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Adults with suspected meningitis are waiting too long for lumbar puncture

Patients with viral meningitis experience diagnostic delays and inappropriate treatment, study finds

Ingrid Torjesen

Monday, 02 July 2018

Adults with viral meningitis experience substantial delays in diagnostic testing and unnecessary treatment, a study* published in The Lancet Infectious Diseases has found.

The study included more than 1100 patients aged over 16 who presented with clinically suspected meningitis to 42 hospitals around England (including all 24 acute hospitals in the northwestern region) from September 2011 to September 2014.

All participants either had a lumbar puncture, or a bacterial or viral pathogen identified in their blood test or culture. The researchers examined the association between time to lumbar puncture and receiving a microbiologically proven diagnosis. Participants were sent questionnaires to assess their quality of life and cognitive function a year after admission.

Of 1113 patients included in the final analysis, nearly two-thirds of the patients (638; 57%) had meningitis. Just over a third of these cases 36% (231) were viral, 16% (99) were bacterial, and 42% (267) were of unknown cause, and 6% (41) had other causes identified.

The study found that in UK hospitals the median time from admission to a lumbar puncture to distinguish between bacterial and viral meningitis was 17 hours – and in a quarter of patients it took more than 29 hours. Patients who received early lumbar puncture were more likely to have a specific cause identified for their illness than those in whom the test was delayed.

The chances of having a pathogen detected was reduced by 1% with every hour of delay in lumbar puncture after admission, and delays in lumbar puncture and unnecessary treatment with antivirals were associated with longer hospital stays.

The authors concluded: “Improved rapid diagnostic testing so that more patients can have a specific cause determined quickly could reduce unnecessary use of antimicrobials—both antibiotics and antivirals—and therefore reduce hospital stays and other investigations.”

“Ideally, this crucial diagnostic test should be completed within a few hours,” said the lead author, Fiona McGill, from the Institute of Infection and Global Health at the University of Liverpool.

“It’s possible that the four-hour accident and emergency treatment target is creating unintended pressure, leading to key investigations like lumbar puncture being postponed until patients have been admitted to a ward. Additional delays of several days can also occur if samples are sent to offsite laboratories for analysis.”

Incidence of bacterial meningitis has decreased in England since the 1990s following the widespread introduction of conjugate vaccines, and the findings gave the first estimate of the annual incidence of confirmed viral meningitis in the UK, which usually occurs in adults, as 2.73 per 100 000.

All individuals with viral meningitis in the study reported substantially poorer quality of life in the year following illness compared with the age-matched UK population, with an excess of pain, anxiety, depression, and reduced activity levels up to 48 weeks after admission.

Dr McGill said: “It's becoming increasingly clear that individuals with viral meningitis experience many lasting effects on their mental health and quality of life. We must better support them during and after hospitalisation with more rapid diagnostics and better treatments and rehabilitation to ensure quicker recovery and to help improve outcomes.”

*McGill, F, Adedeji, A, et al. Incidence, aetiology, and sequelae of viral meningitis in UK adults: a multicentre prospective observational cohort study. Elsevier Ltd, 29 June 2018. DOI:10.1016/S1473-3099(18)30245-7

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