Correspondence
Community-Acquired Bacterial Meningitis
N Engl J Med 2006; 354:1429-1432March 30, 2006
- Article
To the Editor:
In their review article on community-acquired bacterial meningitis (Jan. 5 issue), van de Beek et al.1 suggest that when bacterial meningitis is probable but neuroimaging is not available, lumbar puncture should be given preference in immunocompromised patients or in those with moderate-to-severe impairment of consciousness.
As emergency physicians, we frequently encounter patients with altered consciousness and findings compatible with bacterial meningitis. Lumbar puncture can be performed safely without neuroimaging in selected patients. However, in those with severely impaired consciousness, a reliable neurologic examination is difficult and there is increased likelihood of clinically significant intracranial lesions, including those in nonlateralizing areas such as frontal lobes. Papilledema can be a late finding and difficult to recognize. Immunocompromised patients (including those infected with the human immunodeficiency virus) are at risk for mass lesions such as those associated with toxoplasmosis.
If neuroimaging is not available for such patients, we suggest obtaining blood cultures and beginning empirical therapy for meningitis. Emphasis should then be on identifying intracranial abnormalities that may require other life-saving interventions. Meningitis can be confirmed later with the use of lumbar puncture, and the bacterial cause can often be identified by means of blood cultures, antigen testing, or both.2 Transfer of the patient to another facility for neuroimaging should be considered.
2 ReferencesFredrick M. Abrahamian, D.O.
Gregory J. Moran, M.D.
David A. Talan, M.D.
Olive View–UCLA Medical Center, Sylmar, CA 91342
fmasjc@yahoo.com 1
van de Beek D ,de Gans J ,Tunkel AR ,Wijdicks EFM . Community-acquired bacterial meningitis in adults. N Engl J Med 2006;354:44-53
Full Text | Web of Science | Medline2
Talan DA ,Hoffman JR ,Yoshikawa TT ,Overturf GD . Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art. Rev Infect Dis 1988;10:365-376
CrossRef | Medline
To the Editor:
Van de Beek et al. cite a handful of references to support their assertion that “reports have emphasized the risk of brain herniation as a complication of diagnostic lumbar puncture in patients with meningitis.” We found this assertion surprising, both because this shibboleth has little evidentiary support in the literature and because the authors themselves subsequently state that, at most, a small subgroup of patients with possible meningitis need computed tomography (CT) of the head before lumbar puncture is performed. Either the references cited in fact demonstrate that lumbar puncture is safe, in the absence of certain clinical signs and symptoms, or they explicitly debunk the myth raised by the authors.1-4 An emphasis on the danger (rather than the safety) of lumbar puncture is a matter of concern, especially since the unnecessary use of CT has been associated with a delay in the administration of antibiotics.3
4 ReferencesMalkeet Gupta, M.D.
Richelle J. Cooper, M.D., M.S.H.S.
Jerome R. Hoffman, M.D., M.A.
University of California, Los Angeles, Los Angeles, CA 900241
van Crevel H ,Hijdra A ,de Gans J . Lumbar puncture and the risk of herniation: when should we first perform CT? J Neurol 2002;249:129-137
CrossRef | Web of Science | Medline2
Hasbun R ,Abrahams J ,Jekel J ,Quagliarello VJ . Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001;345:1727-1733
Full Text | Web of Science | Medline3
Oliver WJ ,Shope TC ,Kuhns LR . Fatal lumbar puncture: fact versus fiction -- an approach to a clinical dilemma. Pediatrics 2003;112:e174-e176
CrossRef | Web of Science | Medline4
van de Beek D ,de Gans J . Prognostic factors in adults with bacterial meningitis. N Engl J Med 2005;352:514-514
Web of Science
To the Editor:
Van de Beek and colleagues make two suggestions that must be questioned, since I believe that they are incorrect. First, the authors suggest that a pulmonary-artery catheter be used. There is evidence that the use of a pulmonary-artery catheter in critically ill patients does not alter outcome.1,2 Serious complications are more likely with the insertion of a pulmonary-artery catheter than with that of a central catheter, and in patients who are awake and agitated and, potentially, have coagulopathy, the incidence of complications may be higher.
Second, the authors suggest that the phosphodiesterase inhibitor milrinone be used in patients with meningitis and septic shock. This therapy is not supported by the available evidence3 and is potentially harmful, since milrinone may cause vasodilation and hypotension.4 Instead, the administration of norepinephrine or dopamine through a central catheter would be a more appropriate therapy for hypotension, with an arterial catheter used for monitoring.4
4 ReferencesAndrew M. Johnston, M.R.C.P.I.
University Hospital Birmingham, Birmingham B15 2TH, United Kingdom
amcdj@doctors.org. uk Bryan Carr, F.R.C.A.
