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Bacterial Meningitis Associated with Lumbar Drains: a Retrospective Cohort Study

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Bacterial Meningitis Associated with Lumbar Drains: a Retrospective Cohort Study J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.67.4.468 on 1 October 1999. Downloaded from 468 J Neurol Neurosurg Psychiatry 1999;67:468–473 Bacterial meningitis associated with lumbar drains: a retrospective cohort study William M Coplin, Anthony M Avellino, D K Kim, H Richard Winn, M Sean Grady Abstract risk of meningitis to consider when using this Objectives—The infective potential of modality, and the infective potential of lumbar lumbar drainage is an important topic drainage is an important topic deserving deserving particular study. The aetiology, particular study. We conducted a retrospective incidence, and clinical findings associated cohort study of patients with positive CSF cul- with bacterial meningitis are described in tures after lumbar drain placement to ascertain patients having continuous lumbar CSF the possible aetiologies of meningitis. Our drainage to treat communicating hydro- objectives included defining the incidence of cephalus after subarachnoid haemor- meningitis after lumbar drain placement, rhage or CSF leaks after traumatic dural describing the association of positive CSF cul- rents. tures with the clinical signs and laboratory Methods—Retrospective review of the values considered diagnostic of meningitis, and records of patients with a positive CSF describing potential risk factors for contracting bacterial culture who underwent lumbar lumbar drain associated meningitis. drain placement over a 39 month period. Results—Thirteen cases of bacterial men- Patients and methods ingitis occurred subsequent to the use of PATIENT SELECTION 312 lumbar drain kits (4.2%). All menin- The method of patient selection was identifica- gitic patients had CSF pleocytosis, but not tion of all cases of bacterial meningitis. Cases all had peripheral leukocytosis. Fever, established by culture were identified from a peripheral leukocytosis, and CSF pleocy- list of all positive CSF cultures at Harborview tosis did not help to diVerentiate the pres- Medical Center, Seattle, WA, USA between ence of bacterial meningitis from other June 1992 and December 1995. Hospital infections. Eight patients had prior CSF charts were then screened for those who drainage procedures, including ventricu- received a lumbar drain. We reviewed in detail lostomy (n=5) or lumbar drain (n=5) the records of those patients who underwent placements; two patients received both lumbar drainage. Patients’ charts were used to procedures. Six of 13 patients developed confirm information from other data sources their CSF infection within 24 hours of (for example, microbiology laboratory lumbar drain insertion. Six of 13 patients records). Diagnoses treated by lumbar drains developed meningitis while receiving anti- included communicating hydrocephalus after http://jnnp.bmj.com/ biotics for other reasons. subarachnoid haemorrhage and traumatic cra- Conclusions—External lumbar drainage nial CSF leak. The degree of hydrocephalus or Departments of seems to carry a low risk of infectious CSF leak and the patient’s clinical condition Neurological Surgery meningitis and oVers a safe alternative to determined the duration of drainage. We and Neurology, ventriculostomy or serial lumbar punc- obtained our denominator (the number of Division of Pulmonary tures. Antibiotics do not seem to protect lumbar drain placements over this time) from and Critical Care completely against developing the infec- Medicine, Harborview intrahospital usage of lumbar drain kits. The tion. The infection happens most often number of kits used was likely higher than the Medical Center, on September 26, 2021 by guest. Protected copyright. University of with skin organisms. The meningitis often number of patients treated as there were Washington, Seattle, appears within 24 hours after lumbar patients who had more than one drain placed WA, USA drain placement. Daily CSF samples during their stays in hospital. The Human W M Coplin should include bacterial cultures but cell Subjects Review Committee of the University A M Avellino counts may not oVer any additional useful D K Kim of Washington approved this research activity. H R Winn information in diagnosing the complica- M S Grady tion. Lumbar drain insertion and man- LUMBAR DRAIN TECHNIQUE agement need not be confined to the After shave (if necessary), skin preparation Correspondence to: intensive care unit. (povidone-iodine solution), and draping of the Dr William M Coplin, (J Neurol Neurosurg Psychiatry 1999;67:468–473) Departments of Neurology lumbosacral area, 1% lidocaine was infiltrated and Neurological Surgery, between the palpated spinous processes of the Wayne State University, 4201 Keywords: cerebrospinal