This tragic story appeared in USA Today on March 25, 2019 – Mom wants change after baby dies from meningitis. ‘We wanted to climb mountains with her’.
[Note to myself – Reread the entire article, I think that it has important information that physicians need to consider to try to prevent this sort of tragedy in the future.]
The patient’s mother took the newborn to the Salem Hospital Emergency Department.
Here are excerpts from the USA Today article:
In a matter of days, a mother watched her 7-week-old baby go from happy and alert to gravely sick with meningitis to dying in her arms.
Now she’s searching for answers, urging parents to trust their instincts and demanding changes at Salem Hospital’s emergency room in Oregon after discharging her sick daughter hours before her vital signs crashed.
Evi [the seven week old patient] came down with a fever the morning of March 15. She cried a weak, moaning cry — a cry McCall now knows is a telltale sign of Group B strep meningitis.
McCall said hospital staff told her Evi probably just had a routine infection.
But Evi’s wounded cry — “the worst sound you could imagine” — continued.
“I knew she was in real, terrible pain,” she said.
The emergency department discharged the 7 week old infant.
A few hours later, McCall drove her baby to her pediatrician. Still feverish, Evi threw-up in the exam room. Her doctor told her: Go to the emergency room. Now.
He called ahead to alert hospital staff.
“I figured the doctors would be able to fix it,” McCall said. “I remember thinking — we don’t live in the 1800s, surely someone will save my child.”
Once there, everything became a blur as hospital staff performed a spinal tap and tried to stabilize her daughter.
“It happened so fast. … All of the sudden, she was crashing and they didn’t take a moment to tell us what was happening. We were left in the dark.”
Evi was transported via ambulance to OHSU Doernbecher Children’s Hospital. Her condition deteriorated.
“They did their very best, but by the time she got there, it was just too late,” McCall said.
McCall said she was told Evi had late-onset Group B strep, which caused the meningitis. She wants parents to know the warning signs.
But the Salem Hospital is a large well respected institution in Salem, the capitol of Oregon.
According to the hospital’s website:
Salem Hospital is one of the largest of Oregon’s 62 acute care hospitals and operates the busiest emergency department in Oregon. It is a not-for-profit hospital, licensed for 454 acute-care beds.
The hospital is the Salem’s largest private employer, with approximately 4,700 employees. West Valley Hospital rounds out our numbers with an additional 190 employees.
There are about 820 providers on the active medical staff at Salem Health. In addition, more than 480 people provide nonmedical support as volunteers in both Salem and Dallas.
And so we can safely assume that the emergency department physician(s) who evaluated the newborn were all fully trained and credentialed emergency medicine specialists.
And yet the emergency specialist discharged this febrile 7 week old newborn.
So what happened?
The emergency physician who saw Evi perhaps applied the Rochester criteria [See Resource (1) below]. There is no way, based on the information in the news article, to know the emergency physician’s clinical reasoning. Perhaps the patient had compensated shock that was unrecognized. Perhaps it was something else. Based on the article, we can’t know.
Please see The Many Faces of Late Onset Group B Streptococcus Infection, J Pediatric Infect Dis. 2016, 1:2. doi: 10.21767/2573-0282.100014. [Please note that I accessed this article on Pediatric Infectious Diseases: Open Access which is an outstanding resource.]
What follows are excerpts from the above article:
Abstract
Overall early onset Group B Streptococcus (GBS) infection in the United States has decreased because of preventive protocols. However, late onset GBS remains fairly common disease and can be difficult to diagnose. This paper displays the wide range of presentations of late onset GBS and the possible dire ramifications of the disease.
Introduction
Group B streptococcus (Streptococcus agalactiae; GBS) disease continues to be a tremendous burden to high-income countries. Particularly worrisome is GBS sepsis, which is divided into three categories. Early onset disease caused by GBS (EOD-GBS) occurs during days 1-6 postpartum, late onset disease (LOD-GBS) occurs on days 7-89 postpartum and very-late-onset disease occurs beyond 3 months of life [1,2]. While great strides have been made in the prevention EOD-GBS resulting in significantly decreased rates, LOD has not benefited much from the prevention protocols for EOD-GBS. LOD-GBS rates remain at 0.3 to 0.4 per 1000 live births since 1990 despite changes in intrapartum antibiotic prophylaxis and decreases in early onset disease [3-5]. The lack of progress in the prevention of LOD-GBS is complicated by lack of certainty for not only the acquisition of LOD-GBS, but also the risk factors which predispose infants to LOD-GBS. This lack of progress is troubling, especially with the potential severity of the disease. In infants less than two months of age, GBS was found to be the culprit in 86.1% of all bacterial meningitis cases and up to 27% of LOD GBS sepsis cases have associated meningitis [2,4]. We report another intricacy in the problem: the wide range in presentation within the spectrum of LOD-GBS. All of these factors play a significant role in the diagnostic challenge presented by GBS disease.
