R/O Meningitis... What's your practice?

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pinipig523

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Another attending and I had a discussion the other day regarding meningitis rule out. I usually do:

Gram Stain neg and WBC <4 and pt looks well, dc home.

Otherwise I admit for rule out and culture results.

What do you guys do or do you guys have other comments or suggestions?

Thanks all, much appreciated.
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I agree with sending home a negative tap/non-sick patient. I do not try and adjust-up my WBC cut-off for bloody taps. I know some suggest it, but the data wasn't strong enough for me to be comfortable with that risk.
 
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half of the hospitalists will admit, the other half scream "but it's viiiiral!" if it's all lymphs and no organisms.
 
...unless under 4 weeks, then automatic admit.
But I don't think that's where you were going.

We're seeing a lot of Influenza here now, so a flu swab (even though the sensitivity is lousy) may also change the dispo. Still if I tap someone and it's negative (And they don't have other factors going on and they don't look "sick"), they go home.
 
Yes, most viral meningitis are benign, bu some of our worst M&M's are from viral meningitis.

We've had Herpes encephalitis/meningitis w/ deaths. Esp, in the young.

We've had some really sick enterovirus meningitis.

I tapped a vacationing Mass man in Maine who succumbed to EEE.

"viral" doesn't mean benign.

If they are/look sick, they come in, full court press.
 
Anyone have any recommendations for reading on viral meningitis? Viral meningitis with someone who looks sick seems like an easy sell for me to admit...but any data on the stable "healthy sick" looking viral meningitis?

I remember a 19 yo I tapped last year in the peds ED, he looked okay, not great, but sick enough for us to tap...came up viral meningitis, I think like 45 WBC, with 90% lymphs, the attending wanted to send him home, but I used a "well, he's not quite tolerating PO and he's still a little tachy (95)" and we ended up admitting him and he did fine upstairs.
 
blackavar said:
Anyone have any recommendations for reading on viral meningitis? Viral meningitis with someone who looks sick seems like an easy sell for me to admit...but any data on the stable "healthy sick" looking viral meningitis?

I remember a 19 yo I tapped last year in the peds ED, he looked okay, not great, but sick enough for us to tap...came up viral meningitis, I think like 45 WBC, with 90% lymphs, the attending wanted to send him home, but I used a "well, he's not quite tolerating PO and he's still a little tachy (95)" and we ended up admitting him and he did fine upstairs.
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If they're sick enough to tap, they're sick enough to admit in my mind. LP is a r/o meningitis test, not a r/o bacterial meningitis test.
Now a CSF culture is a bacterial meningitis r/o test, so if they're doing ok and have no growth at 24 hours, that's a different story; but that is not an ED test, that is a floor test.
 
More often than not, if they "look sick", fever, headache, possibly a rash, and are at my shop, they've got murine typhus, not meningitis.

Although I'm sure some of them may have West Nile.
 
blackavar said:
Anyone have any recommendations for reading on viral meningitis? Viral meningitis with someone who looks sick seems like an easy sell for me to admit...but any data on the stable "healthy sick" looking viral meningitis?

I remember a 19 yo I tapped last year in the peds ED, he looked okay, not great, but sick enough for us to tap...came up viral meningitis, I think like 45 WBC, with 90% lymphs, the attending wanted to send him home, but I used a "well, he's not quite tolerating PO and he's still a little tachy (95)" and we ended up admitting him and he did fine upstairs.
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There is no way I would ever, ever send this home. I've been out of residency several years and this is crazy talk. I do not use the WBC or a lymph predominance to determine viral or bacterial meningitis. I can't remember the paper, but there are bacterial meningitis cases where the tap looked viral. I admit people to the hospital for less, why roll the dice on a 19 year old with a weird tap? You may be lucky and get away with this a few times but if you screw up once and the person really dose have bacterial meningitis, they (and you) are hosed.

And what is a 19 year old doing in a peds ED?
 
Interpolfanclub said:
There is no way I would ever, ever send this home. I've been out of residency several years and this is crazy talk. I do not use the WBC or a lymph predominance to determine viral or bacterial meningitis. I can't remember the paper, but there are bacterial meningitis cases where the tap looked viral. I admit people to the hospital for less, why roll the dice on a 19 year old with a weird tap? You may be lucky and get away with this a few times but if you screw up once and the person really dose have bacterial meningitis, they (and you) are hosed.

