 |
|
Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis
Lise E. Nigrovic, MD, MPH;
Nathan Kuppermann, MD, MPH;
Charles G. Macias, MD, MPH;
Christopher R. Cannavino, MD;
Donna M. Moro-Sutherland, MD;
Robert D. Schremmer, MD;
Sandra H. Schwab, MD;
Dewesh Agrawal, MD;
Karim M. Mansour, MD;
Jonathan E. Bennett, MD;
Yiannis L. Katsogridakis, MD, MPH;
Michael M. Mohseni, MD;
Blake Bulloch, MD;
Dale W. Steele, MD;
Ron L. Kaplan, MD;
Martin I. Herman, MD;
Subhankar Bandyopadhyay, MD;
Peter Dayan, MD, MSc;
Uyen T. Truong, MD;
Vincent J. Wang, MD;
Bema K. Bonsu, MD;
Jennifer L. Chapman, MD;
John T. Kanegaye, MD;
Richard Malley, MD; for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics
JAMA. 2007;297:52-60.
Context 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/µL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10 000 cells/µL, 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.
Design, Setting, and Patients 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  10 cells/µL) and who had not received antibiotic treatment before lumbar puncture.
Main Outcome Measure 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.
Author Affiliations: Department of Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Mass (Drs Nigrovic and Malley); Departments of Emergency Medicine (Dr Kuppermann) and Pediatrics (Drs Kuppermann and Truong), University of California, Davis Medical Center, Sacramento, and University of California, Davis School of Medicine, Davis; Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston (Dr Macias); Department of Emergency Medicine, Rady Children's Hospital San Diego Medical Center (Dr Kanegaye) and Department of Pediatrics, University of California, San Diego School of Medicine, San Diego (Drs Cannavino and Kanegaye); Wake Emergency Physicians, PA and WakeMed Health and Hospitals, Raleigh, NC (Dr Moro-Sutherland); Department of Pediatrics, Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City (Dr Schremmer); Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia (Dr Schwab); Department of Emergency Medicine, Children's National Medical Center and George Washington University School of Medicine, Washington, DC (Dr Agrawal); Department of Emergency Medicine, Children's Hospital and Research Center Oakland, Oakland, Calif (Dr Mansour); Department of Pediatrics, Alfred I. duPont Hospital for Children and Thomas Jefferson Medical College, Wilmington, Del (Dr Bennett); Department of Pediatrics, Children's Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, Ill (Dr Katsogridakis); Department of Emergency Medicine, Children's Medical Center and Medical College of Georgia, Augusta (Dr Mohseni); Department of Emergency Medicine, Phoenix Children's Hospital and University of Arizona College of Medicine, Phoenix (Dr Bulloch); Departments of Emergency Medicine and Pediatrics, Hasbro Children's Hospital and Brown Medical School, Providence, RI (Dr Steele); Department of Emergency Medicine, Children's Hospital and Regional Medical Center, and University of Washington School of Medicine, Seattle (Dr Kaplan); Department of Pediatrics, Le Bonheur Children's Medical Center and University of Tennessee Health Science Center, College of Medicine, Memphis (Dr Herman); Department of Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, and Pediatric Emergency Medicine Associates LLC, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Ga (Dr Bandyopadhyay); Department of Emergency Medicine, Morgan Stanley Children's Hospital of New York-Presbyterian and Columbia University College of Physicians and Surgeons, New York, NY (Dr Dayan); Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles (Dr Wang); and Department of Emergency Medicine, Columbus Children's Hospital and The Ohio State University, Columbus (Drs Bonsu and Chapman).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
RELATED LETTERS
Prediction Rule for Bacterial Meningitis in Children
Stephen Obaro
JAMA. 2007;297(15):1653-1654.
EXTRACT
| FULL TEXT
Prediction Rule for Bacterial Meningitis in Children—Reply
Lise E. Nigrovic, Nathan Kuppermann, and Richard Malley
JAMA. 2007;297(15):1654-1655.
EXTRACT
| FULL TEXT
RELATED ARTICLE
Meningitis
Janet M. Torpy, Cassio Lynm, and Richard M. Glass
JAMA. 2007;297(1):122.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Diagnostic Value of Immature Neutrophils (Bands) in the Cerebrospinal Fluid of Children With Cerebrospinal Fluid Pleocytosis
Kanegaye et al.
Pediatrics 2009;123:e967-e971.
ABSTRACT
| FULL TEXT
Clinical Prediction Rules for Meningitis in Children Pretreated With Antibiotics
Devlin and Devlin
Pediatrics 2009;123:e365-e366.
FULL TEXT
Clinical Prediction Rules for Meningitis in Children Pretreated With Antibiotics: In Reply
Nigrovic et al.
Pediatrics 2009;123:e366-e367.
FULL TEXT
Utility of Lumbar Puncture for First Simple Febrile Seizure Among Children 6 to 18 Months of Age
Kimia et al.
Pediatrics 2009;123:6-12.
ABSTRACT
| FULL TEXT
Serum Procalcitonin Level and Other Biological Markers to Distinguish Between Bacterial and Aseptic Meningitis in Children: A European Multicenter Case Cohort Study
Dubos et al.
Arch Pediatr Adolesc Med 2008;162:1157-1163.
ABSTRACT
| FULL TEXT
Meningitis
Mann and Jackson
Pediatr. Rev. 2008;29:417-430.
FULL TEXT
Clinical Predictors of Lyme Disease Among Children With a Peripheral Facial Palsy at an Emergency Department in a Lyme Disease-Endemic Area
Nigrovic et al.
Pediatrics 2008;122:e1080-e1085.
ABSTRACT
| FULL TEXT
Features of Neonatal Herpes Simplex Virus Infection
Pate
AAP Grand Rounds 2008;20:40-40.
FULL TEXT
Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis
Nigrovic et al.
Pediatrics 2008;122:726-730.
ABSTRACT
| FULL TEXT
Other articles noted
Evid. Based Med. 2007;12:127-128.
FULL TEXT
Prediction Rule for Bacterial Meningitis in Children
Obaro
JAMA 2007;297:1653-1654.
FULL TEXT
Ruling Out Bacterial Meningitis in Patients with CSF Pleocytosis
JWatch Emergency Med. 2007;2007:1-1.
FULL TEXT
5 Findings Help Predict Low Risk for Bacterial Meningitis
Rathore
AAP Grand Rounds 2007;17:25-26.
FULL TEXT
Predicting When Meningitis Is Bacterial
JWatch Pediatrics 2007;2007:3-3.
FULL TEXT
Predicting Bacterial Meningitis in Children
JWatch General 2007;2007:4-4.
FULL TEXT
Predicting Whether Meningitis Is Bacterial
JWatch Infect. Diseases 2007;2007:6-6.
FULL TEXT
|
