Intended for healthcare professionals

Rapid response to:


Guidelines for managing acute bacterial meningitis

BMJ 2000; 320 doi: (Published 13 May 2000) Cite this as: BMJ 2000;320:1290

Rapid Response:

Lumbar puncture and CT scan in diagnosis of meningitis

I do not think that any neurologist can suggest that lumbar puncture
is a safe procedure in any condition. However, some patients with
subarachnoid hemorrhage may present with a medical history and clinical
findings consistent with bacterial meningitis and they may also have a
normal CT scan. Fever and premonitory symptoms, which are usually recorded
in meningitis patients are known to be found in subarachnoid hemorrhage
cases. Obviously, these two different pathological conditions require
quite different treatment procedures and both conditions may give rise to
conning if not treated properly. It is essential to perform a CT scan
examination and lumbar puncture procedure to differentiate meningitis from
subarachnoid hemorrhage, rather than eliminating raised intracranial
pressure. Initiating empirical antibiotic treatment and then performing
cerebral angiography for these cases may be even more time consuming and
life threatening. Starting empirical antibiotic treatment together with
administration of intravenous antibiotics before application of lumbar
puncture procedure may be a treatment possibility for cases with suspected
increased intracranial pressure and normal CT scan. However, it is never
possible to give general recommendations for such conditions and special
decisions must be given for different circumstances.

I do not agree with the suggestion that preadmission antibiotics may
be hazardous for the patient. To my knowledge, there are no reports,
either, considering that preadmission antibiotics may make it harder to
get a microbial diagnosis. I have never had, in my clinical practice, any
difficulty in microbial diagnosis of patients with preadmission
antibiotics. It may be quite dangerous, on the other hand, to prolong the
initiation period of empirical antibiotic treatment. I have always
believed that one of the first things to do for a suspected meningitis
patient is to start antibiotic treatment as early as possible since it is
always much more better to have some diagnostic problems than watching
patient dying from conning due to increased intracranial pressure.

Competing interests: No competing interests

14 May 2000
Erdem Tuzun
Istanbul Medical Faculty, Istanbul University, Istanbul, TURKEY