LP first or cefotaxime first?

[watermen]

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In a patient who presented with signs of meningitis? What should you do first? LP first or cefotaxime first?

I came across multiple answers on this topic.

1. Some say start antibiotic first...we shouldn't wait.

2. Some say we should do an LP first b4 we start antibiotic, so we wouldn't affect the CSF result.

3. Some say we should do a CT or MRI to rule tumor b4 starting LP.

So which one is right now?

 

[typhoonegator]

Here is my very general algorithm, as a neurology resident. First, look at the patient and vitals. If they look sick and you suspect infectious meningitis, GET BLOOD CULTURES, then give Vanco 1g, CTX 2g. Don't get fancy, don't give steroids. Depending on your antibiotograms at your hospital, you may use a different cephalosporin for maximal coverage. If you are seriously concerned about Listeria, give Amp, but don't do it just for the hell of it. Same goes for HSV. Next, do a good eye exam. If there are visible venous pulsations, then you can tap the patient safely. If you don't trust your eye exam or are unsure, get an I- CT. If no mass lesions or whatnot, do an LP. Giving the abx a short while before the LP will not measurably change the diagnostic value, and a sick meningitis patient can go downhill in a big hurry without antimicrobials. Always document an OP, don't be lazy. Always send for HSV PCR, and make your lab run it even if the cell counts are low. Write for the lab to save the extra CSF.

Then...admit to medicine. Heh heh.

 

[ericdamiansean]

This study shows otherwise

http://pediatrics.aappublications.org/cgi/content/full/108/5/1169

"The present study demonstrates that CSF sterilization may occur more rapidly after initiation of parenteral antibiotics than previously suggested, with complete sterilization of meningococcus within 2 hours and the beginning of sterilization of pneumococcus by 4 hours into therapy. Lack of adequate culture material may result in inability to tailor therapy to antimicrobial susceptibility or in unnecessarily prolonged treatment if the clinical presentation and laboratory data cannot exclude the possibility of bacterial meningitis"

Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment.Pediatrics. 2001 Nov;108(5):1169-74

But whatever it is, always do a fundoscopy first before an LP, and the general condition of the patient must be taken into consideration, for example, stabilize the vitals first. In good hands (with a normal prior fundoscopy exam), an LP can be done in less than 10 minutes, in one attempt. I think that you can wait for an extra 10 minutes before starting abx

 

[hyperbaric]

Here is my very general algorithm, as a neurology resident. First, look at the patient and vitals. If they look sick and you suspect infectious meningitis, GET BLOOD CULTURES, then give Vanco 1g, CTX 2g. Don't get fancy, don't give steroids. Depending on your antibiotograms at your hospital, you may use a different cephalosporin for maximal coverage. If you are seriously concerned about Listeria, give Amp, but don't do it just for the hell of it. Same goes for HSV. Next, do a good eye exam. If there are visible venous pulsations, then you can tap the patient safely. If you don't trust your eye exam or are unsure, get an I- CT. If no mass lesions or whatnot, do an LP. Giving the abx a short while before the LP will not measurably change the diagnostic value, and a sick meningitis patient can go downhill in a big hurry without antimicrobials. Always document an OP, don't be lazy. Always send for HSV PCR, and make your lab run it even if the cell counts are low. Write for the lab to save the extra CSF.

Then...admit to medicine. Heh heh.

I'm only a second year, so I would never argue treatment with a resident (neuro or otherwise), but what you described is basically what I was taught in my NS2 course. It was highly stressed, do not wait. For whatever that is worth...

 

[Tired]

Here is my very general algorithm, as a neurology resident. First, look at the patient and vitals. If they look sick and you suspect infectious meningitis, GET BLOOD CULTURES, then give Vanco 1g, CTX 2g. Don't get fancy, don't give steroids. Depending on your antibiotograms at your hospital, you may use a different cephalosporin for maximal coverage. If you are seriously concerned about Listeria, give Amp, but don't do it just for the hell of it. Same goes for HSV. Next, do a good eye exam. If there are visible venous pulsations, then you can tap the patient safely. If you don't trust your eye exam or are unsure, get an I- CT. If no mass lesions or whatnot, do an LP. Giving the abx a short while before the LP will not measurably change the diagnostic value, and a sick meningitis patient can go downhill in a big hurry without antimicrobials. Always document an OP, don't be lazy. Always send for HSV PCR, and make your lab run it even if the cell counts are low. Write for the lab to save the extra CSF.

