Trends in the Management of Viral Meningitis at United
States Children’s Hospitals
WHAT’S KNOWN ON THIS SUBJECT: In the era of widespread
conjugate vaccine use, the prevalence of bacterial meningitis has
declined. However, the impact of this decline on the rate of
emergency department visits for viral meningitis and cost of
caring for these children is unknown.
WHAT THIS STUDY ADDS: There was a decline in the rate of
diagnosis of viral meningitis in US children’s hospitals between
2005 and 2011. Most children diagnosed with viral meningitis are
treated with antibiotics and are hospitalized, accounting for
considerable health care costs.
abstract
OBJECTIVE: To determine trends in the diagnosis and management of
children 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 Health
Information System between January 1, 2005, and December 31,
2011. A case of viral meningitis was defined by International
Classification of Diseases, Ninth Revision, discharge diagnosis, and
required performance of a lumbar puncture. We examined trends in
diagnosis, antibiotic use, and resource utilization for children with viral
meningitis over the study period.
RESULTS: We identified 7618 children with viral meningitis (0.05% of ED
visits during the study period). Fifty-two percent of patients were ,1
year of age, and 43% were female. The absolute number and the
proportion of ED visits for children with viral meningitis declined from
0.98 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 for
children with viral meningitis remain substantial (median cost per
case $5056, interquartile range $3572–$7141).
CONCLUSIONS: Between 2005 and 2011, viral meningitis diagnoses at
US children’s hospitals declined. However, most of these children are
hospitalized, and the cost for caring for these children remains con-
siderable. Pediatrics 2013;131:670–676
670 NIGROVIC et al
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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 and
Infectious Diseases, Cincinnati Children’s Hospital Medical Center,
University of Cincinnati, Cincinnati, Ohio
KEY WORDS
viral meningitis, lumbar puncture, resource utilization
ABBREVIATIONS
CSF—cerebrospinal fluid
ED—emergency department
ICD-9—International Classification of Disease, Ninth Revision
IQR—interquartile range
LP—lumbar puncture
PHIS—Pediatric Health Information System
Dr Nigrovic conceived and designed the study, interpreted the
data, and drafted the manuscript; Drs Fine, Shah, and Neuman
conceived and designed the study, interpreted the data, and
critically reviewed the manuscript; and Dr Monuteaux acquired
data, conducted the data analysis, interpreted the data, and
critically 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 of
Emergency Medicine, Boston Children’s Hospital, 300 Longwood
Ave, 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 have
no financial relationships relevant to this article to disclose.
FUNDING: No external funding.

