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Stephen B. Freedman, MDCM, FRCPC; Angela Marrocco, BSc, BPHE; Jonathan Pirie, MD, MEd, FRCPC; Paul T. Dick, MDCM, MSc, FRCPC

Arch Pediatr Adolesc Med. 2001;155:1301-1306.

Objective  To determine if, in the era after Haemophilus influenzae type b, the cerebrospinal fluid (CSF) white blood cell (WBC) count can be safely used to stratify children suspected of having bacterial meningitis into low- and high-risk groups.

Design  Retrospective analysis of CSF samples.

Setting  Tertiary care pediatric center in Toronto, Ontario, between January 1, 1992, and October 1, 1996.

Patients  All CSF samples collected on children aged 2 months to 17 years were included. The final database consisted of 1617 atraumatic samples from children without prior neurologic or immunologic disease who underwent a lumbar puncture to assess the possibility of community-acquired bacterial meningitis.

Main Outcome Measures  The predictive values of CSF WBC count, differential, protein, and glucose.

Results  There were 44 cases of bacterial meningitis. Five had 3 CSF WBCs per microliter or less, and 6 had 4 to 30 CSF WBCs per microliter. The negative predictive value of CSF specimens with 30 WBCs per microliter or less for bacterial meningitis was 99.3%. Cerebrospinal fluid samples with greater than 30 WBCs per microliter had a likelihood ratio for bacterial meningitis of 10.3 (95% confidence interval, 8.0-13.1) and a positive predictive value of 22.3%. Other significant predictors of bacterial meningitis included age, CSF glucose, protein, gram stain, CSF–serum glucose ratio, and peripheral blood band count.

Conclusions  Given the occurrence of bacterial meningitis in children in the absence of CSF pleocytosis, other factors should be considered when managing children with suspected bacterial meningitis. Children older than 6 months with 30 CSF WBCs per microliter or less are at low risk for bacterial meningitis. If clinically stable and without other laboratory markers of bacterial meningitis, hospital admission and empiric antibiotic therapy may be unwarranted.

From the Departments of Pediatrics and Health Administration, Faculty of Medicine, University of Toronto (Drs Freedman, Pirie, and Dick), the Pediatric Outcomes Research Team, Division of Pediatric Medicine (Ms Marrocco and Dr Dick), and the Division of Emergency Medicine (Dr Pirie), The Hospital for Sick Children, Toronto, Ontario.

Corresponding author and reprints: Paul T. Dick, MDCM, MSc, FRCPC, Pediatric Outcomes Research Team, Division of Pediatric Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8 (e-mail: paul.dick{at}sickkids.on.ca).

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