Repeat lumbar puncture in adults with bacterial meningitis

Costerus, Joost M; Brouwer, Matthijs C.; Ende, Arie van der; Beek, Diederik van de

doi:10.1016/j.cmi.2015.12.026

Cited by 24 publications

(20 citation statements)

References 26 publications

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“…One prospective study targeted N. meningitides , another Enterovirus , and another Cryptococcus sp in patients with AIDS, thus increasing the number of these organisms reported [20, 33, 44]. Two prospective cohort studies specifically analyzed meningitis in the absence of pleocytosis by patient age [27, 30]. One specifically analyzed neonates, and the other patients > 16 years of age [27, 30].…”

Section: Discussionmentioning

confidence: 99%

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A systematic review of cases of meningitis in the absence of cerebrospinal fluid pleocytosis on lumbar puncture

Troendle

Pettigrew²

2019

BMC Infect Dis

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Background Definitive diagnosis of meningitis is made by analysis of cerebrospinal fluid (CSF) culture or polymerase chain reaction (PCR) obtained from a lumbar puncture (LP), which may take days. A timelier diagnostic clue of meningitis is pleocytosis on CSF analysis. However, meningitis may occur in the absence of pleocytosis on CSF. Areas of Uncertainty: A diagnosis of meningitis seems less likely without pleocytosis on CSF, leading clinicians to prematurely exclude this. Further, there is little available literature on the subject. Methods Ovid/Medline and Google Scholar search was conducted for cases of CSF culture-confirmed meningitis with lack of pleocytosis. Inclusion criterion was reported cases of CSF culture-positive or PCR positive meningitis in the absence of pleocytosis on LP. Exclusion criteria were pleocytosis on CSF, cases in which CSF cultures/PCR were not performed, and articles that did not include CSF laboratory values. Results A total of 124 cases from 51 articles were included. Causative organisms were primarily bacterial (99 cases). Outcome was reported in 86 cases, 27 of which died and 59 survived. Mortality in viral, fungal and bacterial organisms was 0, 56 and 31%, respectively. The overall percentage of positive initial CSF PCR/culture for viral, fungal and bacterial organisms was 100, 89 and 82%, respectively. Blood cultures were performed in 79 of the 124 cases, 56 (71%) of which ultimately cultured the causative organism. In addition to bacteremia, concomitant sources of infection occurred in 17 cases. Conclusions Meningitis in the absence of pleocytosis on CSF is rare. If this occurs, causative organism is likely bacterial. We recommend ordering blood cultures as an adjunct, and, if clinically relevant, concomitant sources of infection should be sought. If meningitis is suspected, empiric antibiotics/antifungals should be administered regardless of initial WBC count on lumbar puncture. Electronic supplementary material The online version of this article (10.1186/s12879-019-4204-z) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

“…Two prospective cohort studies specifically analyzed meningitis in the absence of pleocytosis by patient age [27, 30]. One specifically analyzed neonates, and the other patients > 16 years of age [27, 30]. Thus, this not only skewed the age of the patients, but also the pathogens reported, as these vary with age.…”

Section: Discussionmentioning

confidence: 99%

A systematic review of cases of meningitis in the absence of cerebrospinal fluid pleocytosis on lumbar puncture

Troendle

Pettigrew²

2019

BMC Infect Dis

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“…However, the utility of repeat LP with meningitis due to pathogens that are not multidrug-resistant is less clear. In adult bacterial meningitis, repeat LP is not commonly performed, although it might be useful in selected cases to confirm the diagnosis, to exclude relapse or persistent infection, or for therapeutic purposes in communicating hydrocephalus [ 17 ]. Durack et al reported that wide ranges of glucose and protein levels and cell counts at the end of treatment were compatible with cure in a series of 165 adults, and concluded that post-treatment lumbar puncture was of no value as a test of cure in bacterial meningitis [ 18 ].…”