In the era of widespread conjugate
vaccines, most children with meningitis
have a viral rather than a bacterial
infection.1–3 Although children with
bacterial meningitis require prompt
initiation of parenteral antibiotics and
hospitalization, those with viral men-
ingitis, a self-limited condition, require
only supportive care. Until recently,
a reliable and accurate method to
distinguish children with viral from
bacterial meningitis based on clinical
and laboratory predictors available
at presentation was not available. The
Bacterial Meningitis Score, a vali-
dated clinical prediction rule, accu-
rately identifies children at low risk
for bacterial meningitis.4,5 However,
the impact of this clinical decision-
making tool on the diagnosis and
management of children with viral
meningitis in the setting of a sub-
stantial decline in the prevalence of
bacterial meningitis2 has not been
evaluated.
Patients with viral meningitis are
commonly hospitalized to receive an-
timicrobial therapy while awaiting
results of bacterial cultures.5,6 How-
ever, recent information regarding
rates of hospitalization for children
with viral meningitis are limited. Al-
though the number of emergency
department (ED) visits for mening-
itis in children and adults combined
remained stable over the past de-
cade,7 the rate of hospitalizations for
pneumococcal meningitis decreased
substantially.8
We sought to determine whether the
rate of diagnosis and management
of children with viral meningitis at
children’s hospitals has changed in
recent years. We examined patients
presenting to the ED of a Pediatric
Health Information System (PHIS)
participating children’s hospital be-
tween 2005 and 2011 to examine
trends in diagnosis and management
of viral meningitis.
PEDIATRICS Volume 131, Number 4, April 2013
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METHODS
Setting
Data for this study were obtained
from PHIS, an administrative database
that contains inpatient, ED, ambulatory
surgery, and observation data from
tertiary care pediatric hospitals in the
United States. These hospitals are af-
filiated with the Children’s Hospital
Association (Overland Park, KS). The
data warehouse function for the PHIS
database is managed by Truven Health
Analytics (Ann Arbor, MI). For the pur-
poses of external benchmarking, par-
ticipating hospitals provide discharge/
encounter data including demographics,
diagnoses, and procedures as well as
resource utilization data (eg, pharma-
ceuticals, imaging, laboratory). Data are
deidentified at the time of submission
and are subjected to a number of re-
liability and validity checks before being
included in the database. We excluded 2
PHIS hospitals due to incomplete ED visit
data. For this study, the number of hos-
pitals contributing complete ED data in-
creased from 37 to 41 over the study
period. This study was approved by the
Institutional Review Board at Boston
Children’s Hospital.
Study Population
Children ,18 years of age who pre-
sented to the pediatric ED of a partici-
pating PHIS institution between January
1, 2005, and December 31, 2011, with
viral meningitis were eligible for in-
clusion. Using a previously reported
classification scheme, children were
excluded if they were transferred to the
receiving institution, had a chronic
comorbid 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
ARTICLE
International Classification of Diseases,
Ninth Revision (ICD-9) discharge di-
agnosis codes: meningitis due to Cox-
sackie viruses (047.0), meningitis due to
echoviruses (047.1), meningitis due to
other 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 by
previous investigators, although we
chose to not include herpes infections in
our case definition.6 Among a subset of
patients with suspected viral meningitis,
we considered a patient to have viral
meningitis if he or she had 1 of the 6 ICD-9
diagnosis codes and also had a lumbar
puncture (LP) performed. We defined
an LP by the presence of either an LP
procedure code or a billing code for
a CSF culture on the day of hospital
presentation.
Measured Exposures and
Outcomes
We evaluated diagnostic testing, re-
source utilization, and costs for children
with viral meningitis. Diagnostic and
laboratory testing were identified by
using clinical tabular codes. We identi-
fied the performance of an LP using
these codes and medication delivery
using the National Drug Code Directory.10
We evaluated admission rate and hos-
pital length of stay for children who
were hospitalized. The admission rate
included inpatient hospitalization or
admission to “observation status” to
account for the variable use of obser-
vation status, “virtual” inpatient admis-
sion, and availability of inpatient beds
among institutions.11,12 For patients
discharged from the ED with viral
meningitis, we identified all return visits
to the ED within 3 days of index visit, as
well as return visits resulting in ad-
mission.
Costs were based on the ratio of cost-to-
charges submitted by the hospitals on
their respective Medicare cost reports
671
and were adjusted by the Centers for
Medicare and Medicaid price/wage
index. We further adjusted all patient
costs to 2011 dollars by using the an-
nual Consumer Price Index inflation
rate for the “Hospital and related serv-
ices” expenditure category as published
by the US Department of Labor.
Statistical Analysis
We summarized demographic charac-
teristics among patients with “sus-
pected” viral meningitis and the subset
meeting our case definition of viral
meningitis. We then stratified our case
series by age and compared the
resulting groups on clinical manage-
ment and outcome factors using a se-
ries of logistic regression models. To
test for changes over time in the rates
of viral meningitis cases, we conducted
a test for trend using a logistic re-
gression with case status as the de-
pendent variable and time in calendar
year as the independent variable. To
test for changes over time in patient
costs, we conducted a test for trend
using a Poisson regression model.
Given that our data were taken from
several hospitals, the assumption of
independent observations may not
hold. To accommodate these data, our
regression models used clustered
sandwich standard error estimates,
which allow for intrahospital correla-
tion, relaxing the assumption that
observations from the same hospital
are independent.
Because the decision to hospitalize
a child with viral meningitis might
be balanced against return visits,
we tested the correlation between
hospital-specific rate of admission and
72-hour return ED visit rate resulting in
admission. Using the Spearman’s corre-
lation coefficient, we measured the
hospital-specific correlation between
initial admission rate and the rate of
return visits to the ED resulting in ad-
mission within 3 days weighted by the
672 NIGROVIC et al
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hospital-specific number of meningitis presented in Table 1. A greater pro-
visits. portion of children with viral meningi-
All analyses were performed by using tis than suspected viral meningitis
Stata 12.1 (College Station, TX). All sta- were ,1 year of age, implying that
tistical tests were 2-tailed, and a was younger children were more likely to
set at .05. have an LP performed for suspected
viral meningitis. A similar proportion
of children with suspected viral men-
RESULTS ingitis and viral meningitis presented
Over the study period, 15 293 012 chil- during the peak enteroviral season
dren were seen in the EDs of the 41 (June 1 through October 31).
participating study institutions. After Clinical management differed by pa-
applying the exclusion criteria, we tient age (Table 2). Of the children #60
identified 130 334 children (0.85% of all days of age, the most common ED ad-
ED visits) who had an LP performed. Of mitting diagnosis was fever (22%) fol-
these, we identified 10 329 visits for lowed by unspecified viral meningitis
suspected viral meningitis (0.07% of ED (17%). Of the children .60 days of age,
visits) and 7618 with viral meningitis the most common ED admitting was
(0.05% of ED visits). The median pro- unspecified viral meningitis (29%) fol-
portion of visits for viral meningitis lowed by headache (19%). Older chil-
among all ED visits across the partici- dren with viral meningitis had a lower
pating institutions was 0.05% (range admission rate (82% for children $3
0.01%–0.57%), and the median hospital years of age vs 99% for children ,3
admission rate was 94% (range 64%– years, P , .001) as well as shorter
100%). Institutions with lower admission length of stay (median 2 days inter-
rates for children with viral meningitis quartile range [IQR] 1–3 days for chil-
did not have higher rates of ED return dren $3 years of age vs median 2 days
visits within 3 days resulting in ad- IQR 2–3 days for children ,3 years of
mission (P = .10). age, P = .01). Older children were more
The demographic characteristics of likely to have a cranial CT performed as
patients with suspected viral meningi- part of their diagnostic evaluation
tis and those with viral meningitis are (43% for children $3 years vs 9% for
TABLE 1 Demographic Characteristics of Patients With Suspected Viral Meningitis Presenting to
the 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 region
Northeast 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 payer
Private 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.
 ARTICLE