And what is a 19 year old doing in a peds ED?
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Agree. "Viral" meningitis, even if it truly is, gets admitted by me for at least obs and the day 1 culture result... I've had a few "negative gram stains" that looked good but ended up with positive Cx.

If you look sick enough for me to tap, then you're sick enough to stay.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk
 
Interpolfanclub said:
There is no way I would ever, ever send this home. I've been out of residency several years and this is crazy talk. I do not use the WBC or a lymph predominance to determine viral or bacterial meningitis. I can't remember the paper, but there are bacterial meningitis cases where the tap looked viral. I admit people to the hospital for less, why roll the dice on a 19 year old with a weird tap? You may be lucky and get away with this a few times but if you screw up once and the person really dose have bacterial meningitis, they (and you) are hosed.

And what is a 19 year old doing in a peds ED?
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That was my inclination as well. This was a pediatric attending working in the peds ER, not a emergency medicine trained person, and not a pediatric attending with a peds EM fellowship, just a straight up pediatric attending. I wasn't sure if he knew something I didn't or had some EBM to fall back on that I didn't know.

Our peds ED takes patients up to 25 years old, usually under 20 just goes to them, 20-25 depends on what they're here for and triage kinda decides based on which way the wind is blowing.
 
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I admit every meningitis, bacterial or viral. I don't have the cahoonas to send a meningitis case home. Even viral should meet just about any 23h obs criteria. Look at all the crazy viral encephalopathies and meningitis cases we've had over the past few years. It freaked the public out. Hell, it freaked me out.
 
i'm not saying i agree w/ the hospitalist... but if they "consult" and dc the pt home... what can i do?
 
Groove said:
I admit every meningitis, bacterial or viral. I don't have the cahoonas to send a meningitis case home. Even viral should meet just about any 23h obs criteria. Look at all the crazy viral encephalopathies and meningitis cases we've had over the past few years. It freaked the public out. Hell, it freaked me out.
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I think that you meant "cojones", but I like "cahoonas" waaay better. :)
 
Groove said:
I admit every meningitis, bacterial or viral. I don't have the cahoonas to send a meningitis case home. Even viral should meet just about any 23h obs criteria. Look at all the crazy viral encephalopathies and meningitis cases we've had over the past few years. It freaked the public out. Hell, it freaked me out.
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I've seen people here on SDN speak with authority about sending home viral meningitis, "because, if I had to admit all of them, there would be no room". Really? Yes, I am admitting all of them.

That's the thing - even the "benign" viral meningitides might not be. Bacterial meningitis - bad juju. Viral meningitis that leads to viral encephalopathy? The above mentioned EEE, WEE, St. Louis virus, dengue, herpes, West Nile, enteroviruses (Cocksackie A) - and more - have a mortality rate; the mantra (or dogma) of "bacterial meningitis - won't feel like it, but will kill you, viral meningitis - won't kill you, but will feel like you are dead alive" doesn't completely hold up.

Again, as cultures can grow out bacteria while the cell count has a heavy lymphocytic predominance, this shows that it isn't always what it looks like. To send home someone with something infectious in their CSF is foolhardy.
 
blackavar said:
That was my inclination as well. This was a pediatric attending working in the peds ER, not a emergency medicine trained person, and not a pediatric attending with a peds EM fellowship, just a straight up pediatric attending. I wasn't sure if he knew something I didn't or had some EBM to fall back on that I didn't know.

Our peds ED takes patients up to 25 years old, usually under 20 just goes to them, 20-25 depends on what they're here for and triage kinda decides based on which way the wind is blowing.
Click to expand...

Then why were they supervising you?
 
Apollyon said:
When I was a resident, the Peds ED had a few attendings that were straight peds, including the best guy there. The others would just fill in holes.
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Same here. The last year of my residency shifted to where there would always be a peds ED attending on at all times, and sometimes there would be extra coverage by a straight peds doc. That year we were technically only allowed to present to the peds ED guy (the peds residents could present to either).
 