Section: Discussionmentioning

confidence: 99%

Predictive value of repeated cerebrospinal fluid parameters in the outcomes of bacterial meningitis in infants <90 days of age

et al. 2020

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Background There are variations in recommendations from different guidelines regarding the indications for repeat lumbar puncture (LP) in young infants with the diagnosis of bacterial meningitis. Objective To evaluate the frequency of repeat LPs and the characteristics of cerebrospinal fluid (CSF) parameters in repeated sampling and their predictive values for adverse outcomes in a national cohort. Methods This cohort study included infants born January 1, 2013 through December 31, 2014, who had proven or suspected bacterial meningitis within the first 90 days of life at seven paediatric tertiary care hospitals across Canada, and who underwent a repeat LP at the discretion of the treating physicians. Results Forty-nine of 111 infants (44%) underwent repeat LP at a median of 5 (IQR: 3, 13) days after the LP that led to the diagnosis of bacterial meningitis. Those who had meningitis caused by gram negative bacilli were more likely to have repeat LP than those with gram positive bacteria (77% versus 57%; p = 0.012). White blood cell (WBC) count on the second spinal tap yielded an area under the curve of 0.88 for predicting sequelae of meningitis at discharge from the hospital, with a cut-off value of 366 × 10 6 /L, providing a sensitivity of 91% and specificity of 88%. Conclusion In this multi-centre retrospective cohort study, infants with gram negative meningitis were more likely to have repeated LP. A high WBC on the second CSF sample was predictive of adverse outcome at the time of discharge from the hospital.

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“…Repeated LP is indicated for patients who have not responded clinically after 48 hours of appropriate antimicrobial therapy, neonates with meningitis due to gramnegative bacilli, patients with CSF shunt infections, 1 and therapeutically in patients with hydrocephalus. 4 Ampicillin is added when there is an increased risk of Listeria monocytogenes meningitis, 5 such as in adults over age 50 years or in those with impaired cellular immunity. In this case, the CSF findings suggest a viral infection, and the patient is immunocompetent; thus, empiric treatment with ampicillin is not indicated.…”

Section: Given Our Patient's Csf Laboratorymentioning

confidence: 99%

“…Additional CSF was sent to the Centers for Disease Control and Prevention for plaque reduction neutralization testing, which was confirmatory for POWV. 4. Which one of the following is the best strategy for preventing this infection?…”

Section: Given Our Patient's Csf Laboratorymentioning

confidence: 99%

57-Year-Old Woman With Fever and Confusion

Chen

Virk

2019

Mayo Clinic Proceedings

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A 57-year-old previously healthy woman presented with a 3-day history of fever and confusion in mid fall. She initially went to her primary care physician with symptoms of fever and fatigue and was prescribed azithromycin. Her family brought her to the emergency department later that day because of worsening confusion, word-finding difficulty, and gait instability. She reported no headache, dysuria, or new skin lesions. She was not taking any medication. She lived in southeastern Minnesota and was an avid outdoors person. She lived alone and did not have a pet. She had no known recent travel or sexual exposures.On physical examination, she appeared somnolent but arousable. Her vital signs included a temperature of 38.5 C, pulse rate of 115 beats/min, respiratory rate of 24 breaths/min, blood pressure of 135/72 mm Hg, and oxygen saturation of 98% while breathing room air. Chest examination revealed normal breath and heart sounds and no murmur. Abdominal examination findings were normal. She was oriented to self, had no cranial nerve abnormalities, and had normal strength and sensation. She had no neck stiffness or pain. Her skin examination revealed blanchable erythematous papules over her back, abdomen, and anterior aspects of the thighs.Initial laboratory studies yielded the following (reference ranges provided parenthetically): hemoglobin, 15.1 g/dL (11.6-15.0 g/dL); leukocyte count, 7.3 Â

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Repeat lumbar puncture in adults with bacterial meningitis

Cited by 24 publications

References 26 publications

A systematic review of cases of meningitis in the absence of cerebrospinal fluid pleocytosis on lumbar puncture

A systematic review of cases of meningitis in the absence of cerebrospinal fluid pleocytosis on lumbar puncture

Predictive value of repeated cerebrospinal fluid parameters in the outcomes of bacterial meningitis in infants <90 days of age

57-Year-Old Woman With Fever and Confusion

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