Does this child have bacterial meningitis? A systematic review of clinical prediction rules for children with suspected bacterial meningitis.

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.

[1]  S. Kaplan,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. , 2004, Pediatrics.

[2]  J. Nolan,et al.  Effect of active compression-decompression resuscitation (ACD-CPR) on survival: a combined analysis using individual patient data. , 1999, Resuscitation.

[3]  B. Lowe,et al.  Diagnosis of acute bacterial meningitis in children at a district hospital in sub-Saharan Africa , 2001, The Lancet.

[4]  H. Harmsen,et al.  Rapid Identification of Bacteria in Blood Cultures by Using Fluorescently Labeled Oligonucleotide Probes , 2000, Journal of Clinical Microbiology.

[5]  S. Goodacre,et al.  Clinical decision rules for children with minor head injury: a systematic review , 2011, Archives of Disease in Childhood.

[6]  H. Imai,et al.  Serum C‐reactive protein in the differential diagnosis of childhood meningitis , 2000, Pediatrics international : official journal of the Japan Pediatric Society.

[7]  Nathan Kuppermann,et al.  Development and validation of a multivariable predictive model to distinguish bacterial from aseptic meningitis in children in the post-Haemophilus influenzae era. , 2002, Pediatrics.

[8]  M. Harper,et al.  Differentiating Acute Bacterial Meningitis From Acute Viral Meningitis Among Children With Cerebrospinal Fluid Pleocytosis: A Multivariable Regression Model , 2004, The Pediatric infectious disease journal.

[9]  I. Stiell,et al.  Methodologic standards for the development of clinical decision rules in emergency medicine. , 1999, Annals of emergency medicine.

[10]  Cheng-Hsien Lu,et al.  Community-acquired bacterial meningitis in adults: the epidemiology, timing of appropriate antimicrobial therapy, and prognostic factors , 2002, Clinical Neurology and Neurosurgery.

[11]  J. Concato,et al.  The Risk of Determining Risk with Multivariable Models , 1993, Annals of Internal Medicine.

[12]  E. Hess,et al.  Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review. , 2008, CJEM.

[13]  Allan R Tunkel,et al.  Practice guidelines for the management of bacterial meningitis. , 2004, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[14]  George A Wells,et al.  The Canadian CT Head Rule for patients with minor head injury , 2001, The Lancet.

[15]  R. C. Baker,et al.  The predictive value of cerebrospinal fluid differential cytology in meningitis. , 1989, The Pediatric infectious disease journal.

[16]  U. Reischl,et al.  Rapid Diagnosis of Bacterial Meningitis by Real-Time PCR and Fluorescence In Situ Hybridization , 2005, Journal of Clinical Microbiology.

[17]  G H Guyatt,et al.  Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. , 2000, JAMA.

[18]  K. Kelleher,et al.  Cerebrospinal fluid findings in aseptic versus bacterial meningitis. , 2000, Pediatrics.

[19]  A. Schuchat,et al.  Bacterial Meningitis in the United States in 1995 , 1997 .

[20]  Diederick E. Grobbee,et al.  A diagnostic decision rule for management of children with meningeal signs , 2003, European Journal of Epidemiology.

[21]  David Moher,et al.  Toward complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. , 2003, Academic radiology.

[22]  A. Evans,et al.  Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions , 2006, Annals of Internal Medicine.

[23]  A. Schuchat,et al.  Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. , 2003, The New England journal of medicine.

[24]  A. Gean,et al.  The spinal tap: a new look at an old test. , 1986, Annals of internal medicine.

[25]  X. Sáez-Llorens,et al.  Bacterial meningitis in children. , 2005, Pediatric clinics of North America.

[26]  F. Harrell,et al.  Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations. , 1989, JAMA.

[27]  E. Lewis,et al.  Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children , 2000, The Pediatric infectious disease journal.

[28]  R. Feigin.  Use of corticosteroids in bacterial meningitis. , 2004, The Pediatric infectious disease journal.

