Bacterial meningitis score is valid in other populations of children

Article Outline

• Dubos F, De la Rocque F, Levy C, Bingen E, Aujard Y, Cohen R, et al. Sensitivity of the bacterial meningitis score in 889 children with bacterial meningitis. J Pediatr 2008;152:378-82
  • Question
  • Design
  • Setting
  • Participants
  • Intervention
  • Outcome
  • Results
  • Conclusions
  • Commentary
• Reference
• Copyright

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Dubos F, De la Rocque F, Levy C, Bingen E, Aujard Y, Cohen R, et al. Sensitivity of the bacterial meningitis score in 889 children with bacterial meningitis. J Pediatr 2008;152:378-82 

Question 

In children with bacterial meningitis, how well does a previously validated bacterial meningitis score (BMS) correctly identify affected children?

Design 

Secondary analysis of prospective data for children presenting with bacterial meningitis to hospital emergency departments between January 2001 and February 2005.

Setting 

France.

Participants 

900 children aged 29 days to 18 years with acute bacterial meningitis.

Intervention 

The BMS was applied to all children with acute bacterial meningitis with the same inclusion criteria proposed by the authors of the rule.

Outcome 

Sensitivity of the BMS rule.

Results 

Use of the BMS correctly identified 884 children with bacterial meningitis, for 99.6% sensitivity (95% CI, 98.9%-99.8%).

Conclusions 

The sensitivity of the BMS in detecting disease was very high, but a few cases of bacterial meningitis were missed. Further refinements of the BMS may be warranted to lower the false-negative rate.

Commentary 

In recent years, we have become “score hunters,” looking for evidence-based ways to justify our gestalt for determining who has bacterial meningitis and who does not. The French Surveillance Network should be applauded for getting us even closer to understanding scoring for bacterial meningitis. In this study, they try to validate the most recently developed score, by Nigrovic et al,¹ by using a large cohort of children >29 days old from a different geographic location. They succeeded in finding a very high sensitivity rate (99.6%) and bringing the confidence interval to almost 100%. Yet, even in a large cohort like this (n = 889), 5 children with meningitis would have been “missed” with the score. Beyond enhancing the level of evidence of the score and supporting its use with caution, the study illustrates that we may never reach a score that will apply to all infants and children with bacterial meningitis, no matter what population or during what era we try to do so. Furthermore, with such a good (but not a perfect) score, we should consider the ethical question related to investigating, prescribing antibiotics, admitting and spending large amounts of money on hundreds of children to find the few with true bacterial meningitis. We can potentially “save” so much if we decide to “accept” a score and with it the remote possibility of discharging home from the emergency department a small percentage of children with bacterial meningitis. It seems that the current consensus is that this rate is 0%, and we should be investigating and treating all children with suspected meningitis. That is, until we find the “ultimate” score.

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Reference 

1. Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM, Schremmer RD, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007;297:52–60
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