I recommend this article to anyone who cares for children in their practice – specifically anyone who will interpret CSF results. In 2007 the Pediatric Emergency Medicine Collaborative Research Committee (PECARN) published the following article in JAMA.
Link
The authors noted that few children who end of being admitted to the hospital on antibiotics with CSF pleocytosis actually have bacterial meningitis in the post-pneumococcal conjugate vaccination era. The previously developed Bacterial Meningitis Score specified that patients at very low risk of bacterial meningitis DID NOT HAVE all of the following:
- Positive CSF Gram stain
- CSF absolute neutrophil count (ANC) of at least 1000 cells/microL
- CSF protein of at least 80 mg/dL
- Peripheral blood ANC of at least 10,000 cells/microL
- History of seizure before or at the time of presentation
In a multicenter retrospective cohort the authors sought to validate this score and calculate a sensitivity, specificity and negative predictive value. 3,295 patients 29 days to 19 years who presented at participating emergency departments with CSF pleocytosis (CSF white blood cells > or =10 cells/microL) and who had not received antibiotic treatment before lumbar puncture were included. Only 121/3,295 had bacterial meningitis, and 3,174 had aspetic meningitis. 80% of the aseptic meningitis patients were hospitalized. They noted that “of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old.”
Thus, you could elect to discharge these patients if they are clinically well appearing and have reliable follow-up
