_id

683a1613c782e11e38d1b198

id

3911

title

Bacterial Meningitis Score for Children

full_title

Bacterial Meningitis Score for Children

short_title

Bacterial Meningitis Score

med_description

Rules out bacterial meningitis.

short_description

Likelihood of bacterial meningitis in children.

slug

bacterial-meningitis-score-children

description

The Bacterial Meningitis Score for Children predicts likelihood of bacterial (versus aseptic) meningitis in children.

keywords

Meningitis, bacterial meningitis, antibiotics, lumbar puncture, LP, spinal tap, CSF, cerebrospinal fluid, pleocytosis, BMS

complaint

[ "Agitation", "Fever", "Headache", "Seizure" ]

formula

Addition of the selected points:

evidence

The original Bacterial Meningitis Score was derived from a multicenter, retrospective cohort study published by Nigrovic et al in JAMA 2007.  Data were collected from 20 participating emergency departments of academic medical centers over a three year period. 3,295 patients aged 29 days to 19 years with CSF pleocytosis were scored using the BMS.

Of the 1,714 who were categorized as very low risk, two were found to have bacterial meningitis. Both miscategorized patients were <2 months of age and had E. coli meningitis with an E. coli UTI but negative urinalysis.

Sensitivity of BMS for bacterial meningitis was 98.3% (95% CI 94.2-99.8%). NPV was 99.9% (95% CI 99.6-100%). The investigators attempted to refine the score using recursive partitioning, which led to a simpler model with only three variables, but it also led to one additional patient with meningitis being misclassified as very low risk.

Given the two misclassified patients were under the age of two months, the investigators analyzed the BMS for a subgroup of all patients under two months of age and found sensitivity was 92.3% (95% CI 74.9-99.4%), NPV 99.5% (95% CI 98.3-99.9%).

The BMS was validated by Nigrovic et al in Archive of Disease in Childhood, 2012. This was a meta analysis of studies published between 2002 and 2012 and included 4,896 patients aged 29 days to 19 years. Sensitivity was 99.3% (95% CI 98.7-99.7%) for bacterial meningitis and NPV was 98.3% (95% CI 96.6-99.3%).

Kulik et al in 2013 published a systematic review of several bacterial meningitis predictive rules, and of the studies reviewed, the BMS had the highest quality evidence and the best performance to date. They recommended that the score still be further evaluated with prospective trials.

measurements

[]

information

Interpretation:

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/17200475", "text": "Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007;297(1):52-60." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/12359784", "text": "Nigrovic LE, Kuppermann N, Malley R. Development and validation of a multivariate predictive model to distinguish bacterial from aseptic meningitis in children in the post-haemophilus influenza era. Pediatrics. 2002; 110: 712-9." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/23910166", "text": "Kulik DM, Uleryk EM, Maguire JL. Does this child have bacterial meningitis? A systematic review of clinical prediction rules for children with suspected bacterial meningitis. J Emerg Med. 2013;45(4):508-19." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/22764093 ", "text": "Nigrovic LE, Malley R, Kuppermann N. Meta-analysis of bacterial meningitis score validation studies. Arch Dis Child. 2012;97(9):799-805." } ], "Validations": [] }

pearls

• The Bacterial Meningitis Score (BMS) predicts bacterial vs. aseptic etiology in pediatric patients (aged 29 days to 19 years) with suspected meningitis.  

• Can help determine if the patient will require admission for parenteral antibiotics while awaiting CSF culture results.
• Higher score indicates higher likelihood of bacterial meningitis.
• Sensitivity, specificity, and negative predictive value of the BMS decrease significantly for children under the age of 2 months.
• Creators of the BMS advise against using the score in children who have already received antibiotics prior to LP, are ill-appearing, are <2 months of age, or have exam findings indicative of invasive bacterial infection such as petechiae and purpura.
• Not effective at ruling out potentially harmful nervous system infections requiring antibiotics (e.g. herpes encephalitis, Lyme meningitis, tuberculous meningitis).
• Meningococcal meningitis can present without CSF pleocytosis; thus, these patients can be misclassified as not having inclusion criteria for the use of the BMS. It is important to perform a thorough physical exam to assess for petechiae or purpura if there is suspicion for meningococcemia or meningitis, as CSF may be falsely normal.

usecase

Pediatric patients (aged 29 days to 19 years) with suspected meningitis.

Do NOT use if the patient:

• Is critically ill, requiring respiratory or vasopressor support.
• Received antibiotics <72 hours prior to lumbar puncture.
• Has a VP shunt or recent neurosurgery.
• Is immunosuppressed.
• Has proof of another bacterial infection (e.g. UTI, bone infection, known bacteremia) that warrants inpatient antibiotic therapy.
• Has known active Lyme Disease.

reasons

Bacterial meningitis incidence has dramatically decreased since the advent of highly effective vaccines against the more common causes (H. flu,S. pneumo), making it more challenging to determine which patients should be admitted and observed while awaiting CSF culture results. Helps stratify which patients do not necessarily require observation, due to higher likelihood of aseptic (i.e., spontaneously resolving) meningitis. Helps avoid financial burden and health risk associated with hospitalization for observation and parenteral antibiotic administration.

next_advice

next_actions

• Physician gestalt, severity of illness and clinical presentation supersedes the application of the BMS prediction rule.
• If significant suspicion for bacterial meningitis, err on the side of caution and admit for observation and empiric antibiotics.

next_management

For patients at very low risk for bacterial meningitis (BMS 0):

• Consider discharge with close follow-up (ideally within 24–48 hours) and return precautions for family, including new seizure activity, altered mental status, purpuric rash, or other concerning symptoms.
• Consider a single dose of long-acting antibiotics with good CSF penetration, such as ceftriaxone, prior to discharge.

