From the Guidelines
Lumbar puncture is contraindicated in suspected meningitis when there are specific conditions present, such as focal neurologic deficits, new-onset seizures, severely altered mental status, or a severely immunocompromised state, as recommended by the ESCMID guideline 1. When these conditions are present, it is crucial to perform cranial imaging before lumbar puncture to rule out potential contraindications.
- Focal neurologic deficits (excluding cranial nerve palsies) require cranial imaging before lumbar puncture.
- New-onset seizures also necessitate cranial imaging before the procedure.
- Severely altered mental status, indicated by a Glasgow Coma Scale score <10, is another condition that requires cranial imaging.
- A severely immunocompromised state also warrants cranial imaging before lumbar puncture. In patients lacking these characteristics, cranial imaging before lumbar puncture is not recommended 1. It is essential to start antibiotic therapy as soon as possible in acute bacterial meningitis patients, with the time period until antibiotics are administered not exceeding 1 hour 1.
- Empiric treatment must be started immediately on clinical suspicion, even if the diagnosis has not been established, especially when lumbar puncture is delayed due to cranial CT. The approach of delaying lumbar puncture for cranial imaging in specific cases, while promptly initiating empiric antibiotic therapy, is critical to balance the need for diagnosis with the risk of complications and the urgency of treating potential bacterial meningitis 1.
From the Research
Meningitis Diagnosis and Lumbar Puncture Contraindications
- Lumbar puncture is a crucial diagnostic tool for suspected meningitis, but its performance may be delayed due to various reasons such as the need for prior computed tomographic (CT) scan or limited clinical facilities 2.
- The decision to perform a lumbar puncture should consider the potential risks and benefits, including the risk of complications such as headaches and low back pain 3.
- Contraindications for lumbar puncture are not explicitly stated in the provided studies, but it is implied that caution should be exercised in patients with certain conditions, such as increased intracranial pressure or space-occupying lesions 3.
Lumbar Puncture Technique and Complications
- The technique for performing a lumbar puncture should be carefully followed to minimize the risk of complications 3.
- Analysis of cerebrospinal fluid (CSF) should include a cell count, glucose and protein concentrations, and other tests as necessary to support the diagnosis 3.
- Complications of lumbar puncture are infrequent but can be severe, and the health professional should be familiar with the regional anatomy and technique used to perform the procedure 3.
Antibiotic Therapy and Lumbar Puncture
- In cases of suspected bacterial meningitis, empiric parenteral antibiotic therapy may be initiated prior to lumbar puncture, especially if there is a delay in performing the procedure 2.
- The choice of antibiotic should depend on the suspected pathogen and the patient's clinical condition, with consideration of the antibiotic's penetration into the CSF 4, 5, 6.
- Repeat lumbar puncture is not recommended for certain causative organisms, such as Haemophilus influenzae, Neisseria meningitidis, and penicillin/cefotaxime/ceftriaxone fully-susceptible Streptococcus pneumoniae 4.