PEDIATRICS Vol. 123 No. 2 February 2009, pp. e366-e367 (doi:10.1542/peds.2008-3720)
LETTER TO THE EDITOR |
Clinical Prediction Rules for Meningitis in Children Pretreated With Antibiotics: In Reply
Lise E. Nigrovic, MD, MPHDivision of Emergency Medicine
Richard Malley, MD
Divisions of Infectious Diseases and Emergency Medicine,
Children's Hospital Boston,
Boston, Massachusetts
Nathan Kuppermann, MD, MPH
Departments of Emergency Medicine and Pediatrics,
University of California,
Davis Medical Center,
Sacramento, California
We appreciate the thoughtful comments and careful review of our manuscript by Drs Devlin and Devlin. As we described in our recent article,1 before performance of a diagnostic lumbar puncture, many children with meningitis receive antibiotics, which may render bacterial culture results falsely negative. Clinicians then have difficulty determining the appropriate duration of antibiotic treatment for these children with pretreated culture-negative meningitis.
If one could determine which patients with pretreated culture-negative meningitis actually have bacterial meningitis, the creation of an accurate prediction rule may be possible. However, because we do not know which of these children have bacterial meningitis, we strongly caution against the application of current meningitis predictive models such as the Bacterial Meningitis Score2 to children with pretreated meningitis. As we demonstrated, antibiotic pretreatment affects the biochemical profiles of children with culture-positive bacterial meningitis. Prediction rules for bacterial meningitis must be extremely accurate, because misclassification of a child with bacterial meningitis can have grave consequences. This type of misclassification could occur on a child whose cerebrospinal fluid (CSF) protein level was below the threshold of the prediction rule as a result of antibiotic pretreatment. In addition, we cannot comment on the influence of antibiotic pretreatment on CSF profiles of children with pretreated culture-negative meningitis, because we did not study these patients for the same reason. The accuracy of a meningitis clinical prediction rule cannot be measured in patients with pretreated culture-negative meningitis, because there is no gold standard to identify which of these children in fact have bacterial meningitis.
As pediatricians, we understand the difficulties in making management decisions for children with pretreated culture-negative meningitis. In the absence of a validated clinical decision rule for these patients, we recommend combining experienced clinical judgment, hematologic and CSF profiles, and viral diagnostic tests to help guide antibiotic therapy and duration in pretreated, otherwise well-appearing children with culture-negative meningitis.
REFERENCES
1. Nigrovic LE, Malley R, Macias CG, et al. Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis.
Pediatrics. 2008;122
(4):726
–730
2. Nigrovic LE, Kuppermann N, Macias CG, et al. A clinical decision rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
JAMA. 2007;297
(1):52
–60
PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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