Most Pediatricians and ER docs I have rotated with require a CT prior to LP. Probably simply that they don't trust their ability to do a good eye exam, I know, but worth mentioning. Also, our baby docs give acyclovir as routine empiric treatment in the little ones.

 

[Arsenic]

start the abx first

im on the neuro rotation right now and they just finished drilling into us that they want abx started first, then ct, then tap. you can always draw blood cultures when you push the abx but always treat first when your suspicion is high.

 

[watermen]

But whatever it is, always do a fundoscopy first before an LP, and the general condition of the patient must be taken into consideration, for example, stabilize the vitals first. In good hands (with a normal prior fundoscopy exam), an LP can be done in less than 10 minutes, in one attempt. I think that you can wait for an extra 10 minutes before starting abx

If this is an 8 year old infant who presented with typical sign of meningitis, how do you do fundoscopic exam?

OK...this is a step 2 UK question from some commercial book.

The question like I said, was an 8 year old infant who presented with typical sign of meningitis, his anterior fontanelle is bulging, his TM is bulging also, he is febrile, he eyes are reactive but do not focus on his parents, what is your next step of management?

A. Do LP
B. Do CT
C. Do MRI
D. Start ampicillin
E. Start cefotaxime.

Tell me what will you do then?

 

[typhoonegator]

You really have to give the antibiotics first. If you are then waiting 2-4 hours before you get around to doing the tap, then you really need to re-evaluate your priorities. However, even if your CSF is miraculously cleared of organisms by the time you get around to the LP, I would much rather have a living patient with an unclear pathogen than a dead patient with documented meningococcus.

 

[Arsenic]

If this is an 8 year old infant who presented with typical sign of meningitis, how do you do fundoscopic exam?

OK...this is a step 2 UK question from some commercial book.

The question like I said, was an 8 year old infant who presented with typical sign of meningitis, his anterior fontanelle is bulging, his TM is bulging also, he is febrile, he eyes are reactive but do not focus on his parents, what is your next step of management?

A. Do LP
B. Do CT
C. Do MRI
D. Start ampicillin
E. Start cefotaxime.

Tell me what will you do then?

cefotaxime.

ampicillin is for listeria coverage but thats only a worry in newborns and the elderly. in a child over 3 months, you go with the cefotaxime or ceftriaxone.

 

[werd]

i agree - abx first. doing antibiotics first you risk never confirming the diagnosis, doing LP first you risk a worse outcome for the patient. i also can't imagine many hospitals would need more than 2-4 hours to get a tap on an AMS patient...

 

[ericdamiansean]

If this is an 8 year old infant who presented with typical sign of meningitis, how do you do fundoscopic exam?

OK...this is a step 2 UK question from some commercial book.

The question like I said, was an 8 year old infant who presented with typical sign of meningitis, his anterior fontanelle is bulging, his TM is bulging also, he is febrile, he eyes are reactive but do not focus on his parents, what is your next step of management?

A. Do LP
B. Do CT
C. Do MRI
D. Start ampicillin
E. Start cefotaxime.

Tell me what will you do then?

In this case, start cefotaxime.
But if you have a child who is relatively stable AND you can do a stat LP, then a LP before abx would be feasible. But, if the patient presents as above, then abx would definately be first choice over anything else, even imaging.

 

[deleted109597]

ABx first. You can kill people by not giving them, whereas you likely won't kill them by waiting for the LP.

However, you have to do the LP anyway, because if they have some other type of meningitis, you have to treat that too.

 

[SoCuteMD]

The pediatric ED attending I worked with this summer put together a whole bunch of literature for us on this. The take home was that in infants/young children - NO ABX WITHOUT A TAP.

 

[pillowhead]

The pediatric ED attending I worked with this summer put together a whole bunch of literature for us on this. The take home was that in infants/young children - NO ABX WITHOUT A TAP.

I've gotta buck the trend of antibiotics first, then LP that's going on here and go with this poster. On my peds ED rotation, it was also drilled into us to always always always tap before antibiotics even with neonates (with literature to back it up).

 

[watermen]

I've gotta buck the trend of antibiotics first, then LP that's going on here and go with this poster. On my peds ED rotation, it was also drilled into us to always always always tap before antibiotics even with neonates (with literature to back it up).

The pediatric ED attending I worked with this summer put together a whole bunch of literature for us on this. The take home was that in infants/young children - NO ABX WITHOUT A TAP.

Yeah...I tend agree with what you all say. But....

the CORRECT answer given by USMLE WORLD is

threat with cefotaxime first!

sigh....seems that Evidence Based Medicine can be applied here???