fluid; lumbar drainage; St Antoine, 8D-UHC, meningitis lower lumbar vertebrae. A 16G Tuohy spinal Detroit, MI 48201, USA. needle was advanced until it punctured the Telephone 001 313 577 meninges. A CSF sample was sent for routine 1242; fax 001 313 745 4216; email Continuous lumbar CSF drainage may serve as studies (cell count and diVerential, glucose, [email protected] a temporising measure in treating communi- protein, gram stain, and culture). The lumbar cating hydrocephalus caused by aneurysmal drain was threaded into the subarachnoid Received 6 July 1998 and in subarachnoid haemorrhage12and is one treat- space. The needle was withdrawn and the drain revised form 25 March 1999 ment for correcting CSF leaks (spinal or attached to a drainage bag. A silk tie secured Accepted 24 April 1999 cranial). Similarly to ventriculostomy, there is a the adapter connecting the intraspinal catheter J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.67.4.468 on 1 October 1999. Downloaded from Bacterial meningitis associated with lumbar drains 469 and the external drainage system. Sterile gauze protein, Gram stain, culture, and sensitivities of dressed the skin wound. A transparent adhesive organisms isolated (if any). dressing covered the external part of the intraspinal catheter to prevent dislodgment. DEFINING VARIABLES Patients did not receive specific antibiotic Meningitis associated with lumbar drains was prophylaxis for the procedure. defined before starting the review. Among Samples of CSF were obtained from a sam- other variables, the review sought to explore pling port along the drainage catheter. This the possible association of leukocytosis, fever, port lies just distal to the junction of the and pleocytosis (predominance of segmented indwelling catheter and its connection to the neutrophils) with meningitis diagnosed by remainder of the drainage system leading to the positive CSF culture. These definitions were collection bag. This site has a three way port derived from a prior study of infections related that was closed to the drainage bag side for to ventriculostomy.3 The incidence of ventricu- sampling. Also, before sampling, the mem- lostomy infections was beyond the scope of this brane over the sampling port was swabbed with study. a povidone-iodine solution that was allowed to The diagnosis of meningitis associated with dry completely before a sterile needle was lumbar drains required the following criteria: introduced through the membrane to obtain (1) no previous meningitis before lumbar drain the CSF sample. insertion; (2) sterile CSF culture at the time of lumbar drain insertion; (3) continuous lumbar drainage>24 hours before the positive culture CLINICAL AND EPIDEMIOLOGICAL DATA was aspirated; and (4) positive culture of a CSF ABSTRACTION specimen collected from the lumbar drain or The following demographic data came from from a lumbar puncture. the charts of patients who had a positive bacte- Fever was defined as a temperature>38.5°C. rial CSF culture and a lumbar drain: age, hos- Association of fever with meningitis required pital admission date, admitting neurological the following criteria: (1) fever within 48 hours diagnosis (for example, subarachnoid haemor- of the positive CSF culture; (2) no other rhage, traumatic CSF leak), and if the patient concurrent infection; (3) if the patient had had a history of diabetes mellitus. Operations fever within 48 hours before the positive CSF were recorded (including if the surgeon entered culture, then a temperature rise>0.6°C within the ventricles) as well as neurological instru- 48 hours of the positive CSF culture; or (4) mentation (for example, placement of intracra- fever lasting for 3 days. nial pressure monitors or ventriculostomies). Peripheral leukocytosis was defined as Other clinical data were gathered—namely, >10 000 white blood cells (WBC)/mm3 of other positive CSF cultures (lumbar puncture, blood. The attribution of the leukocytosis to ventriculostomy); other microbiological cul- meningitis required: (1) leukocytosis occurring ture results (for example, blood, urine, sputum, within 48 hours of the positive CSF culture; (2) wound); CSF cell counts for 48 hours before no other concurrent infection; (3) if the WBC and after drawing the culture positive sample; count was>10 000 48 hours before the positive temperatures for 48 hours before and after CSF culture, then an increase in WBC>1000/ 3 drawing the culture positive sample; signs of mm within 48 hours of the positive culture; or http://jnnp.bmj.com/ drain site infection (for example, leaking CSF, (4) leukocytosis lasting for 3 days. purulence, erythema, induration); duration of Pleocytosis in CSF was defined as a CSF lumbar drainage; peripheral white blood cell WBC count>11 cells/mm3. Attributing CSF count; intracranial and CSF opening pressures; pleocytosis to acute bacterial meningitis
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