Performance of Thirteen Clinical Rules to Distinguish Bacterial and Presumed Viral Meningitis in Vietnamese Children

Background and PurposeSuccessful outcomes from bacterial meningitis require rapid antibiotic treatment; however, unnecessary treatment of viral meningitis may lead to increased toxicities and expense. Thus, improved diagnostics are required to maximize treatment and minimize side effects and cost. Thirteen clinical decision rules have been reported to identify bacterial from viral meningitis. However, few rules have been tested and compared in a single study, while several rules are yet to be tested by independent researchers or in pediatric populations. Thus, simultaneous test and comparison of these rules are required to enable clinicians to select an optimal diagnostic rule for bacterial meningitis in settings and populations similar to ours. MethodsA retrospective cross-sectional study was conducted at the Infectious Department of Pediatric Hospital Number 1, Ho Chi Minh City, Vietnam. The performance of the clinical rules was evaluated by area under a receiver operating characteristic curve (ROC-AUC) using the method of DeLong and McNemar test for specificity comparison. ResultsOur study included 129 patients, of whom 80 had bacterial meningitis and 49 had presumed viral meningitis. Spanos's rule had the highest AUC at 0.938 but was not significantly greater than other rules. No rule provided 100% sensitivity with a specificity higher than 50%. Based on our calculation of theoretical sensitivity and specificity, we suggest that a perfect rule requires at least four independent variables that posses both sensitivity and specificity higher than 85–90%. ConclusionsNo clinical decision rules provided an acceptable specificity (>50%) with 100% sensitivity when applying our data set in children. More studies in Vietnam and developing countries are required to develop and/or validate clinical rules and more very good biomarkers are required to develop such a perfect rule.

背景与目的：细菌性脑膜炎的成功救治需依托快速抗生素治疗，但对病毒性脑膜炎实施不必要的治疗可能会增加药物毒性反应与医疗成本。因此，亟需优化诊断方案，以最大化治疗收益并最小化不良反应与医疗开销。目前已有13项临床决策规则被提出，用于区分细菌性与病毒性脑膜炎。然而，仅有少数规则在单一研究中得到测试与对比，尚有多项规则未被独立研究者验证，或未在儿科人群中开展评估。因此，亟需对上述规则进行同步测试与对比，以便临床医师能够在与本研究相似的环境与人群中，选择最优的细菌性脑膜炎诊断决策规则。
研究方法：本研究在越南胡志明市第一儿童医院感染科开展了一项回顾性横断面研究。采用DeLong法与McNemar检验进行特异性比较，通过受试者工作特征曲线下面积（ROC-AUC）评估各项临床规则的诊断性能。
研究结果：本研究共纳入129例患者，其中80例确诊为细菌性脑膜炎，49例为疑似病毒性脑膜炎。Spanos规则的ROC-AUC最高，达0.938，但与其他规则相比无显著统计学差异。所有规则均无法在特异性高于50%的前提下达到100%灵敏度。通过理论灵敏度与特异性测算，本研究提出，理想的诊断决策规则至少需要包含4个独立变量，且其灵敏度与特异性均需达到85%~90%以上。
研究结论：基于本研究的儿科数据集，尚无任何一项临床决策规则能够在特异性>50%的前提下实现100%灵敏度。未来需在越南及其他发展中国家开展更多相关研究，以开发和/或验证临床决策规则，同时亟需更多优质生物标志物，以构建上述理想的诊断规则。