Clinical Research Department, KEMRI-Wellcome Trust Research Programme, P.O. Box 230 80108, Kilifi, Kenya.
Department of Global Health, Faculty of Medicine, University of Amsterdam, Amsterdam, The Netherlands.
BMC Med. 2021 Jun 4;19(1):122. doi: 10.1186/s12916-021-01998-3.
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.
We 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.
Among 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).
A 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.
诊断细菌性脑膜炎对于优化抗菌治疗的类型和持续时间以限制死亡率和后遗症至关重要。在撒哈拉以南非洲，许多公立医院缺乏实验室能力，依靠临床特征来经验性地治疗或不治疗脑膜炎。我们研究了在引入结合疫苗之前确定的细菌性脑膜炎的临床特征是否仍然可以区分 60 天以上儿童的脑膜炎。
我们进行了一项回顾性队列研究，以验证 2002 年确定的 7 项临床特征（KCH-2002）：前囟膨隆、颈部僵硬、发绀、发热性抽搐年龄范围外的抽搐、局灶性抽搐、意识障碍或无疟疾寄生虫血症和发热、综合儿童疾病管理（IMCI）体征：颈部僵硬、嗜睡、意识障碍或抽搐，并在引入结合疫苗后入院时评估，以区分细菌性脑膜炎。本分析纳入了 2012 年至 2016 年在基利菲县医院住院的年龄≥60 天的儿童。脑膜炎定义为脑脊液（CSF）培养阳性、CSF 显微镜下观察到病原体、CSF 抗原检测阳性、白细胞≥50/μL 或 CSF 与血糖比值＜0.1。
在 12837 例入院患者中，98 例（0.8%）患有脑膜炎。KCH-2002 特征的存在具有 86%（95%CI 77-92）的敏感性和 38%（95%CI 37-38）的特异性。排除“无疟疾寄生虫血症的发热”可将敏感性降低至 58%（95%CI 48-68），特异性增加至 80%（95%CI 79-80）。IMCI 特征的敏感性为 80%（95%CI 70-87），特异性为 62%（95%CI 61-63）。
细菌性脑膜炎的患病率较低，且与 2002 年相比，体征不那么典型，这意味着 KCH-2002 特征的性能降低。临床医生和决策者应该意识到每例脑膜炎需要进行腰椎穿刺（LP）或经验性治疗的次数。建立基本的 CSF 分析能力对于排除有潜在体征的儿童细菌性脑膜炎至关重要。
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