Clinical decision rules to distinguish between bacterial and aseptic meningitis

François Dubos ¹, Bénédicte Lamotte ¹, Fadil Bibi-Triki ¹, Florence Moulin ², Josette Raymond ³, Dominique Gendrel ¹, Gérard Bréart ⁴ and Martin Chalumeau ^1*

¹ Clinical Epidemiology Unit, Department of Paediatrics, Saint Vincent-de-Paul University Hospital, France
² Department of Emergency Medicine, Saint Vincent-de-Paul University Hospital, France
³ Department of Bacteriology, Saint Vincent-de-Paul University Hospital, France
⁴ INSERM U149, France

^* To whom correspondence should be addressed. E-mail: martin.chalumeau{at}wanadoo.fr.

Accepted 28 March 2006

Abstract

Background: Clinical decision rules have been derived to distinguish between bacterial and aseptic meningitis in the emergency room to avoid unnecessary antibiotic treatments and hospitalisations.

Aims: To evaluate the reproducibility and to compare the diagnostic performance of 5 clinical decision rules.

Methods: All children hospitalised for bacterial meningitis between 1995 and 2004 or aseptic meningitis between 2000 and 2004 have been included in a retrospective cohort study. Sensitivity and specificity were calculated by applying each rule to our patients. The best rule was a priori defined as the one yielding 100% sensitivity for bacterial meningitis, the highest specificity and the greatest simplicity for a bedside application.

Results: Among the 166 patients included, 20 had bacterial meningitis and 146 had aseptic meningitis. Although 3 rules achieved 100% sensitivity (95% Confidence Interval [CI]: 84-100), 1 had a significantly lower specificity (13%; 95% CI: 8-19) than those of the other 2 rules (57% [95% CI: 48-65] and 66% [95% CI: 57- 73]), which were not statistically different. The ease of manual computation of the rule developed by Nigrovic et al (a simple list of five items: seizure, blood neutrophil count, cerebrospinal fluid (CSF) gram stain, CSF protein, CSF neutrophil count) was higher than the one developed by Bonsu and Harper.

Conclusion: On our population, the rule derived by Nigrovic et al had the best balance between accuracy and simplicity of manual computation and could help to avoid 2/3rd unnecessary antibiotic treatments and hospitalisations.

Keywords: cohort studies, decision rule, emergency medicine, meningitis

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