University Hospital of North Staffordshire, Stoke on Trent ST4 7LN, United Kingdom1
Harvey S ,Harrison DA ,Singer M , et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005;366:472-477
CrossRef | Web of Science | Medline2
Richard C ,Warszawski J ,Anguel N , et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003;290:2713-2720
CrossRef | Web of Science | Medline3
Beale RJ ,Hollenberg SM ,Vincent JL ,Parrillo JE . Vasopressor and inotropic support in septic shock: an evidence-based review. Crit Care Med 2004;32:Suppl:S455-S465
CrossRef | Medline4
Hollenberg SM ,Ahrens TS ,Annane D , et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med 2004;32:1928-1948
CrossRef | Web of Science | Medline
To the Editor:
In their otherwise excellent review, van de Beek et al. state, “Respiratory isolation for 24 hours is indicated for patients with suspected meningococcal infection.” In actuality, droplet precautions should be used for such patients.1 Indeed, respiratory isolation is not a standard isolation procedure. Presumably, the authors were referring to airborne precautions, which should be reserved for diseases, such as tuberculosis, that are truly transmitted through the air.
1 ReferencesTed Gay, M.D.
Tri City Medical Center, Oceanside, CA 92056
teddelmar@adelphia.net 1
Garner JS, Hospital Infection Control Practices Advisory Committee
CrossRef | Web of Science | Medline
To the Editor:
When evaluating possible neoplastic meningitis in a patient with a high-grade lymphoma, oncologists often give a first dose of empirical intrathecal chemotherapy at the time of the initial lumbar puncture. I have often wondered why the workup of suspected infectious meningitis does not include a first dose of empirical intrathecal vancomycin. Van de Beek et al. recommend vancomycin as an empirical treatment for all suspected cases of bacterial meningitis. Vancomycin can be safely given intrathecally, and this route is routinely used by neurosurgeons to treat patients with infected hardware.1 Empirical intrathecal vancomycin given after the lumbar puncture would bypass the problem of penetration of the blood–brain barrier without undue complication of the workup and treatment of patients with suspected infectious meningitis. It might be worth studying.
1 ReferencesWilliam L. Read, M.D.
University of California, San Diego, San Diego, CA 92093-0987
wread@ucsd.edu 1
Luer MS ,Hatton J . Vancomycin administration into the cerebrospinal fluid: a review. Ann Pharmacother 1993;27:912-921
Web of Science | Medline
Author/Editor Response
The comments made by Dr. Abrahamian and colleagues and Dr. Gupta and colleagues illustrate the dilemma with regard to lumbar puncture, cranial imaging, and the risk of brain herniation. Among patients with acute bacterial meningitis, lumbar puncture is extremely helpful and seldom dangerous. My coauthors and I agree that cranial imaging helps to define contraindications to lumbar puncture only in a small subgroup of patients with suspected bacterial meningitis. In our review, we recommend cranial imaging before lumbar puncture in patients who have new-onset seizures, an immunocompromised state, signs that are suspicious for space-occupying lesions (papilledema or focal neurologic signs, not including cranial-nerve palsy), or moderate-to-severe impairment of consciousness. In many parts of the world, however, cranial imaging will not be available, and transfer to another facility for imaging will not be an option. In such circumstances, it is reasonable, though not supported by data from systematic research, to give preference to lumbar puncture in patients with moderate-to-severe impairment of consciousness or in an immunocompromised state when a diagnosis of bacterial meningitis is probable. When warning signs of a space-occupying lesion (e.g., new-onset seizures, papilledema, or evolving signs of brain-tissue shift) are present, lumbar puncture should not be performed.
Drs. Johnston and Carr are correct in their statement that other inotropes can be used to treat patients with septic shock or those with decreased cardiac function (e.g., due to myocarditis in cases of meningococcal meningitis). We agree that the use of a Swan–Ganz catheter in this patient population (and many others) has not been shown to improve outcomes; however, when used selectively, the device can provide hemodynamic measurements that are very helpful in guiding the initial approach in patients whose condition is complex and rapidly deteriorating.
Dr. Gay is correct that droplet precautions should be used for patients with suspected meningococcal meningitis; we thank him for alerting us to the misstatement about respiratory isolation.
Dr. Read raises an interesting question about the use of empirical intrathecal vancomycin in patients with suspected bacterial meningitis, and this question may warrant further study. However, in a previous study of neonates with gram-negative meningitis and ventriculitis, intrathecal gentamicin failed to produce measurable ventricular concentrations, and intraventricular administration of this agent was associated with a higher mortality rate than was the systemic therapy alone.1,2 Although similar data are not available for vancomycin, it might be assumed that distribution of that drug into the cerebral ventricles would be similar to that with gentamicin and that adequate ventricular concentrations of vancomycin might not be attained after intrathecal administration.3
3 ReferencesDiederik van de Beek, M.D., Ph.D.
University of Amsterdam, 1100 DD Amsterdam, the Netherlands
d.vandebeek@amc. uva. nl 1
McCracken GH Jr ,Mize SG . A controlled study of intrathecal antibiotic therapy in gram-negative enteric meningitis of infancy: report of the Neonatal Meningitis Cooperative Study Group. J Pediatr 1976;89:66-72
CrossRef | Web of Science | Medline2
McCracken GH Jr ,Mize SG ,Threlkeld N . Intraventricular gentamicin therapy in gram-negative bacillary meningitis of infancy: report of the Second Neonatal Meningitis Cooperative Study Group. Lancet 1980;1:787-791
Web of Science | Medline3
Ahmed A . A critical evaluation of vancomycin for treatment of bacterial meningitis. Pediatr Infect Dis J 1997;16:895-903
CrossRef | Web of Science | Medline
