Lumbar puncture in the management of adults
with suspected bacterial meningitis—a survey
Tristan Clarka,b, Erika Duffellc, James M. Stuartc,
Robert S. Heydermana,b,*
aDepartment of Pathology and Microbiology, University of Bristol, Bristol, UK
bBristol Health Protection Agency Laboratory, Bristol, UK
cHealth Protection Agency South West, Stonehouse, UK
Accepted 23 July 2005
Available online 4 October 2005
of suspected community acquired bacterial meningitis in adults.
Methods: A questionnaire was sent to secondary care clinicians (excluding junior
house officers) in general internal and emergency medicine at three acute NHS
healthcare trusts in the south west of England. The questionnaire recorded the
experience of the clinician and asked questions related to case scenarios
representing common presentations of bacterial meningitis or meningococcal
Results: The response rate was 42% (108/260). Nearly all of the respondents (91%)
reported regularly managing patients with suspected meningitis. Most respondents
considered that (i) brain computerised tomography (CT) was necessary prior to
undertaking LP (78%, 60/77), (ii) LP was a useful first line investigation in a patient
with meningococcal shock.(80%, 84/105), (iii) LP could be performed safely in a man
with a falling level of consciousness if the CT brain was normal (89/106, 84%). Early
antibiotic administration was considered important, other management priorities
such as oxygen therapy, volume resuscitation, and critical care involvement were not
Conclusions: Reported clinical practice in the investigation and management of
meningitis in adults is not in line with current published guidance. Efforts to target
interventions that promote consensus in practice are needed.
Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Objectives: Assess the use of lumbar puncture (LP) in the management
Bacterial meningitis is a rare but important cause of
preventable death and disability amongst adults in
Journal of Infection (2006) 52, 315–319
0163-4453/$30.00 Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
*Corresponding author. Address: Department of Pathology and
Microbiology, School of Medical Sciences, University of Bristol,
University Walk, Bristol BS8 1TD, UK. Tel.: C44 117 954 6821;
fax: C44 117 929 9162.
E-mail address: email@example.com
the U.K. Most commonly caused by Neisseria
meningitidis and Streptococcus pneumoniae, anal-
ysis of cerebrospinal fluid (CSF) through diagnostic
lumbar puncture (LP) is the cornerstone of effective
diagnosis and management. CSF examination pro-
vides confirmation of the diagnosis and may yield
vital data regarding aetiology, antibiotic sensi-
tivities and important prognostic information.1,2
Establishing an aetiological diagnosis is essential in
the public health management of meningitis.3
Over the last 15 years there has been a shift in
practice away from performing LP in all patients
presenting with suspected meningitis. Whilst the
view that LP is hazardous in patients with meningo-
coccal septicaemia and shock has gained a wide
consensus,4–7there is still controversy surrounding
the fear that LP may precipitate cerebellar tonsillar
or uncal herniation due to raised intracranial
pressure.8–11Despite a lack of evidence, this has
led to the increasingly common practise for many
clinicians to routinely order computerised tomogra-
phy (CT) of the brain prior to performing LP to rule
out raised intracranial pressure.11–16
Early recognition, stabilisation, appropriate
investigation and institution of specific therapeutic
measures are crucial to the outcome of patients
with suspected meningitis.6,17To examine this
process we undertook a postal survey which focused
on variation in clinicians’ reported attitudes and
practice of LP for the diagnosis of suspected
community acquired meningitis.
A postal survey was undertaken using a sem-
structured questionnaire which outlined three
distinct case management scenarios designed to
test knowledge and attitudes in relation to the
management of common presentations of meningi-
tis or meningococcal septicaemia (Table 1). The
subjects were also asked for details of their
speciality, grade, time since qualification, pro-
fessional qualifications, their experience in per-
forming diagnostic LP and whether they had
received any postgraduate training on the pro-
cedure. The questionnaire was valuated in a pilot
study for its content and reliability (results not
shown). The questionnaire is available as an
Appendix (doi:10.1016/j.jinf.2005.07.025). Ethical
approval for this study was gained from the relevant
local research ethics committees.
The questionnaire, with covering letter and
stamped addressed envelope, was sent out to all
260 secondary care clinicians (excluding junior
Clinical scenarios used to test knowledge and attitudes in relation to the management of three distinct common presentations of meningitis or
Case scenariosA student presenting with headache and neck stiffness
A previously well 19-year-old male student presents to accident and emergency with a sudden onset of headache and photophobia. He has neck stiffness on examination, but
no clinical signs of sepsis. He has no signs of increased intracranial pressure or focal neurological findings on examination.
Interpretation: This patient has clinical features suggestive of meningitis. A lumbar puncture is indicated and there are no clinical contraindications. A CT brain is not
A young woman presenting with a 2-day history of muscle aches, fever, sore throat and malaise
A 28-year-old woman, with no previous medical problems, is admitted to accident and emergency with a 2-day history of general muscle aches, fever, sore throat and general
malaise. On examination she has a mild fever and a widespread purpuric rash. She has mild neck stiffness, is slightly drowsy and has cool peripheries. A CT brain scan, which is
undertaken on admission to accident and emergency, is normal.
