Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
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.
Nigrovic
Lise E
LE
Department of Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Mass 02115, USA. lise.nigrovic@childrens.harvard.edu
Kuppermann
Nathan
N
Macias
Charles G
CG
Cannavino
Christopher R
CR
Moro-Sutherland
Donna M
DM
Schremmer
Robert D
RD
Schwab
Sandra H
SH
Agrawal
Dewesh
D
Mansour
Karim M
KM
Bennett
Jonathan E
JE
Katsogridakis
Yiannis L
YL
Mohseni
Michael M
MM
Bulloch
Blake
B
Steele
Dale W
DW
Kaplan
Ron L
RL
Herman
Martin I
MI
Bandyopadhyay
Subhankar
S
Dayan
Peter
P
Truong
Uyen T
UT
Wang
Vincent J
VJ
Bonsu
Bema K
BK
Chapman
Jennifer L
JL
Kanegaye
John T
JT
Malley
Richard
R
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
D022242:Pneumococcal Vaccines