benign nature of the condition,nearly all children treated at US child-ren’s hospitals for viral meningitiswere hospitalized. Institutions withlower hospitalization rates for viralmeningitis did not have higher rates ofED revisits within 3 days resulting inadmission. Most children with viralmeningitis received parenteral anti-biotics, including almost all children,3 years of age. The costs of caring forchildren with viral meningitis are high,reflecting the high resource utilizationand hospitalization rate associatedwith this condition.

Similar to previouswork, we found thatviral meningitis was a common reasonfor hospitalization with the highestburden in the youngest children. In aninpatient sample of .1000 acute carehospitals in the United States, ∼40 000patients were hospitalized for viralmeningitis in 2005.6 In a recent EDstudy, meningitis was more commonlydiagnosed in children, especially thoseaged #3 years.7 We found that themajority of cases occurred in childrenaged ,3 years with a substantial por-tion within the first 2 months of life.

Our findings differ somewhat fromprevious studies. First, we documenteda substantial decline in the numberandproportion of pediatric ED patients di-agnosed with viral meningitis between2005 and 2011. In a study using a na-tional representative sample of ED visits,the estimates of the rates of bacterialand viral meningitis were based ona small number of observations (only

103 actual pediatric ED visits for men-ingitis over the 15-year study period).7

In a second study of hospitalizations formeningitis, the median length of hos-pital stay for admitted patients was 2days, similar to a previous Canadianstudy of aseptic meningitis in chil-dren.14 However, our observed lengthof hospital stay was considerablyshorter than the 4.1 days observed inthe study of hospitalized patients withmeningitis.6 This difference may be at-tributed to the fact that the latter studyincluded patients of all ages, and hos-pital stays for adults were considerablylonger.

In the era of widespread conjugatevaccines,most childrenwithmeningitishave viral rather than bacterialinfections.2,5 The current availabilityof the new 13-valent Streptococcuspneumoniae and 4-valent Neisseriameningitidis conjugate vaccines in thedeveloped world will further decreasethe incidence of childhood bacterialmeningitis. Although children withbacterial meningitis require promptinitiation of parenteral antibiotics, mostchildren with viral meningitis requireonly supportive care.14 Because bac-terial cultures take several days toexclude bacterial growth reliably, cli-nicians must make management deci-sions before definitive test results areavailable.15,16 Meningitis clinical pre-diction rules combine readily availableclinical and laboratory factors to esti-mate the risk of bacterial meningitis.One model, the Bacterial MeningitisScore, has been validated in 8 publishedstudies and performs with a high de-gree of diagnostic accuracy in a widevariety of clinical settings.17 We wouldexpect that an application of a clinicaldecision rule would reduce the rate ofhospitalization and antibiotic use forchildren determined to be at low risk ofbacterial meningitis. Additionally, avail-able polymerase chain reaction testsmay rapidly identify enteroviruses, the

most common viral cause of meningi-tis.18–20 Children with a positive entero-viral polymerase chain reaction test areat low risk of bacterial meningitis21 andcould be safely managed as outpatients.

In our study population, overall .90%of the children diagnosed with viralmeningitis were hospitalized withsome variability across study sites. Al-though some children may requirehospitalization for hydration, pain con-trol, or to ensure adequate follow-up,most children at low risk for bacterialmeningitis can be appropriately man-aged as outpatients.5 Administration ofa single dose of a long-acting parenteralantibiotic such as ceftriaxone can pro-vide coverage in the unlikely case ofbacterial infection. The absence of na-tional evidence-based guidelines for themanagement of childrenwithmeningitismay have led to overhospitalization ofchildren at low risk of bacterial menin-gitis. Even modest reductions in hospi-talization would substantially reduce thecosts to care for these children. Impor-tantly, the measured costs of inpatientcare do not completely capture the un-intended consequences for the patient(eg, nosocomial infections or adverseevents) and for their caretakers (eg,missed workdays).

