Clinical Prediction Rule for Identifying Children

Authors: Lise E Nigrovic Nathan Kuppermann Charles G Macias Christopher R Cannavino Donna M MoroSutherland 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 for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics

Publish Date: 2007/01/03

Volume: 297, Issue: 1, Pages: 52-60

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Abstract

CSFindicatescerebrospinalfluid Patientscouldbeexcludedformorethan1reason †ForlistofpredictorsseetheBox ‡ReferencestandardtestwasthedeterminationofeitherbacterialmeningitisorasepticmeningitisWedefinedachildashavingbacterialmeningitisiftherewasapositiveCSFcultureCSFpleocytosisinassociationwithapositivebloodcultureforabacterialpathogenorCSFpleocytosisinassociationwithapositiveCSFlatexagglutinationtestforabacterialpathogenWedefinedachildashavingasepticmeningitisiftherewasCSFpleocytosiswithnegativebacterialculturesofbloodandCSFandanegativeCSFlatexagglutinationtestifobtainedContext 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 presentationDesign 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 punctureResults Among 3295 patients with CSF pleocytosis 121 37 95 confidence interval CI 3144 had bacterial meningitis and 3174 963 95 CI 955969 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 983 95 CI 942998 negative predictive value 999 95 CI 996100 and both were younger than 2 months old A total of 2518 patients 80 with aseptic meningitis were hospitalizedConclusions 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 01 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 pleocytosisAlthough bacterial meningitis is the greatest concern when evaluating and treating children with cerebrospinal fluid CSF pleocytosis1 the majority of these children have aseptic rather than bacterial meningitis23 However because exclusion of bacterial meningitis requires negative CSF and blood cultures after 2 to 3 days of incubation45 most children with CSF pleocytosis are admitted to the hospital to receive broadspectrum antibiotics while awaiting culture test results With the widespread introduction of highly effective bacterial conjugate vaccines against Haemophilus influenzae type b67 and Streptococcus pneumoniae812 there has been a significant decrease in the incidence of bacterial meningitis in US children This has further reduced the probability that a child with CSF pleocytosis will have bacterial meningitis A highly accurate decision support tool that could identify which children with CSF pleocytosis had a nearzero risk of bacterial meningitis by using clinical and laboratory parameters readily available at the time of clinical presentation could guide decision making and limit unnecessary hospital admissions and prolonged antibiotic use

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