Published online December 1, 2004
PEDIATRICS Vol. 114 No. 6 December 2004, pp. e713-e719 (doi:10.1542/peds.2004-0007)

This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Berkley, J. A. Articles by Newton, C. R. J. C. Search for Related Content PubMed PubMed Citation Articles by Berkley, J. A. Articles by Newton, C. R. J. C. Related Collections Infectious Disease & Immunity Related AAP Red Book topics: Malaria Social Bookmarking                         What's this?

ELECTRONIC ARTICLE

Indicators of Acute Bacterial Meningitis in Children at a Rural Kenyan District Hospital

James A. Berkley, MD, Anne C. Versteeg, Isaiah Mwangi, MTropPaeds, Brett S. Lowe, MPhil and Charles R. J. C. Newton, MD

From the Centre for Geographic Medicine Research (Coast), Kilifi, Kenya

Objective. Acute bacterial meningitis remains an important cause of death and neurologic sequelae in African children. The clinical features of meningitis are often nonspecific and in this setting may overlap with those of malaria. Early diagnosis and appropriate antibiotic treatment are perhaps the most important steps in management, but published data suggest that fewer than half of the cases of childhood meningitis are identified at first assessment in hospitals in this region. The objective of this study was to identify clinical indicators of acute bacterial meningitis by examining components of the World Health Organization Integrated Management of Childhood Illness (IMCI) referral criteria for meningitis (lethargy, unconsciousness, inability to feed, stiff neck, or seizures) and other symptoms and signs.

Methods. Kilifi District Hospital, serving 200 000 people in a rural, malaria-endemic area of the Kenyan coast, was studied. A Kenya Medical Research Institute research center is located at the hospital. All pediatric admissions aged 60 days between June 2001 and July 2002 were eligible.

Results. A total of 91 (2.0%) of 4582 admissions had meningitis, including 77 (4.0%) of 1929 of those who met the IMCI referral criteria for meningitis at admission (sensitivity: 85%; specificity: 59%). Independent indicators of the presence of meningitis were a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range. One or more of these indicators was present in 895 (19%) of admissions, 72 (8.0%) of whom had meningitis (sensitivity: 79%; specificity: 80%). Independent indicators of the absence of meningitis were the absence of a history of fever, a history of diarrhea, and a positive malaria slide. The area under the receiver operating characteristic curve for a set of simple screening rules based on the positive indicators identified was 0.88 (95% confidence interval: 0.85–0.92).

Conclusions. The presence of 1 of a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range is a clear indication for lumbar puncture and/or presumptive treatment. However, careful observation and reassessment may be the only practical way to identify one fifth of meningitis cases in this setting.

---

Key Words: meningitis • Kenya • sub-Saharan • IMCI • rural

Abbreviations: IMCI, Integrated Management of Childhood Illness • LP, lumbar puncture • CSF, cerebrospinal fluid • PLR, positive likelihood ratio • NLR, negative likelihood ratio • ALR, adjusted likelihood ratio • ROC, receiver operating characteristic

---

Accepted Jul 1, 2004.

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				S Shacham, E Kozer, H Bahat, Y Mordish, and M Goldman Bulging fontanelle in febrile infants: is lumbar puncture mandatory? Arch. Dis. Child., September 1, 2009; 94(9): 690 - 692. [Abstract] [Full Text] [PDF]

				P. Bejon, S. Mohammed, I. Mwangi, S. H Atkinson, F. Osier, N. Peshu, C. R Newton, K. Maitland, and J. A Berkley Fraction of all hospital admissions and deaths attributable to malnutrition among children in rural Kenya Am. J. Clinical Nutrition, December 1, 2008; 88(6): 1626 - 1631. [Abstract] [Full Text] [PDF]

				J. Best and S. Hughes Evidence behind the WHO Guidelines: Hospital Care for Children--What are the Useful Clinical Features of Bacterial Meningitis Found in Infants and Children? J Trop Pediatr, April 1, 2008; 54(2): 83 - 86. [Full Text] [PDF]

				S. Gwer, C. R.J.C. Newton, and J. A. Berkley Over-Diagnosis and Co-Morbidity of Severe Malaria in African Children: A Guide for Clinicians Am J Trop Med Hyg, December 1, 2007; 77(6_Suppl): 6 - 13. [Abstract] [Full Text] [PDF]

				K. D. Cowgill, M. Ndiritu, J. Nyiro, M. P. E. Slack, S. Chiphatsi, A. Ismail, T. Kamau, I. Mwangi, M. English, C. R. J. C. Newton, et al. Effectiveness of Haemophilus influenzae type b Conjugate vaccine introduction into routine childhood immunization in Kenya. JAMA, August 9, 2006; 296(6): 671 - 678. [Abstract] [Full Text] [PDF]

				J. A Berkley, K. Maitland, I. Mwangi, C. Ngetsa, S. Mwarumba, B. S Lowe, C. R. Newton, K. Marsh, J A. G Scott, and M. English Use of clinical syndromes to target antibiotic prescribing in seriously ill children in malaria endemic area: observational study BMJ, April 30, 2005; 330(7498): 995. [Abstract] [Full Text] [PDF]