Discussion
The three cases of late onset GBS diseases reported here illustrate the vast differences in presentation and severity of GBS sepsis. The first case shows the best-case scenario for a GBS sepsis with a good outcome, while the third case shows an uncommon presentation of late onset GBS with osteomyelitis. Not only does osteomyelitis affect roughly only 0.2-1.6 out of 1,000 children annually, but Group B streptococcus is the but the third most prevalent bacteria found on culture in osteo-articular infections [6]. Our second case in particular shows a potential devastating outcome of late onset GBS disease.
GBS meningitis, a common complication of GBS sepsis, has a mortality rate described as high as 10% and permanent neurologic sequelae result in up to 25-35% of the meningitis survivors [7]. Research has shown that this seems to be partially due to hypervirulence which has been associated with certain strains of GBS, including ones exhibiting ST-17 which is associated with causing meningitis, and HvgA, which seems to allow for greater migration across the intestinal barrier and the blood brain barrier [8]. Various new ideas of transmission and prevention are currently being investigated. There has been an identification of breast milk possibly being a risk factor for transmission of the disease [9]. While not perfect, tremendous advances have been made in the prevention of early onset GBS disease, with testing and prophylaxis, but the impact of this on late onset GBS disease if any has been very modest [10]. The ultimate prevention strategy for late onset GBS disease, and indeed early onset GBS disease, lies in the availability of an effective vaccine. While no GBS vaccine is currently available, attempts are being made to develop one. A GBS vaccine has been estimated to prevent over 85% of global group B streptococcus disease in infants younger than 3 months, affecting both early onset and LOD [11]. However, while the understanding of the transmission of late onset GBS is still being researched and the vaccine is currently in development, it is important for clinicians to be aware of the many different presentations of late onset GBS sepsis and the vastly different possible outcomes, dependent on proper identification and treatment. For the three cases reported here and despite the very different presentations, it is reassuring that two infants who were febrile would have been admitted by use of the Rochester Criteria for not being categorized as low risk infants, while the third case was admitted for concern of complications resulting from the infectious process and necessity of imaging. This also underscores the importance of good clinical evaluation.
Conclusion
As illustrated by these cases, late onset group B Streptococcal infection remains a serious disease that can present in many different ways and deserves aggressive management.
Resources
(1) Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis [PubMed Abstract].
Abstract
OBJECTIVES:
The Rochester criteria were developed to identify febrile infants aged 60 days or younger at low-risk of bacterial infection and do not include cerebrospinal fluid (CSF) testing. Prior studies have not specifically assessed criteria performance for bacteremia and bacterial meningitis (invasive bacterial infection). Our objective was to determine the sensitivity of the Rochester criteria for detection of invasive bacterial infection.
METHODS:
Retrospective cohort study of febrile infants aged 60 days or younger with invasive bacterial infections evaluated at 8 pediatric emergency departments from July 1, 2012, to June 30, 2014. Potential cases were identified from the Pediatric Health Information System using International Classification of Diseases, Ninth Revision diagnosis codes for bacteremia, meningitis, urinary tract infection, and fever. Medical record review was then performed to confirm presence of an invasive bacterial infection and to evaluate the Rochester criteria: medical history, symptoms or ill appearance, results of urinalysis, complete blood count, CSF testing (if obtained), and blood, urine, and CSF culture. An invasive bacterial infection was defined as growth of pathogenic bacteria from blood or CSF culture.
RESULTS:
Among 82 febrile infants aged 60 days or younger with invasive bacterial infection, the sensitivity of the Rochester criteria were 92.7% (95% confidence interval [CI], 84.9%-96.6%) overall, 91.7% (95% CI, 80.5%-96.7%) for neonates 28 days or younger, and 94.1% (95% CI, 80.9%-98.4%) for infants aged 29 to 60 days old. Six infants with bacteremia, including 1 neonate with bacterial meningitis, met low-risk criteria.
CONCLUSIONS:
The Rochester criteria identified 92% of infants aged 60 days or younger with invasive bacterial infection. However, 1 neonate 28 days or younger with meningitis was classified as low-risk.
