ANNALS OF EMERGENCY MEDICINE
Systematic Review Snapshot TAKE-HOME MESSAGE No current clinical prediction rule can reliably determine which children should be hospitalized and treated with intravenous antibiotics for bacterial meningitis.
Can a Clinical Prediction Rule Reliably Predict Pediatric Bacterial Meningitis?
DATA SOURCES The authors conducted an electronic search of MEDLINE and EMBASE (January 1950 to September 2012), limited to English-language articles. STUDY SELECTION Derivation, validation, or impact studies of a pediatric bacterial meningitis clinical prediction rule were included. Clinical prediction rules were deﬁned as decision tools making use of 3 or more predictors and provided probability estimates of meningitis or guided treatment in children younger than 18 years. To be included, studies were required to measure cases of bacterial meningitis by cerebrospinal ﬂuid culture. Although both prospective and retrospective studies were eligible, studies assessing neural network algorithms were excluded. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened the titles and abstracts and extracted data from each study. In cases of uncertainty about the results, analysis, or assessment of the clinical prediction rule, consensus was used to determine inclusion. Methods for assessing
Daniel G. Ostermayer, MD Department of Emergency Medicine UT Houston Medical School Houston, TX
Alex Koyfman, MD Department of Emergency Medicine UT Southwestern Medical Center/Parkland Memorial Hospital Dallas, TX
Results Performance characteristics of the Bacterial Meningitis Rule and Modiﬁed Rule. Bacterial Meningitis Score
Nigrovic, 2002 (derivation) Nigrovic, 20073 (validation) Dubos, 20064 (validation) Dubos, 20105 (validation)
Predicated Frequency of Antibiotic Administration
Bacterial Meningitis Frequency
Sensitivity (Lower 95% CI)
Negative Likelihood Ratio (Upper 95% CI)
CI, Conﬁdence interval; NA, not applicable.
After review of 6,387 articles, 11 studies with a total of 6,675 children (aged 28 days to 18 years) were included in the systematic review; 6 were derivation studies and 5 were validation studies. Subjects were from the emergency department and pediatric wards in Europe or the United States. A ﬁnal diagnosis of meningitis was based on speciﬁc diagnostic criteria for bacterial meningitis. Because of
heterogeneity, meta-analysis was not possible.
Commentary Currently, decisions about empiric treatment for suspected bacterial meningitis are based on physical examination ﬁndings and results of cerebrospinal ﬂuid testing. However, the majority of initially treated suspected bacterial meningitis is Annals of Emergency Medicine 1
Systematic Review Snapshot
heterogeneity and intended pooling of the data were not disclosed by the authors. Quality of clinical decision rules was assessed according to the Evidence-Based Medicine Working Group.1
actually aseptic, with only 6% to 18% of patients receiving a ﬁnal diagnosis of bacterial meningitis.6 The decreasing prevalence of bacterial meningitis is largely due to vaccinations against Haemophilus inﬂuenza type B and Streptococcus pneumonia, decreasing the likelihood that an elevated cerebrospinal ﬂuid WBC count correlates with a bacterial cause.7 A clinical prediction rule that incorporates a patient’s clinical status in addition to laboratory values has the potential to efﬁciently guide the use of empiric intravenous antibiotics in children with suspected meningitis. However, the majority of the rules included in this review used chart review, an ultimately unreliable methodology for prediction rule development.
2 Annals of Emergency Medicine
In general, decision rules accurate and reliable enough to allow providers and parents to forgo testing, empiric treatment, or admission when bacterial meningitis is a consideration should be developed and validated prospectively. None of the currently derived and validated clinical prediction rules for bacterial meningitis follow these methods or have been shown adequate to recommend their use. The Bacterial Meningitis Score reported the best performance but has not been prospectively validated or replicated. Impact studies on the most effective and safe method for determining whether a child with suspected bacterial meningitis requires intravenous antibiotics are still needed. Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Kulik DM, Uleryk EM, Maguire JL. Does this child have bacterial meningitis? a systematic review of clinical prediction rules for children with suspected bacterial meningitis. J Emerg Med. 2013;45:508519. http://dx.doi.org/10.1016/j. jemermed.2013.03.042.
1. McGinn TG, Guyatt GH, Wyer PC, et al. Users’ guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA. 2000;284: 79-84. 2. Nigrovic LE, Kuppermann N, Malley R. Development and validation of a multivariable predictive model to distinguish bacterial from aseptic meningitis in children in the post–Haemophilus inﬂuenzae era. Pediatrics. 2002;110:712-719. 3. Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal ﬂuid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007;297:52-60. 4. Dubos F, Lamotte B, Bibi-Triki F, et al. Clinical decision rules to distinguish between bacterial and aseptic meningitis. Arch Dis Child. 2006;91:647-650. 5. Dubos F, Korczowski B, Aygun DA, et al. Distinguishing between bacterial and aseptic meningitis in children: European comparison of two clinical decision rules. Arch Dis Child. 2010;95: 963-967. 6. Saez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003;361: 2139-2148. 7. Kaplan SL, Mason EO Jr, Wald ER, et al. Decrease of invasive pneumococcal infections in children among 8 children’s hospitals in the United States after the introduction of the 7-valent pneumococcal conjugate vaccine. Pediatrics. 2004;113:443-499.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.