Interpretation: This patient has clinical features of severe meningococcal septicaemia. A lumbar puncture is contraindicated.
A middle aged man presenting with a 2-week history of headaches
A 55-year-old man, previously healthy, presents with a 1-week history of fever, headaches, malaise and occasional vomiting. Four days prior to admission he was given a
course of antibiotics. Six hours prior to admission he suffered a generalised convulsion. On admission he was febrile, had no rash and his Glasgow Coma Score was 12. However,
his conscious state deteriorates and he becomes increasingly drowsy.
Interpretation: This patient has clinical features of raised intracranial pressure. A CT brain scans does not exclude raised intracranial pressure. A lumbar puncture is
Interpretation of the scenarios is provided below each case.
T. Clark et al.316
house officers) in general internal and emergency
medicine at three acute NHS trusts in the south
west of England. Completed questionnaires were
returned anonymously and therefore non-respon-
dents could not be re-approached. The data
collected from the questionnaires were analysed
using EPI-INFO 2002 (revision 2; Centres for Disease
Control and Prevention, Atlanta).
Of the 260 questionnaires sent out, 108 (42%) were
returned. Seventy-four (69)% of the respondents
were general internal medicine physicians and 33
(31%) were emergency physicians. Amongst the
respondents, 27% were consultants, 24% specialist
registrars, 33% SHOs, and 15% clinical fellows or
staff grades. Thirty-eight percent had been quali-
fied less than 5 years, 23% had been qualified for
5–10 years and 33% for 11 years or more. Fifty-seven
percent of respondents had gained Membership of
the Royal College of Physicians.
Ninty-eight (91%) respondents reported that they
managed patients with meningitis as part of their
routine clinical practice. Twenty-eight clinicians
(26%), 17 of whom were consultant grade, had not
performed an LP for more than a year. Sixty-five
percent had received postgraduate training in this
area, largely related to the practical procedure
itself and not in the form of formal teaching.
The clinical scenarios, their interpretation (see
Discussion) and the responses to the direct ques-
tions are summarised in Tables 1 and 2.
In this patient with no clinical features of raised
70/80(88%) respondents considered that LP should
be part of the routine management, 7/80 (9%; only
one consultant) answered that LP should not be
done. 72/79 (91%) respondents felt that a lumbar
puncture should be performed if the patients GP
had given antibiotics prior to admission. 60/77
(78%) clinicians overall (14/17 [82%] consultants)
thought that CT brain should be performed prior to
lumbar puncture in this case, 18% (14/77; 2/17
[12%] consultants) considered that a CT brain was
unnecessary. Of 70 respondents, 39 (56%; 9/17
[53%] consultants) thought that antibiotics should
be administered immediately on admission prior to
any investigations, 26 (37%) said antibiotics should
be administered after LP (5/17 (29%) of the
consultants), 1/(1%) said antibiotics should be
or focal neurology,
administered after CT but prior to LP, and 4 (6%)
said antibiotics should not be given at all (no
consultants). When asked whether LP aids manage-
ment in such a patient, only 17/69(25%) respon-
dents considered LP important in confirming a
diagnosis of bacterial meningitis and only 14/69
(20%) indicated that it would be helpful in
determining antibiotic sensitivities.
In this scenario of a young woman witha widespread
purpuric rash and cool peripheries, 84/105 (80%) of
respondents reported that LP should be performed
as one of the routine investigations (26/28 (93%)
consultants). When asked to list three important
acute clinical management priorities: Antibiotics
(96/100 [96%]); general resuscitation, e.g. maintain
airway; high flow oxygen and a large bore cannula
(43/100 [43%]); and intravenous fluid support
(57/100 [57%]) were most commonly mentioned.
26/100 (26%) of respondents mentioned a critical
care team assessment. Few mentioned other
relevant investigations. Only two respondents
indicated the public health aspects of this case as
In this middle aged man with a deteriorating level of
consciousness and a normal CT brain scan, 84%
(89/106) respondents overall (26/29 (90%) consult-
ants) answered that LP should be performed
routinely, 5/106 (5%) were unsure. Twenty-two
percent (23/103; 7/27 (26%) consultants) said that
if CT brain had not been possible but fundoscopy
showed no evidence of papilloedema, LP should be
performed. The three main clinical management
priorities identified by the respondents were
antibiotics (67/100 [67%]); general resuscitation
eg maintain airway; high flow oxygen and a large
bore cannula (60/100 [60%]); and intravenous fluid
support (37/100 [37%]). One respondent considered
adjunctive steroid therapy.