[29]  J. Casado‐flores,et al.  Distinguishing between bacterial and aseptic meningitis in children: European comparison of two clinical decision rules , 2010, Archives of Disease in Childhood.

[30]  M. Galle,et al.  Adult bacterial meningitis: aetiology, penicillin susceptibility, risk factors, prognostic factors and guidelines for empirical antibiotic treatment. , 2004, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[31]  Møller,et al.  Guidelines for managing acute bacterial meningitis in adults , 2000, Western Journal of Medicine.

[32]  W. Schaffner,et al.  Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumoniae. , 2006, The New England journal of medicine.

[33]  A. Laupacis,et al.  Clinical prediction rules. A review and suggested modifications of methodological standards. , 1997, JAMA.

[34]  S B Freedman,et al.  Predictors of bacterial meningitis in the era after Haemophilus influenzae. , 2001, Archives of pediatrics & adolescent medicine.

[35]  H. Sox,et al.  Clinical prediction rules. Applications and methodological standards. , 1985, The New England journal of medicine.

[36]  Kenneth D. Mandl,et al.  Research paper: Linking Surveillance to Action: Incorporation of Real-time Regional Data into a Medical Decision Rule , 2007, J. Am. Medical Informatics Assoc..

[37]  Nathan Kuppermann,et al.  Clinical Prediction Rules for Children: A Systematic Review , 2011, Pediatrics.

[38]  S. Kaplan,et al.  Dexamethasone therapy for children with bacterial meningitis. Meningitis Study Group. , 1995, Pediatrics.

[39]  S. Kaplan,et al.  Dexamethasone Therapy for Children With Bacterial Meningitis , 1995, Pediatrics.

[40]  K. Oizumi,et al.  RETRACTED ARTICLE: Diagnostic value of atypical lymphocytes in cerebrospinal fluid from adults with enteroviral meningitis , 1998, Journal of Neurology.

[41]  D E Grobbee,et al.  Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures , 2001, Acta paediatrica.

[42]  M. Vermeulen,et al.  Antibiotic guidelines and antibiotic use in adult bacterial meningitis in The Netherlands. , 2002, The Journal of antimicrobial chemotherapy.

[43]  R. Booy,et al.  Diagnosis and treatment of bacterial meningitis , 2003, Archives of disease in childhood.

[44]  A. Lever,et al.  The impact of new diagnostic methodologies in the management of meningitis in adults at a teaching hospital. , 2002, QJM : monthly journal of the Association of Physicians.

[45]  E. Bingen,et al.  Performance of a predictive rule to distinguish bacterial and viral meningitis. , 2007, The Journal of infection.

[46]  B. Toye,et al.  Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. , 2005, QJM : monthly journal of the Association of Physicians.

[47]  Kathy Boutis,et al.  Should a Head-Injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules , 2009, Pediatrics.

[48]  D. Gendrel,et al.  Clinical decision rules to distinguish between bacterial and aseptic meningitis , 2006, Archives of Disease in Childhood.

[49]  Dewesh Agrawal,et al.  Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. , 2007, JAMA.

[50]  D. Grobbee,et al.  Children with meningeal signs: predicting who needs empiric antibiotic treatment. , 2002, Archives of pediatrics & adolescent medicine.

[51]  J. Romero,et al.  Enteroviral Meningitis , 2012, PharmacoEconomics.

[52]  Bema K. Bonsu,et al.  A decision rule for predicting bacterial meningitis in children with cerebrospinal fluid pleocytosis when gram stain is negative or unavailable. , 2008, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[53]  D. Musher,et al.  Microscopic Examination and Broth Culture of Cerebrospinal Fluid in Diagnosis of Meningitis , 1998, Journal of Clinical Microbiology.

[54]  D. A. Wellman,et al.  An appraisal of multivariable logistic models in the pulmonary and critical care literature. , 2003, Chest.