Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis

Abstract

This large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.

Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants

“…The third infant had fever without a specific source identified, but had a birth history of vaginal delivery and prolonged labor. The CSF sample from LP for this patient was reported as grossly bloody by the performing clinicians and by the Clinical Microbiology Laboratory, despite a CSF red blood cell count of only 5500 cells/mm 3 .…”

“…CSF protein concentration has been used in clinical decision rules for the prediction of bacterial meningitis in children. 3 Elevated protein levels are difficult to interpret in cases of traumatic LP, and a diagnosis of bacterial meningitis may be more difficult to exclude on the basis of CSF test results. 4 The interpretation of CSF protein levels is further complicated in the youngest infants due to both the changing composition of the CSF as well as the higher rates of traumatic LPs.…”

“…We excluded patients with conditions known to elevate CSF protein, including: serious bacterial infection (bacterial meningitis, urinary tract infection, bacteremia, pneumonia, septic arthritis, and bacterial gastroenteritis), 11 presence of a ventricular shunt, aseptic meningitis (positive CSF enteroviral polymerase chain reaction or CSF herpes simplex virus polymerase chain reaction), congenital infections (eg, syphilis), seizure prior to presentation, and elevated bilirubin (if serum bilirubin was obtained). Due to the fact that grossly bloody CSF samples are difficult to interpret, we excluded those with a CSF RBC count >150,000 cells/mm 3 , a cutoff representing the 99th percentile of CSF RBC values in the cohort after applying other exclusion criteria.…”

“…We analyzed the following groups of children: 1) all eligible patients; 2) children 28 days versus children >28 days; 3) vaginal versus cesarean delivery; and 4) patients without CSF pleocytosis. In the primary subanalysis, CSF pleocytosis was defined as CSF white blood cells (WBCs) >19 cells/ mm 3 17 Finally, linear regression analysis was repeated while including subjects with >150,000 RBC/ mm 3 to determine the effect of including those patients on the association of CSF RBC count and protein con-…”

“…The median age was 34 days (interquartile range: 19-46 days); 45% of patients were male. The median CSF RBC count was 40 cells/mm 3 (interquartile range: 2-1080 cells/ mm 3 ); 11.8% of patients had a CSF RBC >10,000 cells/ mm 3 . CSF protein increased by 1.9 mg/dL (95% confidence interval: 1.7-2.1 mg/dL) per 1000 CSF RBCs for all included patients.…”