In this study we have demonstrated considerable
variation in the diagnostic and management
approach to suspected bacterial meningitis in
adults. We did not identify a reluctance to
undertake LP but the stated approach among
consultants and junior staff was frequently not in
line with published consensusguidelines
Lumbar puncture in the management of meningitis 317
particularly in relationto thediagnostic valueof LP,
the place of CT brain, the dangers of LP in the
presence of shock and the identification of raised
intracranial pressure. Few had received formalised
training in the investigation and clinical approach to
The diagnostic approach to bacterial meningitis
has attracted considerable controversy in recent
years.11,16,18It is argued that LP will not affect the
management of such patients, in our survey only a
minority of our respondents identified confirmation
of the diagnosis or determination of antibiotic
sensitivities as benefits of undertaking LP. Our
findings support the observation that it has become
common practice to arrange a CT brain scan
to exclude raised intracranial pressure prior to
undertaking a LP in patients with suspected
meningitis.11,16This view was more common
amongst consultants than junior doctors in our
survey. This contrasts with the considerable
evidence that clinically significant raised ICP
cannot be ruled out by brain CT and therefore a
normal scan can be falsely reassuring.13–15When
presented with the scenario of a patient with
evidence of raised intracranial pressure (deterior-
ating level of consciousness) most respondents
were reassured by a normal CT or in the absence of
CT brain, the absence of papilloedema, which is a
rare feature of acute bacterial meningitis.13,16
Patients presenting with clinical signs of raised
ICP are the minority and expert opinion holds that
such patients should not undergo LP regardless of
the CT findings.6,11Transporting patients to a CT
scanner before they have been adequately stabil-
ized is unsafe and may result in sudden deterio-
ration in an uncontrolled environment.
Septic shock is a well accepted contraindication
to LP in patients with meningitis.4,6,7Nonetheless,
80% of respondents and 86% of consultants indi-
cated that they would undertake LP in a patient
with a widespread purpuric rash and features of
insipient meningococcal shock (cool peripheries
and drowsiness). LP is neither necessary nor safe
in the initial phases of the management of
meningoccal sepsis which frequently occurs in the
absence of meningeal invasion.19Early institution
of therapy is central to improving patient outcome
in meningococcal sepsis as individuals may appear
relatively well initially and then may unpredictably
deteriorate rapidly without warning. Although
antibiotic therapy was mentioned by most respon-
dents, key interventions such as high-flow oxygen,
fluid resuscitation and critical care team interven-
tion were much less commonly mentioned. As
reported previously, few of those surveyed indi-
cated the importance of other diagnostic investi-
gations20and few appeared to appreciate the
potential public health consequences of making
three distinct common presentations of meningitis or meningococcal septicaemia
Responses to clinical scenarios used to test knowledge and attitudes in relation to the management of
Clinical scenario and questionRespondents
‘Don’t know’ (%)
A student with suspected meningitis and no clinical
features of sepsis or raised intracranial pressure
Would you perform a lumbar puncture as one of
the routine investigations?
Would you still perform a lumbar puncture if the
patient’s general practitioner had given antibiotics
prior to admission to hospital?
Would you perform a CT brain scan prior to
undertaking a lumbar puncture in this patient?
70 (87.5%)7 (8.8%) 3 (3.8%)
72 (91.1%) 5 (6.3%) 2 (2.5%)
60 (77.9%) 14 (18.2%)3 (3.9%)
A young woman with severe meningococcal
Would you perform a lumbar puncture as one of
the routine investigations?
84 (80.0%) 18 (17.1%)3 (2.9%)
A middle aged man with clinical features of raised
The CT scan is normal, would you perform a
lumbar puncture as one of the routine investi-
If a CT brain scan had not been possible, but
fundoscopy showed no evidence of papilloedema,
would you undertake a lumbar puncture as one of
the routine investigations?
89 (84%)12 (11.3%)5 (4.7%)
23 (22.3%) 64 (62.1%) 16 (15.5%)
T. Clark et al.318
such a diagnosis. Our data highlights that many Download full-text
patients with bacterial meningitis and/or meningo-
coccal septicaemia present to clinicians with little
experience of these conditions.
This study was limited by our assessment of the
anticipated rather than actual clinical approach to
these conditions. As bacterial meningitis and
meningococcal septicaemia are rare diseases in
adults, a very large prospective study would have
been necessary to better assess the actual practice.
However, we achieved an acceptable response rate
across a range of seniority for a postal survey on
clinical practice without follow-up. It is unlikely
that there was a bias against reporting of good
medical practice. As the clinicians were drawn from
teaching and district general hospitals with separ-
ate postgraduate training programmes, the results
are likely to have relevance elsewhere in the U.K.
and in a variety of health systems.
It has been argued that the LP as a diagnostic tool
is in danger of becoming a disappearing skill8,11and
our data suggests that it continues to be
implemented incorrectly in this country. Recently
published guidance on the management of bacterial
meningitis and meningococcal disease may help
standardise care,6,7however, this study underlines
the importance of formalised postgraduate training
at all levels in the management of both suspected
acute meningitis and other infection emergencies.
We are grateful to Dr Ardiana Gjini for her critical
review of the manuscript. The authors would also
like to thank all the doctors who participated in the
study and staff at the NHS Trusts’ human resources
departments for their support with sending out the
questionnaires. Funding: None. Conflict of Interest:
Supplementary data associated with this article can
be found at doi:10.1016/j.jinf.2005.07.025.
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Lumbar puncture in the management of meningitis 319