The first patient on my first day as an attending was:
a well-appearing 12 yo old female with a one week history of fever and headache. Nuchal rigidity on exam with no other signs or symptoms of meningismus .
Her blood white count was 7.7. Her CSF showed 650 WBCs (16 Segs/ O Bands/ 72 Lymphs), 10 RBCS, a gram stain was negative, withGLU 63/PRO 71. I gave the patient ceftriaxone and admitted her to the floor.
The next day at morning report I was criticized by a peds ID attending that this was clearly a case of enteroviral meningitis and that the patient should not have been treated, and when I did decide to treat I should have added vancomycin.
I'm more interested in the first issue as to whether any physicians out there would in fact be confident enough to not treat such a patient. The best clinical decision rule I encountered quoted a top sensitivity of 98% and that doesn't seem good enough for the possible sequelae of bacterial meningitis.
Any thoughts and salient references would be appreciated.
Evan Mahl, MD
Division of Pediatric Emergency Medicine
SUNY Downstate Medical Center
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