Clinical decision rules to distinguish between bacterial and aseptic meningitis

Background: Clinical decision rules have been derived to distinguish between bacterial and aseptic meningitis in the emergency room to avoid unnecessary antibiotic treatments and hospitalisations. Aims: To evaluate the reproducibility and to compare the diagnostic performance of five clinical decision rules. Methods: All children hospitalised for bacterial meningitis between 1995 and 2004 or aseptic meningitis between 2000 and 2004 have been included in a retrospective cohort study. Sensitivity and specificity were calculated by applying each rule to the patients. The best rule was a priori defined as the one yielding 100% sensitivity for bacterial meningitis, the highest specificity, and the greatest simplicity for a bedside application. Results: Among the 166 patients included, 20 had bacterial meningitis and 146 had aseptic meningitis. Although three rules achieved 100% sensitivity (95% CI 84 - 100), one had a significantly lower specificity ( 13%, 95% CI 8 - 19) than those of the other two rules ( 57%, 95% CI 48 - 65; and 66%, 95% CI 57 - 73), which were not statistically different. The ease of manual computation of the rule developed by Nigrovic et al ( a simple list of five items: seizure, blood neutrophil count, cerebrospinal fluid ( CSF) Gram stain, CSF protein, CSF neutrophil count) was higher than the one developed by Bonsu and Harper. Conclusion: On our population, the rule derived by Nigrovic et al had the best balance between accuracy and simplicity of manual computation and could help to avoid two thirds of unnecessary antibiotic treatments and hospitalisations.