How Do I Perform a Lumbar Puncture and Analyze the Results to ...

DIAGNOSING BACTERIAL MENINGITIS BY LUMBAR PUNCTURE
blood cells. 2 He also states that a single
polymorphonuclear cell in the CSF with
a white blood cell count of less than 5
µL is considered normal. Steele and colleagues
suggest rapid analysis of CSF
and noted that neutrophil counts can
decrease by 50% within 2 hours of
collection. 59
We found 3 studies that met the inclusion
criteria and that described the
accuracy of CSF Gram stain for diagnosing
bacterial meningitis. 53-55 None
of these studies appeared to be prospective.
All studies reported sensitivity
of Gram stain and 1 study reported
specificity of this test 53 (TABLE 3). If bacteria
are seen on Gram stain, it helps
diagnose bacterial meningitis but if this
test is negative, bacterial meningitis cannot
be ruled out.
We identified 4 studies that met the
inclusion criteria and that reported on
the accuracy of biochemical analysis of
CSF in patients with suspected central
nervous system infection 55-58 (Table 2
and TABLE 4). Only 1 study of CSF
white blood cell counts met our strict
inclusion criteria. A CSF white blood
cell count of 500/µL or higher increases
the likelihood of meningitis (LR,
15; 95% CI, 10-22), whereas a count
less than 500/µL lowers the likelihood
(LR, 0.3; 95% CI, 0.2-0.4). 56
A CSF–blood glucose ratio of 0.4 or
less was accurate for diagnosing bacterial
meningitis (LR, 18; 95% CI, 12-
27), whereas a normal CSF–blood glucose
ratio made this diagnosis less likely
(LR, 0.31; 95% CI, 0.21-0.45). 56,57 A
CSF lactate level of 31.53 mg/dL or
more (3.5 mmol/L) was accurate for
diagnosing bacterial meningitis (LR, 21;
95% CI, 14-32 55-57 ; Table 4), whereas
a CSF lactate level of less than 31.53
mg/dL (3.5 mmol/L) makes the diagnosis
of bacterial meningitis less likely
(LR, 0.12; 95% CI, 0.07-0.23).
Prediction Models
Spanos and colleagues 60 developed a
prediction rule for diagnosing bacterial
meningitis. This rule (TABLE 5) was
derived from a retrospective chart review
of patients with a final diagnosis
of acute meningitis. The sample was divided
into a derivation and validation
set, but data from a large number of
charts (94/214) in the derivation set had
missing data and were excluded from
the analysis. And, the technique used
for CSF cell count changed during the
study period, which could influence the
results of this study. The accuracy as
measured by the area under the receiver
operating curve (AUC) was 0.97
for the validation set.
Hoen and colleagues 61 attempted to
validate the above rule in a retrospective
review and used the same data to
generate their own decision rule
(Table 5) that included 4 different clinical
variables. In their validation of the
work by Spanos and colleagues, the AUC
was 0.98 while that for their derived
equation was 0.99. In another retrospective
review of patients with meningitis,
Leblebicioglu and colleagues 62 assessed
the rules by Hoen and Spanos and the
AUC was 0.99 and 0.95, respectively.
McKinney and colleagues 63 obtained
similar results in their retrospective
review.
In the only prospective validation
that we were able to identify, Baty and
colleagues 64 assessed Hoen’s rule in a
sample of 109 patients aged 1 to 85
years with acute community-acquired
meningitis. Data are only available in
patients with bacterial and viral meningitis,
and thus the specificity of the
model cannot be calculated. The sensitivity
of their computed model was
80% for the diagnosis of bacterial meningitis.
For this decision rule to be recommended
in clinical practice, it needs
to be validated prospectively in larger
populations with broader disease
spectrum. 65
Brivet and colleagues 66 completed a
retrospective study and found that the
presence of at least 1 sign of severity of
disease at the time referral and a CSF
neutrophil count of more than 1000/µL
Table 2. Studies Assessing Cerebrospinal Fluid Analysis in Patients With Suspected Central
Nervous System Infection
Source Study Design Sample Size Age Reference Standard
Dunbar et al, 53
1998
Wasilauskas and
Hampton, 54
1982
Lannigan et al, 55
1980
Lindquist et al, 56
1988
Briem, 57 1983
Retrospective
Retrospective
Cohort
(not clear if
prospective)
Prospective
cohort
Cohort
(not clear if
prospective)
2635 CSF
samples
80 CSF
samples
Adults
Adults
Positive CSF culture
Positive CSF culture
or bacterial antigen
434 16-86 y Positive CSF culture
710 2 mobut
majority adults
Positive CSF culture
or bacterial antigen
266 90% 15 y or older Positive CSF culture
or bacterial antigen
Komorowski Retrospective 562 Adults Positive CSF culture
et al, 58 1986
Abbreviation: CSF, cerebrospinal fluid.
Table 3. Accuracy of Cerebrospinal Gram Stain in Patients With Suspected Bacterial
Meningitis*
Study
Sensitivity, %
(95% CI)
Specificity, %
(95% CI)
Likelihood
Ratio for
Positive Test
(95% CI)
Likelihood
Ratio for
Negative Test
(95% CI)
Dunbar et al, 53 1998 86 (74-92.6) 100 (lower 95 737 (230-2295) 0.14 (0.08-0.27)
confidence
limit 99.7)
Wasilauskas and 60 (47-71) . . . . . . . . .
Hampton, 54 1982
Lannigan et al, 55 1980 56 (34-75) . . . . . . . . .
Abbreviation: CI, confidence interval.
*Ellipses indicate that data are not available.
©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, October 25, 2006—Vol 296, No. 16 2017
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