title: Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
abstract: BACKGROUND
  Children with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/microL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10,000 cells/microL, and a history of seizure before or at the time of presentation.
  
  
  OBJECTIVE
  To validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination.
  
  
  METHODS
  A multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture.
  
  
  METHODS
  The sensitivity and negative predictive value of the Bacterial Meningitis Score.
  
  
  RESULTS
  Among 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized.
  
  
  CONCLUSIONS
  This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.
authors.affiliation: Department of Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Mass 02115, USA. lise.nigrovic@childrens.harvard.edu
authors.forename: Lise E
authors.initials: LE
authors.lastname: Nigrovic
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
authors.forename: Charles G
authors.initials: CG
authors.lastname: Macias
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Cannavino
authors.forename: Donna M
authors.initials: DM
authors.lastname: Moro-Sutherland
authors.forename: Robert D
authors.initials: RD
authors.lastname: Schremmer
authors.forename: Sandra H
authors.initials: SH
authors.lastname: Schwab
authors.forename: Dewesh
authors.initials: D
authors.lastname: Agrawal
authors.forename: Karim M
authors.initials: KM
authors.lastname: Mansour
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Bennett
authors.forename: Yiannis L
authors.initials: YL
authors.lastname: Katsogridakis
authors.forename: Michael M
authors.initials: MM
authors.lastname: Mohseni
authors.forename: Blake
authors.initials: B
authors.lastname: Bulloch
authors.forename: Dale W
authors.initials: DW
authors.lastname: Steele
authors.forename: Ron L
authors.initials: RL
authors.lastname: Kaplan
authors.forename: Martin I
authors.initials: MI
authors.lastname: Herman
authors.forename: Subhankar
authors.initials: S
authors.lastname: Bandyopadhyay
authors.forename: Peter
authors.initials: P
authors.lastname: Dayan
authors.forename: Uyen T
authors.initials: UT
authors.lastname: Truong
authors.forename: Vincent J
authors.initials: VJ
authors.lastname: Wang
authors.forename: Bema K
authors.initials: BK
authors.lastname: Bonsu
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Chapman
authors.forename: John T
authors.initials: JT
authors.lastname: Kanegaye
authors.forename: Richard
authors.initials: R
authors.lastname: Malley
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007964:Leukocytosis / Q000134:cerebrospinal fluid*; D008297:Male; D008582:Meningitis, Aseptic / Q000453:epidemiology; D016920:Meningitis, Bacterial / Q000175:diagnosis* / Q000453:epidemiology; D022242:Pneumococcal Vaccines; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity
chemical_list: D022242:Pneumococcal Vaccines