We were surprised to observe thesubstantial decline in the number andthe proportion of patients with viralmeningitis over the 7-year study period.Although conjugated vaccines havedramatically reduced the prevalence ofbacterial meningitis, we would pre-sume that the rates of viral meningitiswould not have been affected. We ob-served a decline in the number of LPsperformed, consistent with a previ-ously observed long-term seculartrend in the number of LPs performedin the ED setting.22 However, the declinein viral meningitis cases cannot beexplained solely by the decrease in thenumber of LPs performed because theproportion of children who had an LP

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performed and were diagnosed withviral meningitis also declined. We hy-pothesize that this reflects changes inreferral patterns as well as dischargediagnosis coding. Pediatricians andcommunity hospitals may now feelmore comfortable managing childrenwith suspected viral meningitis andmay refer fewer of these children topediatric centers for evaluation. Addi-tionally visits for suspected meningitismay be coded as viral illness ratherthan meningitis, particularly when theLP is not performed.

Our study has the following limitations.First, because we were limited to EDvisits to children’s hospitals included inthe PHIS database, we are unable tomake population based estimatesabout the overall burden of viral men-ingitis in children. However, our directrather than proportional samplingallowed us to make more precise con-clusions about the care each child re-ceived. Second, we selected a specificviral meningitis case definition thatrequired both a discharge diagnosis

code and either an LP procedure codeor a CSF culture. Although we may nothave identified all potential patients,we also identified children with sus-pected meningitis based on dischargediagnosis alone. The trends in diag-nosis and management in childrenwith suspected viral meningitis andviral meningitis were similar. Third, wewere unable to obtain specific clinicaland laboratory information becausethe PHIS database relies primarilyon administrative data. Therefore, wewere unable to exclude children whowere pretreated with antibiotics, whichmay require hospitalization becausebacterial cultures may be falsely neg-ative and CSF profiles affected.23,24

Fourth, we only captured return visitsto PHIS hospitals. However, we believethat the majority of meningitis follow-up care occurred at the institutionwhere the patient had the LP per-formed. Last, we were unable to de-termine the reason some children withviral meningitis were hospitalized;presumably, some children may have

required interventions such as in-travenous hydration or pain control.Future studies should investigate pa-tient management decisions to informthe development of effective clinicalpractice guidelines for children withviral meningitis.

CONCLUSIONS

Bacterial meningitis has become arare disease, especially for pediatricpatients.2 Over the 7-year study period,the number and the proportion ofchildren diagnosed with viral menin-gitis and suspected viral meningitis atUS children’s hospitals has declined.However, admission rates, antibioticuse, and costs for caring for childrendiagnosed with viral meningitis remainhigh. Evidence-based clinical guide-lines for the management of childrenwith meningitis should be developedto guide clinical decision-making bysafely reducing hospitalization andantibiotic use for children with viralmeningitis.

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BOUTIQUE WORMING: When I see the word “boutique,” I tend to think of a smallshop that sells fashionable (and usually expensive) clothes or jewelry. Rarely do Iassociate the word with the digestive powers of earthworms. However, I mayneed 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 liesin their ability to reduce an incredible array of rotting organicmaterial (includingmanure) into a wonder supplement for plants. The product of worm digestion,called vermicompost, helps plants mature faster and assists in preventinga variety of plant diseases. Vermicompost production most often begins withmounds of composted cow manure. This initial composting step generates heatthat 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 turnthe cow manure into a fine loose material that resembles peat moss and isteeming with valuable microorganisms. Scientists believe that the bacteria fromthe worms’digestive systems help generate nitrogen for the growing plants andprevent disease by other virulent organisms.Many growers swear by the product –which costs far more than usual soil additives. Vermicompost has a wide varietyof uses and can restore richness to soil depleted by synthetic fertilizers andpesticides. Interestingly, some plants seem to respond better to different types ofvermicompost. For example, some plants respond best to vermicompost madefrom dairy manure, while others respond better to vermicompost made fromfood waste or cardboard. Vermicompost made from cardboard seems particu-larly good for nut and stone fruit farmers and helps control nutgall, a fungaldisease that afflicts walnut trees. This has led to the development of “boutique”vermiculture producers that specialize in vermicompost for specific types ofplants 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 onlydo the worms help get rid of mounds of waste, but the end product of thebreakdown improves the environment.

Noted by WVR, MD

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DOI: 10.1542/peds.2012-3077; originally published online March 25, 2013; 2013;131;670Pediatrics

NeumanLise E. Nigrovic, Andrew M. Fine, Michael C. Monuteaux, Samir S. Shah and Mark I.

HospitalsTrends in the Management of Viral Meningitis at United States Children's

  

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