Viral meningitis in the UK: time to speed up
Authors: Matthijs C Brouwer, Diederik van de Beek
Journal: The Lancet Infectious Diseases (2018)

The differential diagnosis in patients with suspected CNS infection ranges from life-threatening disease (bacterial meningitis or herpes encephalitis) to typically less concerning disease (viral meningitis), or benign or no disease.1Brouwer MC Thwaites GE Tunkel AR van de Beek D Dilemmas in the diagnosis of acute community-acquired bacterial meningitis.Lancet. 2012; 380: 1684-1692Summary Full Text Full Text PDF PubMed Scopus (169) Google Scholar, 2van de Beek D Brouwer M Hasbun R Koedel U Whitney CG Wijdicks E Community-acquired bacterial meningitis.Nat Rev Dis Primers. 2016; 2: 16074Crossref PubMed Scopus (127) Google Scholar In the diagnostic work-up of these patients, clinical characteristics fail to differentiate between CNS infections and other diagnoses, and cerebrospinal fluid (CSF) analysis is the main contributor to the final diagnosis.3Khatib U van de Beek D Lees JA Brouwer MC Adults with suspected central nervous system infection: a prospective study of diagnostic accuracy.J Infect. 2017; 74: 1-9Summary Full Text Full Text PDF PubMed Scopus (52) Google Scholar In view of the urgent nature of this testing in patients with suspected bacterial meningitis, physicians are advised to carry out lumbar puncture without delay.4Costerus JM Brouwer MC van de Beek D Technological advances and changing indications for lumbar puncture in neurological disorders.Lancet Neurol. 2018; 17: 268-278Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 5van de Beek D Cabellos C Dzupova O et al.ESCMID guideline: diagnosis and treatment of acute bacterial meningitis.Clin Microbiol Infect. 2016; 22: S37-S62Summary Full Text Full Text PDF PubMed Scopus (403) Google Scholar In The Lancet Infectious Diseases, Fiona McGill and colleagues6McGill F Griffiths MJ Bonnett LJ et al.Incidence, aetiology, and sequelae of viral meningitis in UK adults: a multicentre prospective observational cohort study.Lancet Infect Dis. 2018; (published online June 29.)http://dx.doi.org/S1473-3099(18)30245-7Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar describe a large cohort of patients with suspected meningitis presenting in 42 hospitals throughout England. Their main aim was to study the incidence, causes, and impact of viral meningitis. To this end, they set up an impressive population-based study involving 1126 patients with suspected meningitis over a 3-year period. Of these patients, 638 (57%) were diagnosed with meningitis, the causes of which were viral in 231 (36%) cases, bacterial in 99 (16%) cases, and unknown in 267 (42%) cases. The authors provided valuable data for suspected CNS infection in England and showed that many steps need to be taken. Their most striking observation is the delay between emergency entrance and lumbar puncture in this patient population. The median time to lumbar puncture was 17 h (IQR 8–29), and in 25% of patients it took even more than 29 h before lumbar puncture was done. Delay of lumbar puncture leads to a reduced chance of pathogen detection. CSF culture positivity has been reported to decline from 88% to 55% when the lumbar puncture is done more than 4 h after initiation of antibiotics, which contributes to the high proportion of undiagnosed cases.7Nigrovic LE Malley R Macias CG et al.Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis.Pediatrics. 2008; 122: 726-730Crossref PubMed Scopus (128) Google Scholar The current study reports a reduced change of pathogen detection by 1% for every hour of delay. Delay of CSF examination, such a crucial diagnostic test in this patient population, can also lead to unnecessary hospital treatment and hospital admissions, resulting in high costs for society. One of the potential causes of this delay suggested by the authors is the UK requirement to discharge patients within 4 h from the emergency department. Analyses of 735 588 emergency department visits showed that this requirement led to faster help for patients with minor conditions, whereas those with major diseases had to wait longer and were seen in the last 20 min of their 4 h stay.8Mason S Weber EJ Coster J Freeman J Locker T Time patients spend in the emergency department: England's 4-hour rule-a case of