Abstract
BackgroundDiagnosing bacterial meningitis is essential to optimise the type and duration of antimicrobial therapy to limit mortality and sequelae. In sub-Saharan Africa, many public hospitals lack laboratory capacity, relying on clinical features to empirically treat or not treat meningitis. We investigated whether clinical features of bacterial meningitis identified prior to the introduction of conjugate vaccines still discriminate meningitis in children aged ≥60 days.MethodsWe conducted a retrospective cohort study to validate seven clinical features identified in 2002 (KCH-2002): bulging fontanel, neck stiffness, cyanosis, seizures outside the febrile convulsion age range, focal seizures, impaired consciousness, or fever without malaria parasitaemia and Integrated Management of Childhood Illness (IMCI) signs: neck stiffness, lethargy, impaired consciousness or seizures, and assessed at admission in discriminating bacterial meningitis after the introduction of conjugate vaccines. Children aged ≥60 days hospitalised between 2012 and 2016 at Kilifi County Hospital were included in this analysis. Meningitis was defined as positive cerebrospinal fluid (CSF) culture, organism observed on CSF microscopy, positive CSF antigen test, leukocytes ≥50/μL, or CSF to blood glucose ratio <0.1.ResultsAmong 12,837 admissions, 98 (0.8%) had meningitis. The presence of KCH-2002 signs had a sensitivity of 86% (95% CI 77–92) and specificity of 38% (95% CI 37–38). Exclusion of ‘fever without malaria parasitaemia’ reduced sensitivity to 58% (95% CI 48–68) and increased specificity to 80% (95% CI 79–80). IMCI signs had a sensitivity of 80% (95% CI 70–87) and specificity of 62% (95% CI 61–63).ConclusionsA lower prevalence of bacterial meningitis and less typical signs than in 2002 meant the lower performance of KCH-2002 signs. Clinicians and policymakers should be aware of the number of lumbar punctures (LPs) or empirical treatments needed for each case of meningitis. Establishing basic capacity for CSF analysis is essential to exclude bacterial meningitis in children with potential signs.
Highlights
Diagnosing bacterial meningitis is essential to optimise the type and duration of antimicrobial therapy to limit mortality and sequelae
We examined the performance of Kilifi County Hospital (KCH)-2002 [11] and Integrated Management of Childhood Illness (IMCI) signs [9] at admission by calculating their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for meningitis diagnosed by lumbar puncture (LP) either at admission or at any time during hospitalisation versus no meningitis, defined as negative cerebrospinal fluid (CSF) analysis or no clinical suspicion of meningitis until discharge from hospital
Median [interquartile range (IQR)] age of 565 children who died before an LP was 21 months (8.0–60) compared to 20 months (9.5– 59) in 88 children who died after an LP (P=0.874)
Summary
Diagnosing bacterial meningitis is essential to optimise the type and duration of antimicrobial therapy to limit mortality and sequelae. In sub-Saharan Africa, many public hospitals lack laboratory capacity, relying on clinical features to empirically treat or not treat meningitis. We investigated whether clinical features of bacterial meningitis identified prior to the introduction of conjugate vaccines still discriminate meningitis in children aged ≥60 days. CSF culture is the gold standard for bacterial meningitis but has limited sensitivity [4] as it may be compromised by prior administration of antimicrobials [5] and is usually unavailable or unreliable in public hospitals in sub-Saharan Africa. Public hospitals often lack adequate CSF microscopy capacity, and lumbar puncture (LP) may be commonly ordered but not done [6, 7]. Antimicrobial management decisions are often based on clinical features only
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