Meningitis and

Lumbar Puncture
Kari Bradham, DO
August 4th, 2011
Overview

 Features of Bacterial Meningitis

 Features of Viral Meningitis

 Lumbar Puncture:
 Indications/Contraindications
 Procedure
 Interpreting Results
Bacterial Meningitis

 Suspected bacterial meningitis is a medical

emergency, and IMMEDIATE steps must
taken to identify the specific cause.
 These steps include:
 History
 Physical Exam
 Laboratory Data
 Imaging
Bacterial Meningitis: History
 The History should include:
 Birth Hx
 Presence of predisposing factors (i.e. recent
infection, penetrating head trauma, travel to
endemic area, etc.)
 Course of illness (progressive, acute, etc.)
 Presence of symptoms
 Presence of seizures
 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 (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 differential
 Blood culture
 Chem 8
 Coagulation studies if any petechiae or
purpura noted
 CSF:
 Cell Count
 Glucose and protein
 Gram stain
 Culture and sensitivity
 Other (Latex panel)
Bacterial Meningitis: Imaging
 CT scan may be performed to rule out an
intracranial process that might be a
contraindication to an LP.
 Indications:
 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
 0-1mo
 GBS
 E.coli
 Listeria
 1mo – 2yr:
 S. pneumoniae
 N. meningitidis
 GBS
 2yr – 18yr:
 N. meningitidis
 S. pneumoniae
 Hib
Bacterial Meningitis:
Treatment
 Start empiric antibiotics immediately after the
LP is performed.
 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 can penetrate the CSF, usually a
third-generation cephalosporin (eg cefotaxime,
ceftriaxone) and vancomycin.
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
 Do not forget to order a trough
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:

 Also referred to as aseptic

 Most common type of meningitis
 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 has not received
antibiotics)
Viral Meningitis: Clinical
Manifestations
 Common features include:
 Acute onset of fever, headache,
nausea, vomiting, neck stiffness
 Physical findings are generally limited
and nonspecific. 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
 Neonatal dosing 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
 Diagnostic:
 Suspected CNS infection
 Opening pressure measurement

 Therapeutic:
 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
 Provide a clear explanation of the
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:
 Postspinal headache
 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 betadine. The area should include
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.
 Do not forget to write a procedure note.
Lumbar Puncture: Fluid
Collection
 You should label your own CSF. The label
must include the tube number 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,
Latex 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:
 Increase flexion 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.
 Traumatic 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 none

Meningitis slightly↓ slightly↑ ↑lymphs
Lumbar Puncture:
Interpreting Results cont.
 If an LP is bloody it may be a
traumatic tap, or it could be blood in
the CSF.
 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.
 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.
Meningitis and Lumbar
Puncture
 Questions?
You admitted a patient to the hospital yesterday who
had acute onset of fever (temperature of 103.0°F
[39.4°C]), a petechial rash, meningismus, and shock.
She required blood pressure support and mechanical
ventilation during the night. As per the protocol for
your hospital, you placed this child into respiratory
isolation upon admission. Today you are told that her
blood culture is growing Neisseria meningitidis. The
nurse taking care of her asks you how long the child
needs to remain in respiratory isolation.

Of the following, the BEST answer is until the child

A. Complete one day of antimicrobial therapy
B. Defervesces
C. Is clinically stable
D. Is extubated
E. Is proven not to have meningitis
This patient should remain in respiratory isolation until
24 hrs after the initiation of effective antibiotics. The
presence of continued fever, prolonged intubation,
clinical instability, or meningitis is irrelevant to isolation.
Patients treated for invasive disease w/any antibiotic
other than cefotaxime or ceftriaxone also must receive 2
days of rifampin, 1 dose of ceftriaxone, or 1 dose of
cipro prior to hospital D/C to eradicate the NP carriage
of N meningitidis. Family members & individuals who
have had close contact w/the patient should be given
chemoprophylaxis. Exposed individuals who have
received either the polysaccharide or conjugate
meningococcal vaccine still should receive
chemoprophylaxis b/c the vaccine may not contain the
serotype that is specific for the patient's
A 6-month-old boy is brought to the emergency department for
evaluation of a 2-day history of a temperature to 39.8°C,
increasing irritability, constant crying, decreased activity, and
emesis. His mother states that everyone in the house has been
ill with colds and that the baby has had a runny nose and nasal
congestion for the past week. He has only had his 2-month set
of immunizations because he has been ill each time he is
brought in for his vaccines. On physical examination, the infant
has a temperature of 40.0°C, appears ill, and is extremely
irritable. His anterior fontanelle is full, and he has a stiff neck.
Studies obtained on his cerebrospinal fluid show: Glucose, 5.0
mg/dL, protein, 170.0 mg/dL, WBC 550/mm3 2 RBC. Gram stain
is positive for many WBCs and gram-positive cocci.

Of the following, the MOST appropriate empiric antibiotic

regimen for the treatment of this patient is
A. Amp and Gent
B. High dose ceftriaxone
C. High dose ceftriaxone and Gent
D. High dose ceftriaxone and Vanc
E. High dose cefuroxime
Over the past several decades, an increasing proportion of S
pneumoniae strains worldwide have been shown to be
nonsusceptible to PCN and amp; to the third-generation
cephalosporins (cefotaxime , ceftriaxone); & to a # of other
agents, including erythromycin, macrolides, clindamycin, &
TMP-SMX in some areas of the US. In general, due to the
presence of cross-resistance, the susceptibility of the
pneumococcus to other antibiotics decreases in parallel to
decreasing PCN susceptibility. Beta-lactam antibiotics (PCNs
& cephalosporins) generally are clinically effective in treating
the nonsusceptible S pneumoniae strains, except in
meningitis. For proven or suspected bacterial meningitis, the
initial treatment involves a combo of vanc & a third-
generation parenteral cephalosporin (cefotaxime or
ceftriaxone). For children who cannot receive cephalosporins
due to a serious cephalosporin or PCN allergy (eg, hives or
anaphylaxis), rifampin is added to the vanc regimen. Once
susceptibility testing results are available, the treatment
regimen can be tailored accordingly.