Table 1

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

	Study setting	Study design	Inclusion criteria	Exclusion criteria	Sample size	Level of evidence (OCEBM)	Key results
Berkley et al 6	Rural district hospital, Kenya	Cross sectional	All 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 Guinea	Cross sectional	Children aged 1–59 months admitted during normal working hours with suspected meningitis.	CSF not collected for analysis.	697	2	Neck stiffness Sensitivity 53%, specificity 81% PPV 39% [NPV 80%]
Offringa et al 11	Urban hospital, Netherlands	Cross sectional	All 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’ LR+=∞ LR−=0.3 PPV 100% NPV 98%
Curtis et al 2	Global	Systematic review of prospective studies	Studies 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 studies	1	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, Israel	Prospective cohort study	All 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 group)	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, Israel	Cross sectional	Included 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 bacterial)	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).