Original Contributions
Does This Child Have Bacterial Meningitis? A Systematic Review of Clinical Prediction Rules for Children with Suspected Bacterial Meningitis

https://doi.org/10.1016/j.jemermed.2013.03.042Get rights and content

Abstract

Background

Acute meningitis is a relatively common phenomenon in children. Identifying which children are most likely to have bacterial meningitis vs. self-limiting aseptic meningitis is important, as these children require investigation and antibiotic treatment.

Objective

Our aim was to systematically identify and review the quality and performance of published clinical prediction rules (CPRs) for children with suspected bacterial meningitis.

Methods

Medline and Embase were searched for CPRs involving children 0–18 years of age with suspected bacterial meningitis, with cerebral spinal fluid (CSF) culture used as the reference diagnostic standard. CPR quality was assessed using 17 previously published items. CPR performance was evaluated using sensitivity, negative likelihood ratio, and the treatment frequency that would result if the rule was used.

Results

Eleven studies involving 6675 children with acute meningitis fulfilled all inclusion criteria and were entered in the study. They all describe the derivation or validation of six unique CPRs. A rigorously developed, high-performing, and well-validated CPR ready for clinical use to guide which children with suspected bacterial meningitis should be hospitalized and treated with intravenous antibiotics and which can be safely discharged home was not identified. Areas for quality improvement for future CPR studies include prospective validation using standardized inclusion criteria, adequate blinding, predictor reproducibility assessment, and meticulous follow-up of outcomes. The Bacterial Meningitis Score had the highest quality and performance and is the best candidate for prospective validation.

Conclusions

Until consistently high methodological quality and diagnostic performance are demonstrated through prospective validation, caution is warranted in the routine clinical use of existing CPRs for children with suspected bacterial meningitis.

Introduction

Acute meningitis is a relatively common and potentially severe infection in childhood, with approximately 3000 new cases each year in children younger than 18 years of age in the United States 1, 2, 3. Fortunately, most infections are aseptic and resolve spontaneously, but 6–18% are bacterial in origin and require i.v. antibiotic treatment, hospitalization, and close monitoring 4, 5.

Accurately diagnosing bacterial meningitis in children is imperative to avoid severe outcomes, such as neurological impairment or death, and minimize unnecessary antibiotic use and hospitalization in children with self-limiting illness 6, 7, 8, 9, 10, 11, 12, 13. Although diagnostic techniques, such as cerebral spinal fluid (CSF) culture and polymerase chain reaction (PCR) are reliable, physicians must decide which patients to treat with i.v. antibiotics empirically before culture or PCR results are reported 48 h later 14, 15. Weighing the risk of missing a true case of bacterial meningitis with unnecessarily admitting patients without bacterial meningitis for 48 h of i.v. antibiotics remains a major challenge (16).

Clinicians often review results of CSF glucose, protein, white blood cell (WBC) count, Gram stain, and serum WBC count to guide diagnostic decisions (17). Gram stain is highly specific but it is falsely negative in up to 40% of cases and therefore cannot be exclusively relied upon 2, 18, 19, 20. Elevated CSF WBC count is more common in aseptic rather than bacterial meningitis 21, 22, 23, 24, 25, 26, 27. Widespread use of vaccines against Streptococcus pneumonia and Hemophilus influenza type B have decreased the probability of bacterial meningitis in children, further decreasing the likelihood that elevated CSF WBC count is the result of bacterial meningitis 28, 29, 30, 31.

Clinical prediction rules (CPRs) are potentially powerful evidence-based tools for reducing uncertainty and improving accuracy in medical decision making by standardizing the collection and interpretation of clinical data (32). They can also minimize the use of potentially harmful diagnostic tests, such as lumbar puncture, and reduce admissions and adverse events from antibiotic use. They have been defined as clinical decision-making tools that quantify the relative importance of 3 or more variables from history, physical examination, or simple tests to provide the probability of an outcome or suggest a single diagnostic or therapeutic course of action for an individual patient 32, 33, 34.

This study aimed to systematically identify CPRs for children with suspected bacterial meningitis and compare their methodological quality and performance for diagnosing bacterial meningitis using a recently developed framework to evaluate CPRs for children (35).

Section snippets

Search Strategy

Potentially relevant studies were identified through electronic searches of Medline and Embase from January 1950 up to September 2012 (Appendix 1). Because there is no medical subject heading (MeSH) that specifies clinical prediction rules, a previously developed electronic search strategy for CPRs was used with the addition of the MeSH term bacterial meningitis 35, 36. The reference lists of identified clinical prediction rule publications were searched manually to identify additional studies.

Study Selection

A total of 6387 titles and abstracts were identified and screened by the search strategy as potentially relevant (Figure 1). Of these, 379 were extracted as full text articles and assessed for inclusion; 11 studies fulfilled all inclusion criteria. These studies were derivation or validation studies of six unique CPRs.

Description of Studies

Included studies were published between 2001 and 2010 and involved a total of 6675 children (see Table 1 for population characteristics for each study). The median number of

Discussion

This review has identified 11 studies involving the derivation or validation of six different bacterial meningitis clinical prediction rules for children. Using a recently developed framework for evaluating the quality and performance of clinical prediction rules for children, we identified the presence or absence of 17 items generally considered to be of importance for high-quality clinical prediction rules. We also evaluated the diagnostic performance of these rules based on their

Conclusions

In summary, a rigorously developed, high-performing and well-validated CPR that is ready for clinical use to guide which children with suspected bacterial meningitis should be hospitalized and treated with i.v. antibiotics and can be safely discharged home was not identified. A detailed analysis of the methodological quality and performance of identified CPRs suggested areas for quality improvement for future CPR studies. These include prospective validation using standardized inclusion

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