Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage–related bacterial meningitis

Rogier P. Schade M.D., Ph.D.1, Janke Schinkel M.D., Ph.D.1, Freek W. C. Roelandse1, Ronald B. Geskus Ph.D.1, Leo G. Visser M.D., Ph.D.1, Marc C. van Dijk M.D., Ph.D.1, Joan H. C. Voormolen M.D., Ph.D.1, Hans van Pelt1, and Ed J. Kuijper M.D., Ph.D.1
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  • 1 Departments of Medical Microbiology, Clinical Chemistry, Medical Statistics, Infectious Diseases, and Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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Object

Routine microbiological and chemical analysis of cerebrospinal fluid (CSF) is often performed to diagnose external drainage–related bacterial meningitis (ED-BM) at an early stage. A cohort study was performed to investigate the value of several commonly used CSF parameters for the prediction and diagnosis of ED-BM.

Methods

In a cohort of 230 consecutive patients in whom external drains had been placed, CSF samples were collected daily, prospectively evaluated for the presence of bacteria using Gram stain and microbiological culture, and analyzed for leukocyte count, protein concentration, glucose concentration, and ratio of CSF glucose to blood glucose. In addition, the CSF concentration of interleukin-6 (IL-6) was determined. The definition of ED-BM was based on positive culture results in combination with clinical symptoms. A matched case–control study was performed to evaluate the cohort longitudinally and to control for biasing factors such as duration of external drainage.

External drainage–related bacterial meningitis developed in 22 patients (9.6%). Results from analyses of 1516 CSF samples showed no significant differences between the patients in whom ED-BM developed and a control group without ED-BM during the first 3 days of infection or during the 3 days preceding the infection with regard to leukocyte count, protein concentration, glucose concentration, and CSF/blood glucose ratio. No significant difference between groups was found for the CSF IL-6 concentration during the 3 days preceding the infection. In the matched case–control study, none of the parameters had significant predictive or diagnostic value for ED-BM in analyses using absolute values, ratios, and differences between the current and previous day’s values. A comparison of the results from Gram stains and CSF cultures showed that the Gram staining had a very high specificity (99.9%) but a low sensitivity (18% [four of 22 patients] on the 1st day of infection and 60% [nine of 15 patients] on the 2nd day).

Conclusions

Severe disturbances in the CSF of patients with external drains limit the value of routine CSF analysis for prediction or diagnosis of ED-BM. Routine Gram stain of CSF has also limited predictive or diagnostic value due to its low sensitivity in screening for ED-BM.

Abbreviations used in this paper:

CSF = cerebrospinal fluid; ED-BM = external drainage–related bacterial meningitis; IL = interleukin; ROC = receiver operating characteristic.

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