A Decision Rule for Predicting Bacterial Meningitis in Children with Cerebrospinal Fluid Pleocytosis When Gram Stain Is Negative or Unavailable

OBJECTIVES: Among children with cerebrospinal fluid (CSF) pleocytosis, the task of separating aseptic from bacterial meningitis is hampered when the CSF Gram stain result is unavailable, delayed, or negative. In this study, the authors derive and validate a clinical decision rule for use in this setting. METHODS: This was a review of peripheral blood and CSF test results from 78 children (< 19 years) presenting to Children's Hospital Columbus from 1998 to 2002. For those with a CSF leukocyte count of > 7/microL, a rule was created for separating bacterial from viral meningitis that was based on routine laboratory tests, but excluded Gram stain. The rule was validated in 158 subjects seen at the same site (Columbus, 2002-2004) and in 871 subjects selected from a separate site (Boston, 1993-1999). RESULTS: One point each (maximum, 6 points) was assigned for leukocytes > 597/microL, neutrophils > 74%, glucose < 38 mg/dL, and protein > 97 mg/dL in CSF and for leukocytes > 17,000/mL and bands to neutrophils > 11% in peripheral blood. Areas under receiver-operator-characteristic curves (AROCs) for the resultant score were 0.98 for the derivation set and 0.90 and 0.97, respectively, for validation sets from Columbus and Boston. Sensitivity and specificity pairs for the Boston data set were 100 and 44%, respectively, at a score of 0 and 97 and 81% at a score of 1. Likelihood ratios (LRs) increased from 0 at a score of 0 to 40 at a score of > or = 4. CONCLUSIONS: Among children with CSF pleocytosis, a prediction score based on common tests of CSF and peripheral blood and intended for children with unavailable, negative, or delayed CSF Gram stain results has value for diagnosing bacterial meningitis.