 

[oldbearprofessor]

The pediatric ED attending I worked with this summer put together a whole bunch of literature for us on this. The take home was that in infants/young children - NO ABX WITHOUT A TAP.

From an ER perspective this is almost always true. A few neonates will have meningitis without sepsis and it can be very important to get the tap first, especially since in neonates we don't need that CT scan 🙄 .

But, from the NICU nosocomial infection perspective, we will have babies who go from well to shocky and ventilated within minutes, often with gram negative sepsis/meningitis. We need to give them volume, more volume, draw the blood culture and start antibiotics. Often they are too sick to tap (this concept is variable between neonatologists as to if one is ever too sick to tap). For sure, if it's meningitis in this group of preemies, we'll be able to figure it out a few hours or a day later when they can be tapped and aren't shocky anymore. So, we try to tap first, but when the baby is going downhill rapidly (preemies can go from bottle feeding to death in a couple of hours from Gram negative sepsis), the antibiotics go first. Besides, just try getting an NICU nurse to agree to help with the tap while what started as a growing preemie assignment is now getting his X-ray for ET tube placement and she's hanging dopamine in the second IV line she just started while the parents are crying at the bedside...

This is a common rapid decision that needs to be made in an NICU . The same basic reasoning holds for newborns who are full-term. Here there are many babies who get a rule out sepsis without an LP (depends on the center) if they are unlikely to be infected and are not symptomatic. In the case of presentation in the newborn nursery of a baby with shock and probable early onset Group B sepsis, we will again usually follow the pattern of fluid, blood culture and antibiotics and do the tap a few hours to a day later. This is less common due to peripartum GBS testing and treatment than in my residency and fellowship days when it was fairly common.

Recently I was seen doing an LP in this circumstance while the antibiotics were being drawn up by the nurse...a neonatal LP can be done fairly quickly. I got the fluid and the nurse pushed the ampicillin....

 

[Tired]

I've gotta buck the trend of antibiotics first, then LP that's going on here and go with this poster. On my peds ED rotation, it was also drilled into us to always always always tap before antibiotics even with neonates (with literature to back it up).

The point of this question is that the child had signs of severe meningitis, sepsis, and developing neurologic damage. A child that toxic would get the antibiotics without delay. They may have drilled the opposite into you, but in the case of a life-threatening emergency, I doubt anyone would insist on a tap first. Also, in the question stem you have signs that may be interpreted as elevated ICPs, and hence the child would probably need a scan prior to the tap.

 

[ericdamiansean]

Yeah...I tend agree with what you all say. But....

the CORRECT answer given by USMLE WORLD is

threat with cefotaxime first!

sigh....seems that Evidence Based Medicine can be applied here???

EVERY case is unique, and given the patient with that kind of presentation, you would definately treat and support the vitals first before proceeding to investigations.

Literature says to tap first, but the literature which I reviewed also did not state the general status of the samples ie relatively well/tolerating orally or vice versa .

 

[edmadison]

The pediatric ED attending I worked with this summer put together a whole bunch of literature for us on this. The take home was that in infants/young children - NO ABX WITHOUT A TAP.

This is likely based on the guidelines for fever without a source in an otherwise well appearing infant. That doesn't apply in this situation. All the tap does is help define type and duration of therapy. In a kid with meningismus, you are going to treat broadly even if your cultures come back negative. This is why the answer to the mock question is bug juice. You have a kid with a high index of suspicion for meningitis. Bug juice cures, nothing else on the list does.

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Also, most pediatricians can get a spinal tap pretty quick. I've had several where the consent took longer than the procedure. My real problem is in the NICU where the kids are too sick to be tapped. Then they get their whole course of bug juice.

Ed

 

[pillowhead]

The point of this question is that the child had signs of severe meningitis, sepsis, and developing neurologic damage. A child that toxic would get the antibiotics without delay. They may have drilled the opposite into you, but in the case of a life-threatening emergency, I doubt anyone would insist on a tap first. Also, in the question stem you have signs that may be interpreted as elevated ICPs, and hence the child would probably need a scan prior to the tap.

I'm thinking of one particular case where the neonate looked sick as crap. Was being transferred in from an outside clinic and he looked awful. On oxygen but not yet intubated. Still did LP before antibiotics precisely because as others have pointed out, LPs in infants can be done very quickly. I don't know if this child was a "life-threateneing emergency." Quite frankly, I think that can be difficult to tell in the ED sometimes, esp with the neonates. There's no criteria I know of for "life-threatening emergency" vs. oh, crap, this kid doesn't look so good. A neonate that doesn't look so good is always kind of scary and potentially life-threatening. (NICU is totally different because hopefully the child has been followed for several days already and there is already some histor there.) So generally speaking, I stil go with LP before antibiotics.

