Meningitis and

Lumbar Puncture
Jessica Kirk, MD
July 26, 2007
Overview

 Features of Bacterial Meningitis

 Features of Viral Meningitis

 Lumbar Puncture:
 Indications/Contraindications
 Procedure
 Interpreting Results
Bacterial Meningitis: an
overview
 Suspected bacterial meningitis is a medical
emergency, and IMMEDIATE steps must
taken to identify the specific cause.
 These steps include:
 History
 PhysicalExam
 Laboratory Data
 Imaging
Bacterial Meningitis: History
 The History should include, at a minimum, the following
information:
 Course of illness (progressive vs. acute and fulminant)
 Presence of symptoms c/w meningeal inflammation
 Presence of seizures
 Presence of predisposing factors (i.e. recent resp. or
ear infection, penetrating head trauma, travel to
endemic area, etc.)
 Immunization Hx
 Hx of drug allergies (may affect therapy)
 Recent use of antibiotics
Bacterial Meningitis:
Physical Exam
 Important aspects of the physical exam are
as follows:
 Vital signs: provide clues about volume
status, presence of shock/increased ICP
 HC in children <18mo
 Meningeal signs (chin to chest/ Kernig/
Brudzinski)
 Neurologic exam
 Integumentary exam (petichiae and purpura
most commonly assoc. with N. meningitidis)
 Signs of other bacterial infections (i.e.
cellulitis, sinusitis, otitis media, etc.)
Bacterial Meningitis:
Laboratory Data
 Blood Tests:
 CBC with diff
 Blood culture
 Chem 8
 Coags if any petechiae or purpura noted
 CSF:
 CellCount
 Glucose and protein
 Gram stain
 Culture and sensitivity
 Other (meningococcal panel)
Bacterial Meningitis: Imaging
 CT scan may be performed to rule out an
intracranial process that would
contraindicate an LP, but does not exclude
subsequent herniation.
 Indications for CT before LP:
 Coma
 CSF shunt
 Hx of hydrocephalus
 Hx of trauma/neurosurgery
 Papilledema
 Focal neurologic deficit
Bacterial Meningitis:
Diagnosis
 A HIGH LEVEL OF SUSPICION IS KEY TO
DIAGNOSING MENINGITIS IN CHILDREN.
 Acute bacterial meningitis should be suspected in
children with fever and signs of meningeal inflammation.
 In infants the signs may include fever, hypothermia,
lethargy, resp. distress, jaundice, poor feeding,
vomiting, diarrhea, seizures, restlessness, irritability,
and/or bulging fontanel.
 No single clinical sign is pathognomonic.
 Either isolation of bacteria in CSF, OR isolation of
bacteria in blood cultures in a patient with CSF
pleocytosis confirms the diagnosis.
Bacterial Meningitis:
Causative Organisms
 1mo – 2yr:
 S. pneumoniae (*penicillin resistance)
 N. meningitidis
 GBS
 2yr – 18yr:
 N. meningitidis
 S. pneumoniae
 Hib
Bacterial Meningitis:
Treatment
 Empiric treatment of meningitis should be started
immediately after the LP is performed. You cannot
delay treatment of there is a contraindication or
inability to perform an LP. For example, if the LP is
delayed due to a need for imaging, blood cultures
should be obtained and antibiotics started before the
imaging study.
 Empiric treatment consists of bactericidal antibiotics
that have good CSF penetrance, usually a third-
generation cephalosporin (eg cefotaxime, ceftriaxone)
and vancomycin.
 If cephalosporins or Vanc are contraindicated in a
patient, consult ID.
Bacterial meningitis:
Treatment cont.
 Cefotaxime 200mg/kg/day or
50mg/kg/dose IV Q6hrs
 Ceftriaxone 100mg/kg/day or
50mg/kg/dose IV Q12hrs
 75mg/kg loading dose
 Vancomycin 60mg/kg/day or
15mg/kg/dose IV Q6hrs
Bacterial Meningitis:
Treatment cont.
 Duration of treatment is determined
on a case-by-case basis with
assistance from Peds ID. Contributing
factors may include positive CSF cx,
clinical course, causative pathogen,
and response to therapy.
Bacterial Meningitis:
Outcomes
 The mortality rate of untreated bacterial
meningitis approaches 100%.
 Meta-analysis has shown a mortality rate of
~5% in developed countries, depending on
causative organism.
 The most common sequelae are neurologic,
and occur in 15-25% of survivors:
 Deafness
 Mental Retardation
 Spasticity/Paresis
 Seizures
Bacterial Meningitis:
Follow-up
 Hearing Evaluation: at or shortly after
discharge
 Developmental surveillance
Viral Meningitis: an overview
 Viral, or aseptic, meningitis is the most
common type of meningitis. It is defined
as:
A febrile illness with clinical signs and
symptoms of meningeal irritation
 No associated neurologic dysfunction
 No evidence of bacterial pathogens in
the CSF (in a pt. who hasn’t received
antibiotics)
Viral Meningitis: Clinical
Manifestations
 Common features include:
 Acute onset of fever, headache, nausea,
vomiting, stiff neck.
 Physical findings are generally limited,
nonspecific, and not necessarily present.
The most prevalent are:
 Nuchal rigidity, bulging fontanel, and
other signs of viruses such as rash,
conjunctivitis, and pharyngitis.
Viral Meningitis: Laboratory
Data
 CSF:
 WBC
 Glucose
 Protein
 Enterovirus PCR
 HSV PCR
Viral Meningitis: Causative
Organisms
 Enteroviruses
 Herpesviruses