Apollyon said:
When I was a resident, the Peds ED had a few attendings that were straight peds, including the best guy there. The others would just fill in holes.
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Rendar5 said:
Same here. The last year of my residency shifted to where there would always be a peds ED attending on at all times, and sometimes there would be extra coverage by a straight peds doc. That year we were technically only allowed to present to the peds ED guy (the peds residents could present to either).
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Qualifications for Emergency Medicine Faculty

All emergency medicine faculty supervising emergency medicine residents on emergency medicine rotations must be board certified by the American Board of Emergency Medicine, or have appropriate educational qualifications in emergency medicine. Examples of educational qualifications acceptable to the RRC include:
Certification by the American Osteopathic Board of Emergency Medicine
Certification by a subspecialty board sponsored or cosponsored by the American Board of Emergency Medicine
Recent residency or fellowship graduates actively working toward certification by the above boards

Additionally, faculty providing supervision to emergency medicine residents on emergency medicine rotations must have appropriate qualifications relative to the patient population for which they provide EM resident supervision. For example, a faculty member board certified in pediatrics and pediatric emergency medicine would be qualified to supervise EM residents on pediatric cases, but not adult cases.
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Those are the current ACGME guidelines, from here

Not to say this hasn't changed relatively recently, but to my understanding this is what they want, and if a significant proportion of training is done outside these guidelines, they start making little marks on the residency file.

Of course, we have some pediatric attendings who also grandfathered the EM boards way back when as well.
 
My thought is, we admit people for a heck of alot less. Failure to thrive, recurrent chest pain that is too 'high risk', etc. it's not like meningitis is even that common and can't imagine getting pushback trying to admit one that appears viral
 
PEM here--I admit all kids (any age) with CSF pleocytosis, and almost everyone gets a dose of Cefotaxime or Ceftriaxone 50 mg/kg, pending culture results. If <4 weeks of age with CSF pleocytosis, I start Ampicillin, Cefotaxime, and Acyclovir. I'm in an area with a lot of Lyme disease, so I end up sending Lyme PCR and antibody screen from the CSF quite a bit, in addition to the viral stuff (HSV PCR in the infants or those with risk factors/other findings suspicious for HSV, EBV PCR in all age groups, etc). I can remember 3 cases of lyme meningitis ultimately diagnosed in school-aged kids I've admitted with CSF pleocytosis. Definitely not a diagnosis that I want to miss.
 
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You guys are all awesome... thanks!

IF they're sick enough to tap, they're staying. I got it... some attendings were telling me that's how they practiced, that's how I'll do it from now on.

Thanks!
 
I just want to make sure I understand- those who say that if they're sick enough to tap, they're staying - you're admitting patients with totally negative taps?
 
WilcoWorld said:
I just want to make sure I understand- those who say that if they're sick enough to tap, they're staying - you're admitting patients with totally negative taps?
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This also confused me.

When I have fever/headache/etc patient that I decide to LP, if the CSF comes back negative and they end up looking pretty good after a couple liters of fluid/antipyretics/zofran and a pep-talk...I don't admit that.

As a related aside, when I was moonlighting towards the end of my 3rd year I had a young girl (like 7 or 8) come in with c/o fever and headache. Looked kind of ill/uncomfortable but not toxic. She had absolutely no other c/o. I went straight ahead with full court press, abx upfront, got the blood, did the LP (which she handled like a champ)....CSF negative, and, oh wait - I still don't have that UA back. Of course she had a raging pyelo (LE+, Nitrite +, >30 wbc). It was moonlighting nerves that made me do that, but now when I see young females with fever/headache who don't have rash or look toxic, I definitely eval for pyelo and see how they look after fluids/meds before going down the LP road.
 
WilcoWorld said:
I just want to make sure I understand- those who say that if they're sick enough to tap, they're staying - you're admitting patients with totally negative taps?
Click to expand...

No, if they're sick enough to warrant a tap and it comes back with a viral meningitis picture, then it's a sick enough viral meningitis to admit, despite any protests from a hospitalist.
 
Rendar5 said:
No, if they're sick enough to warrant a tap and it comes back with a viral meningitis picture, then it's a sick enough viral meningitis to admit, despite any protests from a hospitalist.
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I understand that, but I'm not wondering about what you do with lymphocytic predominance. I'm asking about a negative CSF analysis, as in <5 WBC's, no organisms, normal protein and normal glucose?
 
Speaking of which. Everyone in my house has GI Upset and diarrhea accompanied by pure chills x3days. No thermometer but they feel hot. Everyone woke up with a stiff neck this morning including my self. I can barely look around and no change in sleep style. Other than feeling cold in the middle of summer without the AC i feel like a champ. The other 5 look like hell.

