Retrospective Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Neurol. Jul 31, 2023; 9(4): 37-43
Published online Jul 31, 2023. doi: 10.5316/wjn.v9.i4.37
Role of lumbar puncture in clinical outcome of suspected acute bacterial meningitis
Arunava Saha, Shihla Shireen Kanamgode, Sarat Chandra Malempati, Sirshendu Chaudhuri, Jeffrey Scott
Arunava Saha, Shihla Shireen Kanamgode, Sarat Chandra Malempati, Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
Sirshendu Chaudhuri, Assistant Professor, Indian Institute of Public Health, Hyderabad 500030, Telangana, India
Jeffrey Scott, Department of Pulmonary and Critical Care Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
Author contributions: Saha A, Kanamgode SS and Scott J were involved in the conception of idea and study design; Chaudhuri S and Scott J provided administrative support; Scott J helped in provision of study materials or patients; Saha A, Kanamgode SS and Malempati SC were involved in collection and assembly of data; Saha A, Chaudhuri S and Scott J were involved in data analysis and interpretation; All authors were involved in manuscript writing; and the final draft was approved by all authors.
Institutional review board statement: The study-protocol was approved by the Ethics Committee of Metrowest Medical Center, IRB#2023-005.
Informed consent statement: Informed consent was waived as it was a retrospective chart review.
Conflict-of-interest statement: The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at saha.arunava100@gmail.com. It was a retrospective study, hence consent was not obtained but the presented data are anonymized and risk of identification is low.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Arunava Saha, MD, Department of Internal Medicine, Saint Vincent Hospital, 123, Summer Street, Worcester, MA 01608, United States. saha.arunava100@gmail.com
Received: May 20, 2023
Peer-review started: May 20, 2023
First decision: June 15, 2023
Revised: June 26, 2023
Accepted: July 7, 2023
Article in press: July 7, 2023
Published online: July 31, 2023
Abstract
BACKGROUND

Meningitis remains a significant source of mortality and morbidity, with an incidence of 1 per 100000 persons in the United States. Guidelines recommend obtaining blood cultures and cerebrospinal fluid (CSF) studies in patients presenting with acute meningitis syndrome, and beginning treatment with broad spectrum antibiotics based on the age and certain predisposing conditions. In some patients however, the diagnostic lumbar puncture (LP) is not performed due to a multitude of reasons, ranging from increased intracranial pressure to failed attempt. In such situations, appropriate therapy is initiated empirically and often continued without establishment of a definitive diagnosis.

AIM

To determine whether a diagnostic LP in acute meningitis syndrome was associated with a better outcome and less duration of antibiotic therapy, along with potential causes for deferral of procedure.

METHODS

A retrospective study was conducted amongst the patients presenting to a 360 bedded community hospital in central Massachusetts with a diagnosis of acute meningitis syndrome between January 2010 – September 2022. The electronic health records were accessed to collect necessary demographic and clinical data, including etiology of meningitis, lumbar puncture results, reason for procedure deferral, duration of antibiotic therapy and clinical outcome. The patients were subsequently divided into two groups based on whether they received a LP or not, and data was analyzed.

RESULTS

A total of 169 patients admitted with acute meningitis syndrome between September 2010-2022 were included in the study. The mean age of the participants was 54.3 years (SD +/- 19.2 years). LP was performed for 130 (76.9%) participants, out of which, 28 (21.5%) showed some growth in CSF culture. The most commonly identified organism was streptococcus pneumoniae. Amongst the 39 patients in whom LP was deferred, the major reasons recorded were: Body habitus (n = 6, 15.4%), and unsuccessful attempt (n = 4, 10.3%). While 93 (71.5%) patients with LP received antibiotic therapy, only 19 (48.7%) patients without LP received the antibiotics, with the principal reason being spontaneous improvement in sensorium without any diagnosed source of infection. The mean duration of antibiotic use was 12.3 days (SD +/- 5.6) in the LP group and 11.5 days (SD +/- 7.0) in the non-LP group (P = 0.56; statistically not significant). We observed higher long term sequalae in the non-LP group (n = 6, 15.4%) compared to the LP group (n = 9, 6.9%). Similarly, the death rate was higher in the non-LP group (n = 7, 18.0%) compared to the LP group (n = 9, 6.9%).

CONCLUSION

LP remains the cornerstone for diagnosing meningitis, but often CSF results are unavailable, leading to empiric treatment. Our study identified that body habitus and unsuccessful attempts were the most common reasons for LP not being performed, leading to empiric antibiotic coverage. There was no difference between the duration of antibiotics received by the two groups, but a lower proportion of patients without LP received antibiotics, attributed to a spontaneous improvement in sensorium. However, the residual neurological sequelae and death rates were higher in patients without LP, signifying a potential under-treatment. A LP remains crucial to diagnose meningitis, and a lack of CSF analysis predisposes to under-treatment, leading to higher neurological sequelae and increased chances of death.

Keywords: Meningitis, Acute meningitis syndrome, Lumbar puncture, CSF analysis, Acute bacterial meningitis, Suspected meningitis

Core Tip: Cerebrospinal fluid (CSF) analysis is considered the gold standard for diagnosing meningitis, but often CSF results are unavailable and patients are treated empirically. There are a multitude of reasons for lumbar puncture (LP) deferral, predominantly unsuccessful attempts and body habitus. A lack of CSF analysis in patients with suspected meningitis is associated with prolonged antibiotic use in some and poor outcome in others secondary to potential under-treatment. Every patient with a clinical suspicion for meningitis should undergo LP, radiology-assisted if necessary, and have a CSF analysis to confirm or rule out meningitis to guide need for antibiotic therapy.