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.

PEDIATRICS Volume 131, Number 4, April 2013 673

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total costs for children ,3 years of age
were higher than those $3 years of
age (median of $5429, IQR $4050–$7377
for ,3 years of age vs $4536, IQR
$2748–$6771 for .3 years, P = .03).
DISCUSSION
We observed that the absolute rates and
relative proportions of children with
viral meningitis presenting to an ED
decreased from 2005 to 2011. Despite
the benign nature of the condition,
nearly all children treated at US child-
ren’s hospitals for viral meningitis
were hospitalized. Institutions with
lower hospitalization rates for viral
meningitis did not have higher rates of
ED revisits within 3 days resulting in
admission. Most children with viral
meningitis received parenteral anti-
biotics, including almost all children
,3 years of age. The costs of caring for
children with viral meningitis are high,
reflecting the high resource utilization
and hospitalization rate associated
with this condition.
Similar to previous work, we found that
viral meningitis was a common reason
for hospitalization with the highest
burden in the youngest children. In an
inpatient sample of .1000 acute care
hospitals in the United States, ∼40 000
patients were hospitalized for viral
meningitis in 2005.6 In a recent ED
study, meningitis was more commonly
diagnosed in children, especially those
aged #3 years.7 We found that the
majority of cases occurred in children
aged ,3 years with a substantial por-
tion within the first 2 months of life.
Our findings differ somewhat from
previous studies. First, we documented
a substantial decline in the number and
proportion of pediatric ED patients di-
agnosed with viral meningitis between
2005 and 2011. In a study using a na-
tional representative sample of ED visits,
the estimates of the rates of bacterial
and viral meningitis were based on
a small number of observations (only
674 NIGROVIC et al
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103 actual pediatric ED visits for men-
ingitis over the 15-year study period).7
In a second study of hospitalizations for
meningitis, the median length of hos-
pital stay for admitted patients was 2
days, similar to a previous Canadian
study of aseptic meningitis in chil-
dren.14 However, our observed length
of hospital stay was considerably
shorter than the 4.1 days observed in
the study of hospitalized patients with
meningitis.6 This difference may be at-
tributed to the fact that the latter study
included patients of all ages, and hos-
pital stays for adults were considerably
longer.
In the era of widespread conjugate
vaccines, most children with meningitis
have viral rather than bacterial
infections.2,5 The current availability
of the new 13-valent Streptococcus
pneumoniae and 4-valent Neisseria
meningitidis conjugate vaccines in the
developed world will further decrease
the incidence of childhood bacterial
meningitis. Although children with
bacterial meningitis require prompt
initiation of parenteral antibiotics, most
children with viral meningitis require
only supportive care.14 Because bac-
terial cultures take several days to
exclude bacterial growth reliably, cli-
nicians must make management deci-
sions before definitive test results are
available.15,16 Meningitis clinical pre-
diction rules combine readily available
clinical and laboratory factors to esti-
mate the risk of bacterial meningitis.
One model, the Bacterial Meningitis
Score, has been validated in 8 published
studies and performs with a high de-
gree of diagnostic accuracy in a wide
variety of clinical settings.17 We would
expect that an application of a clinical
decision rule would reduce the rate of
hospitalization and antibiotic use for
children determined to be at low risk of
bacterial meningitis. Additionally, avail-
able polymerase chain reaction tests
may rapidly identify enteroviruses, the
most common viral cause of meningi-
tis.18–20 Children with a positive entero-
viral polymerase chain reaction test are
at low risk of bacterial meningitis21 and
could be safely managed as outpatients.
In our study population, overall .90%
of the children diagnosed with viral
meningitis were hospitalized with
some variability across study sites. Al-
though some children may require
hospitalization for hydration, pain con-
trol, or to ensure adequate follow-up,
most children at low risk for bacterial
meningitis can be appropriately man-
aged as outpatients.5 Administration of
a single dose of a long-acting parenteral
antibiotic such as ceftriaxone can pro-
vide coverage in the unlikely case of
bacterial infection. The absence of na-
tional evidence-based guidelines for the
management of children with meningitis
may have led to overhospitalization of
children at low risk of bacterial menin-
gitis. Even modest reductions in hospi-
talization would substantially reduce the
costs to care for these children. Impor-
tantly, the measured costs of inpatient
care do not completely capture the un-
intended consequences for the patient
(eg, nosocomial infections or adverse
events) and for their caretakers (eg,
missed workdays).
We were surprised to observe the
substantial decline in the number and
the proportion of patients with viral
meningitis over the 7-year study period.
Although conjugated vaccines have
dramatically reduced the prevalence of
bacterial meningitis, we would pre-
sume that the rates of viral meningitis
would not have been affected. We ob-
served a decline in the number of LPs
performed, consistent with a previ-
ously observed long-term secular
trend in the number of LPs performed
in the ED setting.22 However, the decline
in viral meningitis cases cannot be
explained solely by the decrease in the
number of LPs performed because the
proportion of children who had an LP

