Meningitis—Viral Versus Bacterial
Fred D. Haruda, MDTucson, AZ 85717-1297, USA
To the Editor.—
The article by Nigrovic et al1 is thought-provoking but must be considered with caution by practitioners. As a child neurologist, I have seen hundreds of cases of bacterial meningitis and thousands of cases of viral meningitis. Although I have a "good feel" for which is which, I have been surprised by culture-proven bacterial meningitis with cerebrospinal fluid protein of <46 or pleiocytosis of <10. Partially treated meningitis further clouds the issue. I have also been asked to step in and pick up the pieces after someone else had guessed wrong, with catastrophic results.
I can state that I have never guessed wrong because I always treat suspected bacterial meningitis as if it was proven, a "full-court press" starting at the initial presentation, even if the case looks viral. I have done the following risk-benefit analysis: What is the worst outcome if I treat the patient? Possibly a drug reaction, but the patient is hospitalized so I can catch it quickly. What is the worst outcome if I don’t treat the patient? Death. To treat is a "no-brainer"; it’s best for the patient. This analysis does not take into account the risk-benefit analysis for the practitioner treating the patient.
One hopes that medical insurance carriers do not demand the premature discharge of patients before culture results are available. This would place practitioners in an impossible situation. Outpatient treatment of bacterial meningitis has not been shown to be an effective alternative.
The safest and most prudent course of action is "to hope for the best and treat for the worst."
REFERENCE
- Nigrovic LE, Kuppermann N, Malley R. Development and validation of a multivariable predictive model to distinguish bacterial from aseptic meningitis in children in the post-Haemophilus influenzae era.
Pediatrics.2002; 110
:712
–719
[Abstract/Free Full Text]
Lise E. Nigrovic, MD*
Nathan Kuppermann, MD, MPH
Richard Malley, MD*,
* Department of Medicine
Divisions of Infectious Diseases and Emergency Medicine Childrens Hospital and Harvard Medical School, Boston, MA, USA
Department of Internal Medicine Division of Emergency Medicine and
Department of Pediatrics
University of California Davis
Davis, CA, USA
In Reply.—
In our study of 696 hospitalized children with meningitis, we derived and validated a prediction rule to identify nonpretreated children at very low risk of bacterial meningitis.1 Dr Haruda is concerned that, based on his experience, some patients who are predicted to be at low risk by our model (negative Gram stain, cerebrospinal fluid absolute neutrophil count (ANC) <1000 cells/mm3, peripheral ANC <10 000 cells/mm3, cerebrospinal protein <80 mg/dL, and no seizure at or before presentation) may actually have bacterial meningitis.
We share Dr Haruda’s concerns that any prediction rule may erroneously classify patients, a concern that is all the more relevant when the disease in question is as serious as bacterial meningitis. At the same time, we strongly disagree with his contention that a clinical decision rule has no role in the management of patients with meningitis. It is worthwhile to point out here that the purpose of a predictive model is to assist the physician in reaching a decision regarding the most appropriate management of a clinical situation, not to replace nor dictate clinical decision-making. Clearly, only patients who are deemed to be well-appearing and well-hydrated by the clinician and who are predicted to be at very low risk for bacterial meningitis by our model should be considered for early discharge. For these very low-risk patients, we believe that it is appropriate to consider outpatient management after the administration of long-acting antibiotics.
Given that 60% of hospitalized patients in our series had a score of 0 by our model (and therefore an estimated risk of bacterial meningitis 
0.5%), it is clear that the hospitalization of many of these patients could be avoided. The inappropriate admission of low-risk patients with meningitis is not without risks. Serious complications from medical errors in hospitalized patients have been extensively reported2–5; additionally, hospitalization can lead to emotional trauma to patients and their families. We believe that the use of our model may help reduce the risk of such occurrences.
REFERENCES
- Nigrovic LE, Kuppermann N, Malley R. Multivariate predictive model to distinguish bacterial from aseptic meningitis in hospitalized children in the post-Haemophillus influenzae era. Pediatrics.2002; 110 :712 –719
- Institute of Medicine. To Err Is Human. Building a Safer Health System. Washington, DC: National Academy Press; 1999
- Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events and negligence in hospitalized patients: results from the Harvard Medical Practice Study I. N Engl J Med.1991; 324 :370 –376[Abstract]
- Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care.2000; 38 :261 –271[CrossRef][Web of Science][Medline]
- Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients.
JAMA.2001; 285
:2114
–2120
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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