What is the treatment for cerebrospinal fluid (CSF) findings of elevated opening pressure, elevated protein, low glucose, and increased white blood cell (WBC) count?

From the Guidelines

The treatment for CSF findings of elevated opening pressure, elevated protein, low glucose, and increased WBC count should involve urgent reduction of intracranial pressure through removal of CSF, as well as empiric antimicrobial therapy, with the goal of reducing the pressure to 50% of the opening pressure or 200 mm of H2O, whichever is greater, as recommended by the 2016 IDSA clinical practice guideline for the treatment of coccidioidomycosis 1.

The patient's CSF findings, including elevated opening pressure, elevated protein, low glucose, and increased WBC count, are concerning for increased intracranial pressure (ICP) and potential CNS infection.

• The elevated opening pressure of 300 mm H2O is significantly higher than the concerning range of 180-250 mm H2O, and requires urgent intervention to prevent further complications.
• The elevated protein and low glucose levels in the CSF are indicative of an infectious process, and the increased WBC count suggests a significant inflammatory response.
• The management of increased ICP and potential CNS infection should be guided by the principles outlined in the 2016 IDSA clinical practice guideline for the treatment of coccidioidomycosis, which recommends urgent reduction of intracranial pressure through removal of CSF, as well as empiric antimicrobial therapy 1.

Key considerations in the treatment of this patient include:

• Urgent reduction of intracranial pressure through removal of CSF, with the goal of reducing the pressure to 50% of the opening pressure or 200 mm of H2O, whichever is greater.
• Empiric antimicrobial therapy, with coverage for potential CNS pathogens, including bacteria, fungi, and viruses.
• Close monitoring of the patient's neurological status, with frequent assessments of mental status, cranial nerve function, and motor function.
• Consideration of neurosurgical consultation, particularly if the patient's condition does not improve with medical therapy, or if there are signs of increased ICP or hydrocephalus on imaging studies.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dexamethasone sodium phosphate injection, 4 mg per mL– For intravenous, intramuscular, intra-articular, intralesional, and soft tissue injection. Cerebral Edema Dexamethasone sodium phosphate injection is generally administered initially in a dosage of 10 mg intravenously followed by four mg every six hours intramuscularly until the symptoms of cerebral edema subside. Tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy

The treatment for cerebrospinal fluid (CSF) findings of elevated opening pressure, elevated protein, low glucose, and increased white blood cell (WBC) count may involve the use of dexamethasone. The dosage for cerebral edema is typically 10 mg intravenously followed by 4 mg every six hours intramuscularly until symptoms subside. Additionally, tuberculous meningitis with subarachnoid block or impending block may be treated with dexamethasone concurrently with antituberculous chemotherapy 2 2.

• Key points:
  • Dexamethasone may be used to treat cerebral edema and tuberculous meningitis.
  • The dosage for cerebral edema is 10 mg intravenously followed by 4 mg every six hours intramuscularly.
  • Dexamethasone should be used concurrently with antituberculous chemotherapy for tuberculous meningitis.

From the Research

Treatment for CSF Findings

The treatment for cerebrospinal fluid (CSF) findings of elevated opening pressure, elevated protein, low glucose, and increased white blood cell (WBC) count is typically focused on addressing the underlying cause of these abnormalities, which is often bacterial meningitis.

• The use of empiric vancomycin plus a third-generation cephalosporin for suspected bacterial meningitis has been recommended since 1997 3.
• Ceftriaxone, a cephalosporin with an extended half-life and excellent antibacterial activity, has been used to treat bacterial meningitis, given as a single daily intravenous dose of 100 mg/kg on day one, followed by 80 mg/kg daily 4.
• Ceftriaxone has been compared to traditional therapy (ampicillin and chloramphenicol) for the treatment of bacterial meningitis, and has been shown to be a safe and effective antibiotic for the treatment of bacterial meningitis when administered once daily 5, 6.

Antibiotic Therapy

The choice of antibiotic therapy depends on the suspected or confirmed causative pathogen, as well as the patient's clinical condition and other factors.

• Vancomycin, ceftriaxone, and rifampicin have been studied alone and in combination for the treatment of meningitis caused by highly cephalosporin-resistant Streptococcus pneumoniae 7.
• The combination of ceftriaxone plus vancomycin, and vancomycin plus rifampicin, has been shown to be effective in the therapy of experimental pneumococcal meningitis caused by highly cephalosporin-resistant strains 7.

Key Considerations

When treating CSF findings of elevated opening pressure, elevated protein, low glucose, and increased WBC count, it is essential to:

• Identify the underlying cause of these abnormalities, such as bacterial meningitis
• Choose an appropriate antibiotic regimen based on the suspected or confirmed causative pathogen and the patient's clinical condition
• Monitor the patient's response to treatment and adjust the antibiotic regimen as needed 3, 4, 5, 6, 7