Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.