 

[Tired]

I'm thinking of one particular case where the neonate looked sick as crap. Was being transferred in from an outside clinic and he looked awful. On oxygen but not yet intubated. Still did LP before antibiotics precisely because as others have pointed out, LPs in infants can be done very quickly.

Are you a peds resident? I'm a graduating MSIV, and the case you cite scares the pi$$ out of me. The lack of a true "cutoff" for what constitutes "looking like crap" is precisely the reason I was taught to error on the side of caution, and initiate definitive treatment prior to diagnostics if there is any concern about the child's well-being.

In the case you cite, my faculty would have been extremely angry that antibiotics were not started prior to transfer. We can quibble about waiting a few minutes to grab a tap once you have ahold of the patient, but waiting for the >1hr most transfers/transports frequently take seems grossly negligent, IMHO.

While I understand the rationale of your argument, I think that as a general rule it is a really bad idea, and will get you burned sooner or later.

 

[edmadison]

In the case you cite, my faculty would have been extremely angry that antibiotics were not started prior to transfer.

And they should, but this happens every day. Ask anyone who has worked in the ED of a peds referral center. If they call you first, sure you tell 'um to make sure the bug juice is running, but some just walk in the door.

Ed

 

[beastmaster]

question here. Is it appropriate to reevaluate effectiveness of abx empirically? Changing from one type of "bug juice" to another, without LP or culture results, according to symptomatology?

 

[stretch210]

how I learned it...

Lumbar puncture first...then antibiotics.

Where the confusion comes in is if there is a possibility that a brain abscess (mass) exists. If so, a CT scan should be performed and empiric antibiotics administered. After the CT scan and within FOUR hours a lumbar puncture can be performed and cultured and an accurate reading can still be achieved.

 

[MSHARO]

Here's how I learned it from the person who wrote the chapter on it in Harrison's, however as you all know...opinions will vary.

Anyways...if you think the patient has meningitis, treat first!!! The CT, MRI, LP etc are all secondary. As she likes to say..."time is brain"

Get a CT before an LP if you see altered level of consciousness, papilledema, new onset seizure, or if they are immunocompromised. However many I have talked to still get a CT before LP regardless (CYA). With the CT you are specifically looking at the 4th ventricle and quadribeminal cistern not necessarily just an abcess etc.

As far as the drugs...

First...steroids. Dexamethasone 20mg q6 x 4d- pref 15-20' before abx.(obviously this is still controversial and I can't rememer what she said about peds situations but I assume she would still use the steroids. Most of the peds docs here that I have talked to don't use the steroids however)

then..Empirical abx and antivirals
1. ceftriaxone 2g q12 or cefotaxime 3g q4 or cefepime 2g q12
2. Vanc 500mg q6 or 1g q 12
3. Acyclovir 10mg/kg q8
4. Doxycycline 100mg q12 if tick season where you are
5. Amp/gent if worried about listeria, immunocompromised, elderly, etc.

Oh... getting blood cultures is also a given of course

 

[velo]

This study shows otherwise

http://pediatrics.aappublications.org/cgi/content/full/108/5/1169

That's what he said though, "giving abx a short time before won't ruin your CSF cultures." 2-4hrs? You're not going to be sitting on a patient you really suspect has meningitis for that long.

 

[velo]

If this is an 8 year old infant who presented with typical sign of meningitis, how do you do fundoscopic exam?

OK...this is a step 2 UK question from some commercial book.

The question like I said, was an 8 year old infant who presented with typical sign of meningitis, his anterior fontanelle is bulging, his TM is bulging also, he is febrile, he eyes are reactive but do not focus on his parents, what is your next step of management?

A. Do LP
B. Do CT
C. Do MRI
D. Start ampicillin
E. Start cefotaxime.

Tell me what will you do then?

an 8 year old wouldn't have a bulging fontanelle

I'd start ceftriaxone. Always treat first, if you really suspect a patient has bacterial meningitis getting them antibiotics as quickly as possible is the most important thing. You really want your patient sitting in the scanner without antibiotic coverage getting a Head CT so you can do your LP just because you really want your culture to grow something?? The CSF will still give you the diagnosis even if it doesn't give you the bug, and if you don't grow something its not the end of the world. It is, however, the end of the patient's world if you don't treat quickly enough.