 Arboviruses

 Influenza
Viral Meningitis: Treatment
 Herpes meningitis in children is treated with
Acyclovir 30mg/kg/day, or 10mg/kg/dose IV
Q8hrs, for a minimum of 14-21 days
 Neonataldosing is 60mg/kg/day, or
20mg/kg/dose IV Q8hrs for 21 days.
 EV infections are treated symptomatically and
rarely require hospitalization beyond the
neonatal period.
 Treatment for EBV, Arbovirus, and Influenza
meningitis is mainly supportive.
Lumbar Puncture:
Indications
 Suspected CNS infection
 Suspected SAH

 Introducing chemotherapy or contrast

 Removal of CSF
Lumbar Puncture:
Contraindications
 Absolute:
 Increased ICP
 Relative:
 Cardiopulmonary instability
 Soft tissue infection at puncture site
 Bleeding diathesis:
• Active bleeding
• Platelet count <50,000
• INR > 1.4
Lumbar Puncture: Patient
Counseling
 Your job is to provide a clear
explanation of the urgent indications
of the procedure, as well as the
details of the procedure itself.
 In order to obtain informed consent,
you must list both risks and benefits.
Lumbar Puncture: Patient
Counseling cont.
 Risks:
 Postspinalheadache
 Epidermoid tumor
 Infection
 Cerebral herniation
 Spinal hematoma
 Benefits:
 The benefit of early diagnosis far outweighs the risk of
the procedure if there are no contraindications.
Lumbar Puncture: Anatomy

 In older children, LP can be performed

from the L2-L3 interspace to the L5-
S1 interspace. In children younger
than 12mo, LP must be performed
below the L2-L3 interspace.
 An imaginary line that connects the 2
PSIC intersects the spine at
approximately L4.
Lumbar Puncture:
Pre-procedure
 Local anesthesia can be provided with
either lidocaine and/or EMLA.
 The patient must be well-positioned to see
landmarks:
 Hips and shoulders should be perpendicular
to the exam table
 The gluteal crease should align with the
spinous processes.
 Feel free to ask the nurse to reposition the
patient.
 Watch for respiratory function throughout
the entire procedure!
Lumbar Puncture:
Procedure
 An LP is performed using universal
precautions and sterile technique.
 Put on sterile gloves and clean the puncture
site with betadyne. The area should be
large, including the PSIS to use as a
landmark.
 Place sterile drapes around the puncture
site.
 If infiltrating with Lidocaine, do this now.
Lumbar Puncture:
Procedure cont.
 Check your spinal needle- Is the stylet in
place? Is it the appropriate diameter and
length? Is it a spinal needle?
 Are your collection tubes upright and open?
 Find your landmark- you may want to mark
it with your fingernail.
 Advance the spinal needle, bevel up,
parallel to the exam table, with the tip of the
needle advancing toward the patient’s
umbilicus.
Lumbar Puncture:
Procedure cont.
 Advance SLOWLY. In newborns, you may
only get the bevel in before you are in the
subarachnoid space.
 The stylet may be removed as the needle is
advanced to look for CSF.
 Use of a manometer is optional at this time
to measure opening pressure.
 Put ~1cc, or about 15-20 drops in each of
the 4 tubes.
 Replace the stylet and remove the needle.
 DISPOSE OF YOUR SHARPS IMMEDIATELY.
Lumbar Puncture: Fluid
Collection
 You should label your own CSF. The label
must include the tube number and what test
you want ordered, as well as your initials,
time, and date.
 CSF #1: Gram stain and culture
CSF #2: Glucose and protein
CSF #3: Cell count
CSF #4: Save (or Herpes PCR, EV PCR,
mening. Panel, etc.)
Lumbar Puncture: Misc.
 Please be
courteous and
clean up your own
mess. Dispose of
all unused sharps
before throwing
away the kit.
Lumbar Puncture:
Troubleshooting
 Bony resistance:
 Increaseflexion of patient, or
 Withdraw needle to soft tissue and re-palpate to
make sure spine is not rotated.
 Poor flow:
 Rotate needle by 90 degrees
 Replace stylet and advance slightly
 Pull needle back and redirect
 Remove needle and attempt different site
*You must use a new needle at this time.
Lumbar Puncture:
Troubleshooting cont.
 Taumatic Tap:
 Occurs when needle hits venous
plexus
 CSF typically clears if in subarachnoid
space
 Remove needle and reattempt with
new needle if clot forms or fluid
doesn’t clear.
 Lumbar Puncture:
Interpreting Results Cont.
Glucose Protein # of Organism
WBC’s present

Bacterial ↓ ↑ >1000 Gram stain

Meningitis ↑neutros CSF/bld cx

Viral Nl or Nl or ~10-500 no
Meningitis slightly↓ slightly↑ ↑lymphs
Lumbar Puncture:
Interpreting Results cont.
 When a tap is bloody it may be a
traumatic tap, or it could be blood in
the CSF. Your CSF analysis will
provide % crenated and uncrenated
RBC’s. Crenated means the RBC’s
have started breaking down, and
therefore have likely been in the CSF
longer. This may be a sign that you
are dealing with Herpes meningitis.
Lumbar Puncture:
Interpreting Results
 Interpreting CSF can be subjective in many
cases. Results will vary based on timing of
the tap in the course of the illness, antibiotics
given, other cultures obtained, and quality of
the tap.
 You should use the resources available to
you such as your teammates’ experience and
Peds ID consult to help you decide on a
course of action.
Lumbar Puncture

 Demonstration of the LP kit

Meningitis and Lumbar
Puncture
 Questions?

 Sources will be available on website.