title: Performance of thirteen clinical rules to distinguish bacterial and presumed viral meningitis in Vietnamese children.
abstract: OBJECTIVE
  Successful outcomes from bacterial meningitis require rapid antibiotic treatment; however, unnecessary treatment of viral meningitis may lead to increased toxicities and expense. Thus, improved diagnostics are required to maximize treatment and minimize side effects and cost. Thirteen clinical decision rules have been reported to identify bacterial from viral meningitis. However, few rules have been tested and compared in a single study, while several rules are yet to be tested by independent researchers or in pediatric populations. Thus, simultaneous test and comparison of these rules are required to enable clinicians to select an optimal diagnostic rule for bacterial meningitis in settings and populations similar to ours.
  
  
  METHODS
  A retrospective cross-sectional study was conducted at the Infectious Department of Pediatric Hospital Number 1, Ho Chi Minh City, Vietnam. The performance of the clinical rules was evaluated by area under a receiver operating characteristic curve (ROC-AUC) using the method of DeLong and McNemar test for specificity comparison.
  
  
  RESULTS
  Our study included 129 patients, of whom 80 had bacterial meningitis and 49 had presumed viral meningitis. Spanos's rule had the highest AUC at 0.938 but was not significantly greater than other rules. No rule provided 100% sensitivity with a specificity higher than 50%. Based on our calculation of theoretical sensitivity and specificity, we suggest that a perfect rule requires at least four independent variables that posses both sensitivity and specificity higher than 85-90%.
  
  
  CONCLUSIONS
  No clinical decision rules provided an acceptable specificity (>50%) with 100% sensitivity when applying our data set in children. More studies in Vietnam and developing countries are required to develop and/or validate clinical rules and more very good biomarkers are required to develop such a perfect rule.
authors.affiliation: Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki City, Japan.
authors.forename: Nguyen Tien
authors.initials: NT
authors.lastname: Huy
authors.forename: Nguyen Thanh Hong
authors.initials: NT
authors.lastname: Thao
authors.forename: Nguyen Anh
authors.initials: NA
authors.lastname: Tuan
authors.forename: Nguyen Tuan
authors.initials: NT
authors.lastname: Khiem
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Moore
authors.forename: Doan
authors.initials: D
authors.lastname: Thi Ngoc Diep
authors.forename: Kenji
authors.initials: K
authors.lastname: Hirayama
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019540:Area Under Curve; D015415:Biomarkers / Q000378:metabolism; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D020000:Decision Support Systems, Clinical; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D055552:Infectious Disease Medicine / Q000379:methods / Q000592:standards; D008297:Male; D016920:Meningitis, Bacterial / Q000175:diagnosis*; D008587:Meningitis, Viral / Q000175:diagnosis*; D010372:Pediatrics / Q000379:methods / Q000592:standards; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014744:Vietnam
chemical_list: D000900:Anti-Bacterial Agents; D015415:Biomarkers