Could it be Mingengitis [SIC]?
 
WilcoWorld said:
I understand that, but I'm not wondering about what you do with lymphocytic predominance. I'm asking about a negative CSF analysis, as in <5 WBC's, no organisms, normal protein and normal glucose?
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I dunno guess it depends on whatever else is ailing them. If they're altered and febrile, I'd admit, if they're headache and febrile, then I'll get rid of their headache and send em out.
 
Rendar5 said:
I dunno guess it depends on whatever else is ailing them. If they're altered and febrile, I'd admit, if they're headache and febrile, then I'll get rid of their headache and send em out.
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That makes perfect sense to me. If they're altered, I'll admit them. I guess I should've clarified that I'm considering an otherwise well patient who is getting the LP to rule out meningitis because they're febrile and have a chief complaint of headache - not someone with fever and AMS.

So, do the above posters not think that headache + fever is an indication for LP or are you admitting every headache + fever that you tap? (Exclude febrile patients with strep + headache, pneumonia + headache, pyelonephritis + headache, etc)

I'm not trying to be argumentative - if I'm tapping too many or admitting too few, that's something I'd like to know.
 
WilcoWorld said:
That makes perfect sense to me. If they're altered, I'll admit them. I guess I should've clarified that I'm considering an otherwise well patient who is getting the LP to rule out meningitis because they're febrile and have a chief complaint of headache - not someone with fever and AMS.

So, do the above posters not think that headache + fever is an indication for LP or are you admitting every headache + fever that you tap? (Exclude febrile patients with strep + headache, pneumonia + headache, pyelonephritis + headache, etc)

I'm not trying to be argumentative - if I'm tapping too many or admitting too few, that's something I'd like to know.
Click to expand...

Ok. My practice is:
Do I think meningoencephalitis is likely ( e.g. fever + headache without other identifiable etiology)?

No = no tap
Yes = tap

Tap results:
Stone cold normal = probably discharge (unless something else feels off, or in the case of peds, sketchy parents / followup)
Any abnormality = admit for abx pending Cx results.

Savvy?
-d

Sent from my DROID BIONIC using Tapatalk
 
Daiphon said:
Ok. My practice is:
Do I think meningoencephalitis is likely ( e.g. fever + headache without other identifiable etiology)?

No = no tap
Yes = tap

Tap results:
Stone cold normal = probably discharge (unless something else feels off, or in the case of peds, sketchy parents / followup)
Any abnormality = admit for abx pending Cx results.

Savvy?
-d

Sent from my DROID BIONIC using Tapatalk
Click to expand...

Yep, sounds perfectly reasonable. Gotta love (sarcasm) how it only takes 30+ posts to understand someone on the internet.
 
Funny, this week I had a pt with fever to 103 for 6 days, ha and neck pain. No other sx except mild sinus pressure. Sent by urgent care for r/o meningitis. I did a septic w/u although by the time he got to me fever had broken and he looked pretty good.

Discused lp with pt and his wife and they reluctantly agreed. I made a joke about west Nile (haven't been bitten by any Mosquitos have you? ) and the nurse says no, but he had a tick bite.... But got it off right away. What? Any rashes? You know like a big target? No no nothing like that, got it right off doc. So I proceed with LP which is negative. Then, as he's getting dressed he notes an 8 cm target rash on his inner right thigh. Doh.

Good ole Lyme:luck:
 
Anyone use the bacterial meningitis score (the nigrovic score) in kids? Absence of seizures, CSF protein less than 80, negative gram stain, CSF ANC less than 1000 and peripheral ANC less than 10000. supposed to be >99% sensitive for bacterial meningitis in kids 2 mo to 18 yrs.

Although, I can't imagine who's gonna send home a kid w/ 900 PMNs in his CSF
 
Interesting. I haven't heard of that scoring system and will have to read more. But in principle, that discussion all comes down to what is the acceptable miss rate of meningitis in ages 2-18 that you've tapped. Let's say it was 99% sensitive. Are you comfortable sending home 1% of true meningitis? I'm guessing that's around 3-4 cases in a career roughly where you've just thrown some serious lawyer dice. You have to also consider what our baseline miss rate is for meningitis anyways. If this is equivalent then maybe it's reasonable but it'd have to be the most fool proof study validated by an RCT on a large scale, relevant population and account for both bacterial and viral meningitis for it to change my practice.
 
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