Acute bacterial meningitis without cerebrospinal fluid pleocytosis in children: results from a nationwide prospective surveillance system between 2001 and 2022.

Objectives: We aimed to describe cases of acute bacterial meningitis (ABM) without cerebrospinal fluid (CSF) pleocytosis and the clinical and biological characteristics of affected children.
Methods: We analyzed results of a nation-wide population-based prospective surveillance study of acute ABM in children aged 3 months to 15 years in France. Absence of CSF pleocytosis was defined as CSF leukocyte count ≤5/mm ³ .
Results: We included 4754 cases of acute ABM from 2001 to 2022: 173 patients (3.6%) did not have CSF pleocytosis. ABM cases without CSF pleocytosis were mainly related to meningococcus (70% vs 44% with CSF pleocytosis, P <0.001). When performed in CSF with normal leukocyte count, Gram staining results were positive for 33%, culture for 80%, polymerase chain reaction results for 41%, and antigen detection for 20% of cases. Case fatality rate was higher for cases without than those with CSF pleocytosis (18% vs 6%, P <0.001). On multivariate analysis, absence of CSF pleocytosis was associated only with seizures before hospital arrival (adjusted odds ratio 2.3, 95% confidence interval 1.2-4.6, P <0.01).
Conclusions: ABM without CSF pleocytosis is infrequent but not exceptional, particularly in children with seizures before hospital arrival. Extended vaccination against meningococcus could prevent this clinical form with a high case fatality rate.
Competing Interests: Declarations of competing interest Corinne Levy received grants from Pfizer during the conduct of the study, personal fees from Pfizer and MSD, and nonfinancial support from Pfizer outside the submitted work. Emmanuelle Varon received grants from the French Public Health Agency during the conduct of the study, and from Pfizer and MSD outside the submitted work. Muhamed Kheir Taha performs contract work for the Institut Pasteur funded by GSK, Pfizer, and Sanofi Pasteur, and has a patent with GSK (“Vaccines for serogroup X meningococcus”; NZ630133A Patent). Naïm Ouldali received grants from Pfizer to his institution during the conduct of the study and travel grants from Pfizer, Sanofi, and GlaxoSmithKline outside the submitted work. François Angoulvant received personal fees from MSD, Sanofi, and AstraZeneca outside the submitted work. Robert Cohen received personal fees from Sanofi, Pfizer, MSD, Viatris, and GSK; travel grants from Sanofi, Pfizer, and MSD; and grants from Sanofi, Pfizer, MSD, and GSK outside the submitted work. Alexis Rybak received personal fees from MSD and Pfizer outside the submitted work and nonfinancial support from Pfizer and AstraZeneca. The remaining authors report no conflict of interest.
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