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Outpatient management of children at low risk for bacterial meningitis
  1. Silvia Garcia1,2,
  2. Janire Echevarri1,2,
  3. Eunate Arana-Arri3,
  4. Mercedes Sota4,
  5. Javier Benito1,2,
  6. Santiago Mintegi1,2
  7. on behalf of the Meningitis group of RISEUP-SPERG
    1. 1Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
    2. 2Department of Pediatrics, University of the Basque Country, Bilbao, Spain
    3. 3Clinical Epidemiology Unit, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
    4. 4Microbiology Department, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
    1. Correspondence to Dr Santiago Mintegi, Paediatric Emergency Department, Cruces University Hospital, Bilbao 48903, Spain; santiago.mintegi{at}osakidetza.eus

    Abstract

    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.

    • infectious diseases
    • paediatrics, paediatric emergency medicine

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    Footnotes

    • Contributors SG conceptualised and designed the study, supervised data collection, analysed the data, wrote the initial draft of the manuscript and approved the final manuscript as submitted. JE supervised data collection, analysed the data and approved the final manuscript as submitted. EA-A collaborated in the design of the study, analysed the data and critically revised the manuscript. MS supervised data collection and approved the final manuscript as submitted. JB collaborated in the design of the study and critically revised the manuscript. SM collaborated in the design of the study, analysed the data, revised multiple versions of the initial manuscript and critically revised the final manuscript. All the members of the meningitis group of RISEUP-SPERG gave the final approval of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Parental/guardian consent obtained.

    • Ethics approval Ethical Committee of the Basque Country.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators Meningitis group of Research Network of the Spanish Society for Paediatric Emergency Medicine (RISEUP-SPERG). Site investigators: Ana Isabel Fernandez (Paediatric Emergency Department, Basurto University Hospital, Bilbao, Basque Country, Spain); Sara Puente (Paediatric Department, Río Hortega Hospital, Valladolid, Spain); Anna Fernandez (Paediatric Department, Arnau de Vilanova de Lleida University Hospital, Lleida, Spain); Itziar Iturralde (Paediatric Department, Quiron Bizkaia Hospital, Bilbao, Basque Country, Spain); Maria Jose Martin (Paediatric Emergency Department, Niño Jesus Paediatric University Hospital, Madrid, Spain); Jose Rodriguez (Paediatric Department, Virgen de la Arrixaca University Hospital, Murcia, Spain).

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