Outpatient management of children at low risk for bacterial meningitis

García, Silvia; Echevarri, Janire; Arana-Arri, Eunate; Sota, Mercedes; Benito, Javier; Mintegi, Santiago

doi:10.1136/emermed-2017-206834

Cited by 6 publications

(7 citation statements)

References 22 publications

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“…The remaining 14 articles were eligible for data extraction, of which four articles reported two different sets of data using different cutoff values; thus, they were regarded as two separate studies. Finally, 18 studies comprising 1462 samples [ 10 , 16 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ] were included ( Figure 1 ).…”

Section: Resultsmentioning

confidence: 99%

Blood Procalcitonin Level as a Diagnostic Marker of Pediatric Bacterial Meningitis: A Systematic Review and Meta-Analysis

2021

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Early diagnosis and treatment of bacterial meningitis in children are essential, due to the high mortality and morbidity rates. However, lumbar puncture is often difficult, and cerebrospinal fluid (CSF) culture takes time. This meta-analysis aims to determine the diagnostic accuracy of blood procalcitonin for detecting bacterial meningitis in children. We conducted a systematic search on electronic databases to identify relevant studies. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated, and a hierarchical summary receiver operating characteristic curve and area under the curve (AUC) were determined. Eighteen studies with 1462 children were included in the analysis. The pooled sensitivity, specificity, and the DOR of blood procalcitonin for detecting bacterial meningitis were 0.87 (95% confidence interval (CI): 0.78–0.93); 0.85 (95% CI: 0.75–0.91), and 35.85 (95% CI: 10.68–120.28), respectively. The AUC for blood procalcitonin was 0.921. Blood procalcitonin also showed higher diagnostic accuracy for detecting bacterial meningitis than other conventional biomarkers, including serum C-reactive protein and leukocyte count, CSF leukocyte and neutrophil count, and CSF protein and glucose levels. Blood procalcitonin can be a good supplemental biomarker with high diagnostic accuracy in detecting bacterial meningitis in children.

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Section: Resultsmentioning

confidence: 99%

Blood Procalcitonin Level as a Diagnostic Marker of Pediatric Bacterial Meningitis: A Systematic Review and Meta-Analysis

2021

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“…In a multicenter study including children with meningitis conducted by the Research Network of the Spanish Society of Pediatric Emergencies, 17 the prevalence of bacterial meningitis was 6.2%. To achieve an accuracy of 5.0% in the estimation of percentages with a normal 95% bilateral asymptotic confidence interval (CI), we needed to include 90 patients in the study; hence, assuming a 10% drop-out rate, we needed to recruit 100 patients diagnosed with bacterial meningitis.…”

Section: Derivation Setmentioning

confidence: 99%

“…In the aforementioned study, 17 we diagnosed 1 child .2 years of age with bacterial meningitis per 20 000 ED episodes, and 1 patient per 51 000 ED episodes would have met the inclusion criteria for the study. On the basis of these data, we would have required ∼5 100 000 ED episodes.…”

Section: Derivation Setmentioning

confidence: 99%

“…11,16 In a previous series, the replacement of the peripheral absolute neutrophil count (ANC) with procalcitonin significantly increased the specificity of the BMS. 17 Our main objective of this study was to develop and validate a score, which we have called the meningitis score for emergencies (MSE), to distinguish bacterial meningitis from aseptic meningitis in children with pleocytosis when initially evaluated at the ED. Our secondary objective was to compare the performance of the new decision support tool to the BMS.…”

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Clinical Prediction Rule for Distinguishing Bacterial From Aseptic Meningitis

