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To the Editor: Dr Nigrovic and colleagues¹ studied the validation of a clinical prediction rule to identify children with cerebrospinal fluid (CSF) pleocytosis who are at low risk of having bacterial meningitis. I have a number of concerns about their conclusions.

First, 342 patients (10% of the study cohort) did not have blood cultures drawn but had examination of the CSF. Of these, only 3 patients had a positive CSF culture and therefore, by definition, meningitis. CSF pleocytosis with clinical improvement after less than 7 days of empirical antibiotic treatment does not exclude bacterial meningitis, even with a negative CSF culture.^2-3 Clinical response is unlikely to be that rapid for pneumococcal meningitis.⁴ However, other forms of bacterial meningitis, such as Neisseria meningitidis, the second most common etiologic agent in their study, may be rapidly responsive to antibiotic treatment.^2-4 Thus, in the absence of a blood culture it is possible . . . [Full Text of this Article]

Stephen Obaro, MD, PhD
stephen.obaro@chp.edu
Department of Pediatrics
Children's Hospital of Pittsburgh
Pittsburgh, Pa

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RELATED LETTER

Prediction Rule for Bacterial Meningitis in Children—Reply
Lise E. Nigrovic, Nathan Kuppermann, and Richard Malley
JAMA. 2007;297(15):1654-1655.
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RELATED ARTICLE

Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis
Lise E. Nigrovic, Nathan Kuppermann, Charles G. Macias, Christopher R. Cannavino, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vincent J. Wang, Bema K. Bonsu, Jennifer L. Chapman, John T. Kanegaye, Richard Malley, and for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics
JAMA. 2007;297(1):52-60.
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