ABSTRACT
BACKGROUND: Clinical decision rules (CDRs) could be helpful to safely distinguish between bacterial and aseptic meningitis (AM). OBJECTIVE: To compare the performance of two of these CDRs for children: the Bacterial Meningitis Score (BMS) and the Meningitest. DESIGN: Secondary analysis of retrospective multicentre hospital-based cohort study. SETTING: Six paediatric emergency or intensive care units of tertiary care centres in five European countries. PATIENTS: Consecutive children aged 29 days to 18 years presenting with acute meningitis and procalcitonin (PCT) measurement. Intervention None. MAIN OUTCOME MEASURES: The sensitivity and specificity of the BMS (start antibiotics in case of seizure, positive cerebrospinal fluid (CSF) Gram staining, blood neutrophil count ≥10 ×10(9)/l, CSF protein level ≥80 mg/dl or CSF neutrophil count ≥1000 ×10(6)/l) and the Meningitest (start antibiotics in case of seizure, purpura, toxic appearance, PCT level ≥0.5 ng/ml, positive CSF Gram staining or CSF protein level ≥50 mg/dl) were compared using a McNemar test. RESULTS: 198 patients (mean age 4.8 years) from six centres in five European countries were included; 96 had bacterial meningitis. The BMS and Meningitest both showed 100% sensitivity (95% CI 96% to 100%). The BMS had a significantly higher specificity (52%, 95% CI 42% to 62% vs 36%, 95% CI 27% to 46%; p<10(-)8). CONCLUSION: The Meningitest and the BMS were both 100% sensitive. This result provides level II evidence for the sensitivity of both rules, which can be used cautiously. However, use of the BMS could safely avoid significantly more unnecessary antibiotic treatments for children with AM than can the Meningitest in this population.
Subject(s)
Decision Support Systems, Clinical , Meningitis, Aseptic/diagnosis , Meningitis, Bacterial/diagnosis , Adolescent , Child , Child, Preschool , Decision Making , Diagnosis, Differential , Early Diagnosis , Emergency Service, Hospital , Epidemiologic Methods , Humans , Infant , Infant, NewbornABSTRACT
OBJECTIVE: To validate procalcitonin (PCT) level as the best biological marker to distinguish between bacterial and aseptic meningitis in children in the emergency department. DESIGN: Secondary analysis of retrospective multicenter hospital-based cohort studies. SETTING: Six pediatric emergency or intensive care units of tertiary care centers in 5 European countries. PARTICIPANTS: Consecutive children aged 29 days to 18 years with acute meningitis. MAIN OUTCOME MEASURES: Univariate analysis and meta-analysis to compare the performance of blood parameters (PCT level, C-reactive protein level, white blood cell count, and neutrophil count) and cerebrospinal fluid parameters (protein level, glucose level, white blood cell count, and neutrophil count) quickly available in the emergency department to distinguish early on between bacterial and aseptic meningitis. RESULTS: Of 198 patients analyzed, 96 had bacterial meningitis. Sensitivity of cerebrospinal fluid Gram staining was 75%. The PCT level had significantly better results than the other markers for area under the receiver operating characteristic curve (0.98; 95% confidence interval, 0.95-0.99; P = .001). At a 0.5-ng/mL threshold, PCT level had 99% sensitivity (95% confidence interval, 97%-100%) and 83% specificity (95% confidence interval, 76%-90%) for distinguishing between bacterial and aseptic meningitis. The diagnostic odds ratio between high PCT level and bacterial meningitis was 139 (95% confidence interval, 39-498), without significant heterogeneity between centers. CONCLUSIONS: The PCT level is a strong predictor for distinguishing between bacterial and aseptic meningitis in children in the emergency department. Its combination with other parameters in an effective clinical decision rule could be helpful.