performed and were diagnosed with
viral meningitis also declined. We hy-
pothesize that this reflects changes in
referral patterns as well as discharge
diagnosis coding. Pediatricians and
community hospitals may now feel
more comfortable managing children
with suspected viral meningitis and
may refer fewer of these children to
pediatric centers for evaluation. Addi-
tionally visits for suspected meningitis
may be coded as viral illness rather
than meningitis, particularly when the
LP is not performed.
Our study has the following limitations.
First, because we were limited to ED
visits to children’s hospitals included in
the PHIS database, we are unable to
make population based estimates
about the overall burden of viral men-
ingitis in children. However, our direct
rather than proportional sampling
allowed us to make more precise con-
clusions about the care each child re-
ceived. Second, we selected a specific
viral meningitis case definition that
required both a discharge diagnosis
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code and either an LP procedure code
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were pretreated with antibiotics, which
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bacterial cultures may be falsely neg-
ative and CSF profiles affected.23,24
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to PHIS hospitals. However, we believe
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up care occurred at the institution
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formed. Last, we were unable to de-
termine the reason some children with
viral meningitis were hospitalized;
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ARTICLE
required interventions such as in-
travenous hydration or pain control.
Future studies should investigate pa-
tient management decisions to inform
the development of effective clinical
practice guidelines for children with
viral meningitis.
CONCLUSIONS
Bacterial meningitis has become a
rare disease, especially for pediatric
patients.2 Over the 7-year study period,
the number and the proportion of
children diagnosed with viral menin-
gitis and suspected viral meningitis at
US children’s hospitals has declined.
However, admission rates, antibiotic
use, and costs for caring for children
diagnosed with viral meningitis remain
high. Evidence-based clinical guide-
lines for the management of children
with meningitis should be developed
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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

676 NIGROVIC et al
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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:
Services http://pediatrics.aappublications.org/content/131/4/670
References This article cites 21 articles, 7 of which you can access for free at:
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following collection(s):
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diseases_sub
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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: .

Downloaded from http://pediatrics.aappublications.org/ by guest on November 15, 2017

 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;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/131/4/670

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: .

Downloaded from http://pediatrics.aappublications.org/ by guest on November 15, 2017