For patients with at least 1 risk factor for bacterial meningitis or high clinical suspicion (BMS >0):

• Consider admission for parenteral antibiotics and observation while awaiting CSF culture results.
• Make sure CSF is sent for culture.
• Consider continuous monitoring of vital signs and regular neurologic exams.
• If not previously administered, start empiric broad spectrum antibiotics.
• Consider expanding antimicrobial coverage:
• If concern for herpes encephalitis, add acyclovir.
• If high clinical suspicion for tuberculous meningitis, consult with infectious disease specialist and consider rifAMPin, isoniazid, pyrazinamide, and a fluoroquinolone or aminoglycoside.
• Consider steroid administration based on clinical presentation, geographic area, and potential risk factors.

diseases

[ "Meningitis" ]

input_schema

[ { "conditionality": "", "default": 0, "label_en": "<abbr title='Cerebrospinal Fluid'>CSF</abbr> Gram stain positive", "md_calc_info_concept": null, "name": "gram", "option_fhir_rules": null, "optional": false, "options": [ { "label": "No", "value": 0 }, { "label": "Yes", "value": 1 } ], "show_points": true, "tips_en": "", "type": "toggle" }, { "conditionality": "", "default": 0, "label_en": "CSF <abbr title='Absolute Neutrophil Count'><calculator id='19'>ANC</calculator></abbr> ≥1,000 cells/µL", "md_calc_info_concept": null, "name": "spinal_neut", "option_fhir_rules": null, "optional": false, "options": [ { "label": "No", "value": 0 }, { "label": "Yes", "value": 1 } ], "show_points": true, "tips_en": "", "type": "toggle" }, { "conditionality": "", "default": 0, "label_en": "CSF protein ≥80 mg/dL (800 mg/L)", "md_calc_info_concept": null, "name": "prot", "option_fhir_rules": null, "optional": false, "options": [ { "label": "No", "value": 0 }, { "label": "Yes", "value": 1 } ], "show_points": true, "tips_en": "", "type": "toggle" }, { "conditionality": "", "default": 0, "label_en": "Peripheral blood <calculator id='19'>ANC</calculator> ≥10,000 cells/µL", "md_calc_info_concept": null, "name": "blood_anc", "option_fhir_rules": null, "optional": false, "options": [ { "label": "No", "value": 0 }, { "label": "Yes", "value": 1 } ], "show_points": true, "tips_en": "", "type": "toggle" }, { "conditionality": "", "default": 0, "label_en": "Seizure at (or prior to) initial presentation", "md_calc_info_concept": null, "name": "seizures", "option_fhir_rules": null, "optional": false, "options": [ { "label": "No", "value": 0 }, { "label": "Yes", "value": 1 } ], "show_points": true, "tips_en": "", "type": "toggle" } ]

instructions

Use in patients aged 29 days to 19 years with CSF WBC ≥10 cells/μL. Do not use if patient is critically ill, recently received antibiotics, has a VP shunt or recent neurosurgery, is immunosuppressed, or has other bacterial infection requiring antibiotics (including Lyme disease).

published

2022-04-21T20:29:23.952Z

purpose

[ "Diagnosis", "Rule Out" ]

search_terms

[ "gram stain", "csf protein", "anc", "seizures", "spinal fluid", "bms", "bacterial meningitis", "aseptic meningitis", "csf", "spinal tap", "lumbar puncture", "LP", "cerebrospinal fluid", "spinal fluid", "pleocytosis", "meningitis" ]

seo

{ "keywords_en": "Meningitis, bacterial meningitis, antibiotics, lumbar puncture, LP, spinal tap, CSF, cerebrospinal fluid, pleocytosis, BMS ", "meta_description_en": "The Bacterial Meningitis Score for Children predicts likelihood of bacterial (versus aseptic) meningitis in children." }

specialty

[ "Critical Care (Pediatric)", "Emergency Medicine", "Family Practice", "Infectious Disease", "Pediatrics" ]

departments

[ "Immunologic", "Infectious", "Neurologic" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 10204, "short_title_en": "PECARN Febrile Infants (29-60 Days Old)", "slug": "pecarn-rule-low-risk-febrile-infants-29-60-days-old" }, { "calcId": 19, "short_title_en": "Absolute Neutrophil Count", "slug": "absolute-neutrophil-count-anc" }, { "calcId": 3401, "short_title_en": "Immunization Schedule Calculator", "slug": "immunization-schedule-calculator" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "immunology", "infectious", "neurology" ]

cleaned_use

[ "Pediatric patients (aged 29 days to 19 years) with suspected meningitis.", "Is critically ill, requiring respiratory or vasopressor support.", "Received antibiotics <72 hours prior to lumbar puncture.", "Has aVPshunt or recent neurosurgery.", "Is immunosuppressed.", "Has proof of another bacterial infection (e.g. UTI, bone infection, known bacteremia) that warrants inpatient antibiotic therapy.", "Has known active Lyme Disease." ]

pub

false