Routine Repeat LP may not be necessary in all cases of meningitis
We read the review article on neonatal meningitis by Heath and colleagues with great interest.
We would like to bring to notice couple of issues that are of importance especially to the situation in developing countries.
1.Firstly, cultures are positive only in a small proportion of cases of meningitis in developing countries. This may be related to prior antibiotic exposure that is common, or poor microbiology services. The diagnosis of culture negative meningitis in neonates, is however often controversial. Newborns normally have cells (even polymorphs) and high protein in their cerebrospinal fluid (CSF). What constitutes a deviation from this normal range can be difficult to decide. What should one do if a baby with suspected or blood culture proven sepsis has a minor abnormality in only one of the CSF parameters? It has been suggested that CSF analysis should be seen in totality, and even if one parameter is positive, it should be treated as meningitis.[3,4]
2. Second, we do not agree with the author’s recommendation of repeating the CSF examination after 24-48 hours. As mentioned above, if to begin with, most of the cases of neonatal meningitis are culture negative, repeating a lumbar puncture to see if the organism is still persisting will not be of any value. Since, most of the cases of neonatal meningitis are diagnosed on the basis of abnormalities in CSF cytology, protein and/ or sugar content, repeat lumbar puncture will only show the changes in these parameters. It has been shown that cytologic and biochemical abnormalities take time to normalize, despite appropriate and adequate antibiotics. The cell count may even go up on second day . Also, a quarter to one-third of lumbar punctures (LP) in neonates can be traumatic or dry taps. Moreover, the procedure carries the risk of causing pain and hypoxemia in small babies, introduction of infection and other complications like spinal epidermoid tumors and contamination of CSF with bone marrow cells.
Hence, we believe that repeating a CSF examination after 24-48 hours as a universal rule has more risks than benefits. It would be more rationale to do a close clinical monitoring of the baby and do an ultrasound examination of the head after 48-72 hours of treatment. LP should be repeated around 48-72 hours if the baby is not recovering as expected, or if ultrasound shows development of ventriculitis or other complications. A survey of pediatricians and neonatologists by Agarwal et al. showed that currently, most of them are not doing routine repeat CSF examinations. Xavier and McCracken in a recent review recommended that a repeat lumbar puncture should be done at 24–48 hours after admission if a resistant pneumococcus has been isolated from the initial CSF culture, and if the patient has not shown clear clinical improvement .
(1) Heath P T, Yusoff NKN, Baker C J. Neonatal meningitis. Arch Dis Child Fetal and Neonatal Edition 2003;88:F173-8.
(2) Kumar P, Verma IC. Antibiotic therapy for bacterial meningitis in children in developing countries. Bull World Health Organ 1993;71:183-88.
(3) Schaad UB, Nelson JD, McCracken GH Jr. Recrudescence and relapse in bacterial meningitis of childhood. Pediatrics 1981; 67:188–95.
(4) Volpe JJ. Neurology of the Newborn, 4th Edition. Philadephia: WB Saunders, 2002; 774-812.
(5) Converse GM, Gwaltney JM Jr, Strassburg DA. Alteration of cerebrospinal fluid findings by partial treatment of bacterial meningitis. J Pediatr 1973;83:220–225.
(6) Kumar P, Sarkar S, Narang A. Role of routine lumbar puncture in neonatal sepsis. J Paediatr Child Health 1995;31:8-10.
(7) Agarwal R, Emmerson AJ. Should repeat lumbar punctures be routinely done in neonates with bacterial meningitis? Results of a survey into clinical practice. Arch Dis Child 2001;84:451–2.
(8) Saez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet 2003;361:2139-48.
Repeat Lumbar Puncture in Group B sreptococcal meningitis?
We read with interest the review of Neonatal meningitis by PT Heath et al. Neonatal meningitis remains a very important cause of morbidity and mortality. Group B streptococcus (GBS) remains the leading pathogen.
We report a case of GBS meningitis that was a challenge for management. A term baby born by normal vaginal delivery with birth weight of 3.26 kg, presented at 5 days of age with 24 hour history of fever and seizures prior to admission. There were no antenatal risk factors. Full septic screen was done.Hb-18.6gm/dl,WCC-8.25/cmm,CRP-177. CSF was turbid,CSF Proteins-1.79gm/l,Glucose-0.3mmol/l [Blood glucose- 4.3mmol/l], WCC-4873/cmm-50% Polymorphs and 50% Lymphocytes. Baby was commenced on intravenous antibiotics [cefotaxime and penicillin] in appropriate high doses. Group B streptococcus, sensitive to these antibiotics was isolated from both blood and CSF.Baby clinically improved over next 2 days. Cranial ultrasound was normal. Antibiotic treatment was prescribed for 3 weeks but was discontinued after 19 days because of difficult venous access. Baby remained asymptomatic with normal physical examination.
Repeat Blood culture after 2 days was sterile; there was improvement in serial CRP. Lumbar puncture was not repeated, as baby was clinically well. Baby was observed for further 24 hours after stopping antibiotic and as he remained well, he was discharged home with follow up arrangements.
He was readmitted after 36 hours with signs of sepsis. Following full septic screen, which included FBC, WCC, CRP, Blood culture and LP, he was recommenced on intravenous antibiotics [penicillin and cefotaxime] in appropriate high doses. Blood and CSF culture revealed GBS again. Gentamicin was added as per sensitivity result. Subsequently he developed seizures. CT scan of brain was normal but MRI scan revealed mild bilateral subdural effusions. Repeat MRI scan one week later showed significant improvement. His immunoglobulins and complement levels were normal. His clinical examination was normal. Serial lumbar punctures were done in view of persistent low CSF glucose levels [range-1.5-2.2], though repeat CSF was sterile and showed improvement in white cell count and proteins. Antibiotic treatment was continued for 6 weeks following consultation with neurologist. Following discharge, baby remains well, developing normally with no neurological deficit.
There are no controlled clinical studies to guide the recommended duration of antibiotic therapy for neonatal meningitis. Standard textbooks on neonatology recommend minimum 2 weeks of antibiotic therapy for GBS meningitis and repeat lumbar puncture in the course of treatment to ensure adequate response to antibiotics. However current practice differs from centre to centre from this as per survey by Agarwal et al. We disagree with recommendation of Schaad et al.that if clinical response is uneventful then it is unnecessary to repeat lumbar puncture at the end of therapy.
We agree with author’s recommendation of repeating lumbar puncture during course of treating meningitis to document CSF sterilisation but the principal issues that require attention are the timing of lumbar puncture and value of CSF biochemistry to guide management in the absence of organisms in repeat lumbar puncture.
(1) P T Heath K Yusoff,C J Baker. Neonatal meningitis. Arch Dis Child Fetal Neonatal Ed 2003;88:F173-178.
(2) Holt DE,Halket S, J de Louvois,et al. Neonatal meningitis in England and Wales:10 years on. Arch Dis Child Fetal Neonatal Ed 2001;84:F85-9.
(3) Agarwal R,Emmerson AJ.Should repeat lumbar punctures be routinely done in neonates with bacterial meningitis? Results of a survey into clinical practice. Arch Dis Child 2001;84:451-2.
(4) Schaad UB,Nelson JD,McCracken GH Jr.Recrudescence and relapse in bacterial meningitis of childhood. Pediatrics 1981;67:188-95.
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