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acterial meningitis score is valid in otheropulations of childrenubos F, De la Rocque F, Levy C, Bingen E, Aujard Y, Cohen, et al. Sensitivity of the bacterial meningitis score in 889hildren with bacterial meningitis. J Pediatr 2008;152:378-82.

uestion In children with bacterial meningitis, how welloes a previously validated bacterial meningitis score (BMS)orrectly identify affected children?

esign Secondary analysis of prospective data for childrenresenting with bacterial meningitis to hospital emergencyepartments between January 2001 and February 2005.

etting France.

articipants 900 children aged 29 days to 18 years withcute bacterial meningitis.

ntervention The BMS was applied to all children withcute bacterial meningitis with the same inclusion criteriaroposed by the authors of the rule.

utcome Sensitivity of the BMS rule.

esults Use of the BMS correctly identified 884 childrenith bacterial meningitis, for 99.6% sensitivity (95% CI,8.9%-99.8%).

onclusions The sensitivity of the BMS in detecting diseaseas very high, but a few cases of bacterial meningitis wereissed. Further refinements of the BMS may be warranted to

ower the false-negative rate.

ommentary In recent years, we have become “score hunt-rs,” looking for evidence-based ways to justify our gestalt foretermining who has bacterial meningitis and who does not.he French Surveillance Network should be applauded foretting us even closer to understanding scoring for bacterialeningitis. In this study, they try to validate the most recently

eveloped score, by Nigrovic et al,1 by using a large cohort ofhildren �29 days old from a different geographic location.hey succeeded in finding a very high sensitivity rate (99.6%)

nd bringing the confidence interval to almost 100%. Yet,ven in a large cohort like this (n � 889), 5 children witheningitis would have been “missed” with the score. Beyond

nhancing the level of evidence of the score and supporting itsse with caution, the study illustrates that we may never reachscore that will apply to all infants and children with bacterialeningitis, no matter what population or during what era we

ry to do so. Furthermore, with such a good (but not a perfect)core, we should consider the ethical question related tonvestigating, prescribing antibiotics, admitting and spendingarge amounts of money on hundreds of children to find theew with true bacterial meningitis. We can potentially “save”o much if we decide to “accept” a score and with it theemote possibility of discharging home from the emergencyepartment a small percentage of children with bacterialeningitis. It seems that the current consensus is that this

ate is 0%, and we should be investigating and treating all r

46

hildren with suspected meningitis. That is, until we find theultimate” score.

Ran D. Goldman, MDUniversity of British Columbia

Vancouver, BC, Canada

REFERENCE. Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM,chremmer RD, et al. Clinical prediction rule for identifying children with cerebrospinaluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52-60.

mall increases in prednisolone can preventelapse during upper respiratory infections inatients with nephrotic syndromebeyagunawardena AS, Trompeter RS. Increasing the dose ofrednisolone during viral infections reduces the risk of relapse

n nephrotic syndrome: a randomised controlled trial. Archis Child 2008;93:226-8.

uestion In children with nephrotic syndrome, does a smallhort-term increase in the dose of prednisolone reduce theisk of relapse during viral upper respiratory tract infectionsURTIs), compared with placebo?

esign Randomized, double-blind, placebo-controlled cross-ver trial.

etting Nephrology clinic at a tertiary referral center in Srianka.

articipants 48 children receiving low-dose (�0.6 mg/kg)rednisolone on alternate days as maintenance therapy wereecruited, and 40 completed the trial (29 male, 11 female).ge at entry ranged from 1.5 to 13.2 years (median, 5.3

ears).

ntervention At the first sign of a URTI, patients wereandomized to receive either placebo or prednisolone on theays when they were not regularly scheduled to get pred-isolone. The intervention lasted 7 days (ie, 3 or 4 extra dosesf prednisolone) and the prednisolone dose (or placebo dose)as identical to the patient’s usual alternative day pred-isolone dose. During a subsequent URTI, the patientsrossed over interventions.

utcomes Relapse, defined as the presence of 3� protein-ria for 3 consecutive days.

esults The relapse rate after viral URTI was 19 of 40 (48%)n the placebo group and 7 of 40 (18%) in the prednisoloneroup (P � .014, number needed to treat [NNT] � 4). Theean dose of alternate day prednisolone was 0.36 mg/kg

range, 0.1-0.6 mg/kg). No significant adverse effects of thencreased prednisolone were noted.

onclusions Additional doses of prednisolone during URTIsn patients with glucocorticoid-dependent nephrotic syn-rome maintained on alternative day prednisone decreases the

elapse rate without notable adverse effects.

The Journal of Pediatrics • July 2008

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omment The treatment of patients with frequently relaps-ng nephrotic syndrome, glucocorticoid-dependent nephroticyndrome, or both poses many challenges for clinicians andamilies. In many patients, prolonged low-dose alternate-daylucocorticoid therapy provides adequate control without sig-ificant adverse effects. In this study, a URTI triggered re-

apse in �50% of the patients treated with placebo. This trialrovides evidence that an additional 3 to 4 relatively low dosesf prednisolone can reduce the relapse rate in these difficult-o-treat patients by �60% during URTIs. This confirms thearlier findings of Mattoo and Mahmoud.1 This study did notescribe how long after a URTI a relapse would be ascribed totreatment group or the number of relapses deemed not

elated to URTIs. In 1 older study, 70% of relapses weressociated with URTIs.2 Thus, this relatively benign strategy

ould have a major impact on the overall incident of relapse in

2v

linical Research Abstracts for Pediatricians

hese patients. For those patients who continue to relapse onlternate-day glucocorticoid therapies, there are a variety ofmmunomodulating agents that can be used, often associatedith significant costs and adverse effects. Definitive con-

rolled trials are needed in this area, and this study stronglyupports the inclusion of a daily glucocorticoid during URTIsn the intervention arm in such trials.

David Kershaw, MDUniversity of MichiganAnn Arbor, Michigan

REFERENCES. Mattoo TK, Mahmoud MA. Increased maintenance corticosteroids during upperespiratory infection decrease the risk of relapse in nephrotic syndrome. Nephron000;85:343-5.

. MacDonald NE, Wolfish N, McLaine P, Phipps P, Rossier E. Role of respiratoryiruses in exacerbations of primary nephrotic syndrome. J Pediatr 1986;108:378-82.

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