hitting the target but missing the point?.Ann Emerg Med. 2012; 59: 341-349Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar A retrospective analysis9Bobrovitz N Lasserson DS Briggs ADM Who breaches the four-hour emergency department wait time target? A retrospective analysis of 374,000 emergency department attendances between 2008 and 2013 at a type 1 emergency department in England.BMC Emerg Med. 2017; 17: 32Crossref PubMed Scopus (19) Google Scholar of 374 000 UK emergency department attendances between 2008 and 2013 showed that complex diagnostics, such as cranial CT, were a major cause of breaching the 4 h target, which could be a reason to admit patients to a ward without having finished all diagnostic procedures, including lumbar punctures. Another explanation could be the low availability of neurologists in the UK and their rare involvement in acute care,10The Lancet NeurologyUK neurological care: time to confront the crisis.Lancet Neurol. 2011; 10: 671Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar potentially leading to postponing of the lumbar puncture to office hours. Finally, the physician's fear of cerebral herniation due to the lumbar puncture in patients with acute CNS infection might contribute to delay.4Costerus JM Brouwer MC van de Beek D Technological advances and changing indications for lumbar puncture in neurological disorders.Lancet Neurol. 2018; 17: 268-278Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar A prospective cohort study11Costerus JM Brouwer MC Sprengers MES Roosendaal SD van der Ende A van de Beek D Cranial CT, lumbar puncture, and clinical deterioration in bacterial meningitis: a nationwide cohort study.Clin Infect Dis. 2018; (published online March 7.)DOI:10.1093/cid/ciy200Crossref PubMed Scopus (28) Google Scholar showed that this fear is not justified, since only 0·1% of patients with bacterial meningitis deteriorated within 1 h of lumbar puncture. By use of questionnaires, the authors showed decreased quality of life in patients after viral meningitis, with an excess of pain, anxiety, and depression, and reduced activity levels up to 48 weeks after admission.6McGill F Griffiths MJ Bonnett LJ et al.Incidence, aetiology, and sequelae of viral meningitis in UK adults: a multicentre prospective observational cohort study.Lancet Infect Dis. 2018; (published online June 29.)http://dx.doi.org/S1473-3099(18)30245-7Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar Previous smaller studies have emphasised the negative impact of viral meningitis on cognitive functioning even in patients with an apparent favourable outcome.12Schmidt H Heimann B Djukic M et al.Neuropsychological sequelae of bacterial and viral meningitis.Brain. 2006; 129: 333-345Crossref PubMed Scopus (116) Google Scholar The results confirm that viral meningitis is not as benign a condition as it is generally considered to be, and new treatments, better follow-up, and rehabilitation strategies should be developed. We need to speed up care for patients with CNS infections. There is a clear need to improve diagnostic tests for patients with suspected CNS infections because a substantial proportion of patients do not have a cause-specific diagnosis, which impedes early directed treatment and hinders trials of new treatments. New methods, such as pathogen discovery sequencing, use of RNA biosignatures, and point-of-care PCR tests might improve the yield of CSF examination, and should be tested in large prospective studies, including cost-effectiveness analyses. Implementation of fast diagnostic tests and early identification of pathogens in CSF will, however, be of little use if lumbar puncture is delayed considerably. The current study should be a wake-up call for policy makers to improve care for patients with CNS infections. We declare no competing interests. Incidence, aetiology, and sequelae of viral meningitis in UK adults: a multicentre prospective observational cohort studyViruses are the most commonly identified cause of meningitis in UK adults, and lead to substantial long-term morbidity. Delays in getting a lumbar puncture and unnecessary treatment with antivirals were associated with longer hospital stays. Rapid diagnostics and rationalising treatments might reduce the burden of meningitis on health services. Full-Text PDF Open Access