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Outpatient management of children at low risk for bacterial meningitis
Silvia Garcia1,2, Janire Echevarri1,2, Eunate Arana-Arri3
1Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain.
Insights
Outpatient management without antibiotics is safe for children with cerebrospinal fluid (CSF) pleocytosis and low risk for bacterial meningitis. This approach avoids unnecessary antibiotic use in pediatric patients.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Decision Making
- Evidence-Based Medicine
Background:
- Cerebrospinal fluid (CSF) pleocytosis in children can indicate meningitis, necessitating careful risk assessment.
- Distinguishing between bacterial and aseptic meningitis is crucial for appropriate management.
- Current guidelines often recommend antibiotics for suspected meningitis, even in low-risk cases.
Purpose of the Study:
- To evaluate the safety and outcomes of managing children aged 2-14 years with CSF pleocytosis and very low risk for bacterial meningitis as outpatients without antibiotics.
- To assess the efficacy of a refined low-risk criteria including procalcitonin (PCT) for outpatient management.
- To compare the diagnostic performance of the Bacterial Meningitis Score (BMS) with and without PCT.
Main Methods:
- A multicentre, prospective, observational study was conducted in nine Spanish pediatric emergency departments.
- Children aged 2-14 years with clinical suspicion of meningitis and CSF pleocytosis were assessed.
- Very low-risk criteria included: well appearance, BMS=0, PCT<0.5 ng/mL, and <24 hours observation without deterioration.
Main Results:
- Of 182 children with meningitis, 45 met very low-risk criteria and were managed as outpatients without antibiotics.
- No patient diagnosed with bacterial meningitis or returned due to clinical deterioration.
- Patients with BMS=1 and PCT <0.5 ng/mL managed as outpatients were diagnosed with aseptic meningitis and had good outcomes.
- BMS incorporating PCT demonstrated equal sensitivity and greater specificity compared to the classic BMS.
Conclusions:
- A defined set of low-risk criteria, including PCT, appears safe for outpatient management of children with CSF pleocytosis without antibiotics.
- This strategy can potentially reduce unnecessary antibiotic exposure in pediatric patients.
- Further research is warranted to validate the predictive value of replacing peripheral absolute neutrophil count (ANC) with PCT in the BMS for broader application.
Objective:
To determine the outcome of children aged 2-14 years with cerebrospinal fluid (CSF) pleocytosis and at very low risk for bacterial meningitis managed as outpatients without antibiotics.
Methods:
Multicentre, prospective, observational study conducted at nine Spanish paediatric EDs. Patients were diagnosed with meningitis based on clinical suspicion of meningitis and CSF pleocytosis when evaluated in the ED. Children between 2 and 14 years of age with pleocytosis and very low-risk criteria for bacterial meningitis (well appearing, Bacterial Meningitis Score (BMS)=0, procalcitonin (PCT)<0.5 ng/mL and observation without deterioration for less than 24 hours in the ED) were treated as outpatients without antibiotics pending CSF cultures. The primary composite outcome was a final diagnosis of bacterial meningitis or return to the ED for clinical deterioration.
Results:
Of 182 children between 2 and 14 years old diagnosed with meningitis, 56 met the very low-risk criteria and 45 were managed as outpatients. None was diagnosed with bacterial meningitis or returned due to clinical deterioration. Another 31 patients with BMS=1 (due to a peripheral absolute neutrophil count (ANC)>10 000/mm3) and PCT <0.5 ng/mL were managed as outpatients, diagnosed with aseptic meningitis and did well. BMS using PCT had the same sensitivity but greater specificity than classic BMS.
Conclusions:
This set of low-risk criteria appears safe for the outpatient management without antibiotics of children with CSF pleocytosis. Larger studies are needed to evaluate the predictive values of replacing peripheral ANC with PCT in the BMS.
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