et al. 2020

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BACKGROUND: New biomarkers like procalcitonin and C-reactive protein may help design an accurate decision support tool used to identify children with pleocytosis at low or high risk of bacterial meningitis. Our objective was to develop and validate a score (that we call the meningitis score for emergencies [MSE]) to distinguish bacterial meningitis from aseptic meningitis in children with pleocytosis when initially evaluated at the emergency department. METHODS:We included children between 29 days and 14 years old with meningitis admitted to 25 Spanish emergency departments. A retrospective cohort from between 2011 and 2016 was used as the derivation set and a prospective cohort recruited during 2017 and 2018 was used as the validation set.RESULTS: Among the 1009 patients included, there were 917 cases of aseptic meningitis and 92 of bacterial meningitis. Using multivariable logistic regression analysis, we identified the following predictors of bacterial meningitis from the derivation set: procalcitonin .1.2 ng/mL, cerebrospinal fluid (CSF) protein .80 mg/dL, CSF absolute neutrophil count .1000 cells per mm 3 , and C-reactive protein .40 mg/L. Using the derivation set, we developed the MSE, assigning 3 points for procalcitonin, 2 points for CSF protein, and 1 point for each of the other variables. An MSE $1 predicted bacterial meningitis with a sensitivity of 100% (95% confidence interval [CI]: 95.0%-100%), a specificity of 83.2 (95% CI: 80.6-85.5), and a negative predictive value of 100% (95% CI 99.4-100.) CONCLUSIONS:The MSE accurately distinguishes bacterial from aseptic meningitis in children with CSF pleocytosis.WHAT'S KNOWN ON THIS SUBJECT: No single variable distinguishes bacterial from aseptic meningitis in children with cerebrospinal fluid pleocytosis. Combinations of several variables have been used to distinguish these two types of meningitis.WHAT THIS STUDY ADDS: The meningitis score for emergencies can be used to guide initial clinical decisionmaking in children with cerebrospinal fluid pleocytosis, without misclassifying children with bacterial meningitis. Including procalcitonin and C-reactive protein achieves a more accurate decision support tool.

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“… 5–11 However, previously published CPRs seem to perform poorly in the ED setting, with no demonstrated impact on clinical practice and rates of discharge from the ED and few external validation studies. Highly accurate CPRs that incorporate newer laboratory tests and biomarkers such as procalcitonin (PCT) 12–15 are needed to identify low-risk infants who do not require invasive diagnostic testing, empirical antibiotics treatment or admission. Looking ahead, host expression patterns such as RNA biosignatures suggest a new diagnostic paradigm, 16 17 although these tools will require additional refinement and validation before their introduction to clinical practice.…”

Section: Introductionmentioning

confidence: 99%

Assessment of the impact of a new sequential approach to antimicrobial use in young febrile children in the emergency department (DIAFEVERCHILD): a French prospective multicentric controlled, open, cluster-randomised, parallel-group study protocol

et al. 2020

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IntroductionFever is one of the most common reasons for consultation in the paediatric emergency department (ED). Because of fear of bacterial infection in parents and caregivers, clinicians often overprescribe laboratory tests and empirical antibiotic treatment. The aims of this study are to demonstrate that using a procalcitonin (PCT) rapid test-based prediction rule (1) would not be inferior to usual practice in terms of morbidity and mortality (non-inferiority objective) and (2) would result in a significant reduction in antibiotic use (superiority objective).Methods and analysisThis prospective multicentric cluster-randomised study aims to include 7245 febrile children aged 6 days to 3 years with a diagnosis of fever without source in 26 participating EDs in France and Switzerland during a 24-month period. During first period, all children will receive usual care. In a second period, a point-of-care PCT-based algorithm will be used in half of the clusters. The primary endpoints collected on day 15 after ED consultation will be a composite outcome of death or intensive care unit admission for any reason, disease-specific complications, diagnosis of bacterial infection after discharge from the ED for the non-inferiority objective and proportion of children with antibiotic treatment administered for the superiority objective. The endpoints will be compared between the two groups (experimental and control) by using a mixed logistic regression model adjusted on clustering of participants within centres and period within centres.DiscussionIf the algorithm is validated, a new strategy will be discussed with medical societies to safely manage fever in young children without the need for invasive procedures for microbiological testing or empirical antibiotics.Ethics and disseminationThis study was submitted to an independent ethics committee on 17 May 2018 (no. 2018-A00252-53). Results will be submitted to international peer-reviewed journals and presented at international conferences.Trial registration numberNCT03607162.

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Outpatient management of children at low risk for bacterial meningitis

Abstract: This set of low-risk criteria appears safe for the outpatient management without antibiotics of children with CSF pleocytosis. Larger studies are needed to evaluate the predictive values of replacing peripheral ANC with PCT in the BMS.

Cited by 6 publications

References 22 publications

Blood Procalcitonin Level as a Diagnostic Marker of Pediatric Bacterial Meningitis: A Systematic Review and Meta-Analysis

Blood Procalcitonin Level as a Diagnostic Marker of Pediatric Bacterial Meningitis: A Systematic Review and Meta-Analysis

Clinical Prediction Rule for Distinguishing Bacterial From Aseptic Meningitis

Assessment of the impact of a new sequential approach to antimicrobial use in young febrile children in the emergency department (DIAFEVERCHILD): a French prospective multicentric controlled, open, cluster-randomised, parallel-group study protocol

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