Table 1

A summary of studies quantifying the diagnostic performance of clinical signs of meningitis

Study settingStudy designInclusion criteriaExclusion criteriaSample sizeLevel of evidence (OCEBM)Key results
Berkley et al 6 Rural district hospital, KenyaCross sectionalAll paediatric patients older than 60 days admitted during 13-month study period.4582 patients
(91 bacterial
meningitis cases)
2 Neck stiffness
LR+ 13.3, LR− 0.74
Lehmann et al 4 Rural hospital, Papua New GuineaCross sectionalChildren aged 1–59 months admitted during normal working hours with suspected meningitis.CSF not collected for analysis.6972 Neck stiffness
Sensitivity 53%, specificity 81%
PPV 39% [NPV 80%]
Offringa et al 11 Urban hospital, NetherlandsCross sectionalAll children between 3 months and 6 years of age who presented with first episode of seizure with fever at two urban hospitals during 2-year period.309 (23 cases)2 Nuchal rigidity
OR 128 if ‘definite’
OR 2.1 if ‘dubious’
Combined history and examination features to define ‘major features of meningitis’
PPV 100%
NPV 98%
Curtis et al 2 GlobalSystematic review of prospective studiesStudies that described history and examination features of children with meningitis confirmed on LP compared with an LP-negative comparison group. Data collected prospectively and amenable to calculation of accuracy estimates.
Not pretreated with antibiotics.
Not prospective.
No comparison group.
No data or mixed data.
Pretreated with antibiotics.
10 studies1 Meningeal signs (any one of NR, KS or BS)
Sensitivity 64%, specificity 89%
LR+ 4.5 (2.4–8.3), LR− 0.41 (0.3–0.57)
Neck stiffness
Sensitivity 51%, specificity 89%
LR+ 4 (2.6–6.3), LR− 0.56 (0.43–0.72)
Kernig’s sign
Sensitivity 53%, specificity 85%
LR+ 3.5 (2.1–5.7), LR− 0.56 (0.41–0.75)
Brudzinski’s sign
Sensitivity 66%, specificity 74%
LR+ 2.5 (1.8–3.6), LR− 0.46 (0.31–0.68)
Bilavsky et al 7 Urban hospital, IsraelProspective cohort studyAll children aged 3 months to 17 years who were diagnosed with bacterial meningitis in a 4-year period.
Control group were children who were suspected to have bacterial meningitis but ruled out on LP.
Antibiotic therapy before arrival to ED.86 (40 in study
2 Nuchal rigidity
Sensitivity 64.9%, specificity 53.5%
LR+ 1.39, LR− 0.66
Brudzinski’s sign
Sensitivity 52.6%, specificity 77.5%
LR+ 2.34, LR− 0.61
Kernig’s sign
Sensitivity 51.3%, specificity 95%
LR+ 10.27, LR− 0.51
Amarilyo et al 5 Urban tertiary hospitals, IsraelCross sectionalIncluded patients with clinically suspected meningitis between the ages of 2 months and 16 years.Severe chronic disease, immune deficiency or any neurological condition, patients in whom LP was not performed.108 (58 cases of
meningitis, 6 confirmed
2 Nuchal rigidity
Sensitivity 65%, specificity 67%
PPV 0.8 [NPV 0.62]
Brudzinski’s sign
Sensitivity 51%, specificity 80%
PPV 0.81 [NPV 0.58]
Kernig’s sign
Sensitivity 27%, specificity 0.87
PPV 0.77 [NPV 0.51]
Prevalence 53.7%
  • Predictive values in square brackets were not reported by the original study but have been calculated by the authors for the purposes of this review. 95% CIs are given in brackets.

  • CSF, cerebrospinal fluid; ED, emergency department; LP, lumbar puncture; LR+, positive likelihood ratio; LR−, negative likelihood ratio; NPV, negative predictive value; OCEBM, Oxford Centre for Evidence-Based Medicine; PPV, positive predictive value.

  • See appendix for search strategy used to identify studies for inclusion (online supplementary file 1).