Role of lumbar puncture in clinical outcome of suspected acute bacterial meningitis

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.

A case report of acute pediatric bacterial meningitis due to the rare isolate,Pseudomonas putida

Acute bacterial meningitis(ABM)is the medical emergency which warrants an early diagnosis and an aggressive therapy.Despite the availability of the potent newer antibiotics,the mortality caused by ABM and its complications remain high in India,ranging from 16%to 32%.The aim of this case report is to present the rare isolation of Pseudomonas putida from cerebrospinal fluid sample.Besides this,the author also emphasizes the importance of correctly identifying the organism and thus the selection of the most accurate antibiotic from the susceptibility profile to allow for early recovery and to improve the patient outcome and survival.

Blood–brain barrier dysfunction in intensive care unit

The central nervous system is characterized by a peculiar vascularization termed blood–brain barrier(BBB),which regulates the exchange of cells and molecules between the cerebral tissue and the whole body.BBB dysfunction is a life-threatening condition since its presence corresponds to a marker of severity in most diseases encountered in the intensive care unit(ICU).During critical illness,inflammatory response,cytokine release,and other phenomena activating the brain endothelium contribute to alterations in the BBB and increase its permeability to solutes,cells,nutrients,and xenobiotics.Moreover,patients in the ICU are often old,with underlying acute or chronic diseases,and overly medicated due to their critical condition;these factors could also contribute to the development of BBB dysfunction.An accurate diagnostic approach is critical for the identification of the mechanisms underlying BBB alterations,which should be rapidly managed by intensivists.Several methods were developed to investigate the BBB and assess its permeability.Nevertheless,in humans,exploration of the BBB requires the use of indirect methods.Imaging and biochemical methods can be used to study the abnormal passage of molecules through the BBB.In this review,we describe the structural and functional characteristics of the BBB,present tools and methods for probing this interface,and provide examples of the main diseases managed in the ICU that are related to BBB dysfunction.