Cerebrospinal fluid lactate: a differential biomarker for bacterial and viral meningitis in children

Acute infections of the central nervous system in children and adults: diagnosis and management

Central nervous system infections are due to different microorganisms such as viruses, bacteria, mycobacteria, fungi, amoebas, and other parasites. The etiology depends on multiple risk factors, and it defines the infection location because some microorganisms prefer meninges, brain tissue, cerebellum, brain stem or spinal cord. The microorganisms induce diseases in the nervous system through direct invasion, neurotoxin production, and the triggered immune response. To determine the infection etiology, there are several diagnostic tests which may be conducted with cerebrospinal fluid, blood, respiratory and stool samples. These tests include but are not limited to direct microscopic examination of the sample, stains, cultures, antigenic tests, nucleic acid amplification tests, metagenomic next-generation sequencing, immunologic biomarker and neuroimaging, especially contrast-enhanced magnetic resonance imaging. The treatment may consist of specific antimicrobial treatment and supportive standard care. Since viruses have no specific antiviral treatment, antimicrobial treatment is mainly targeted at non-viral infections. This article will focus on diagnosis and treatment of acute acquired infections of the central nervous system beyond the neonatal period. The discussion defines the disease, provides the clinical presentation, explains the etiology and risk factors, and briefly mentions potential complications. This updated review aims to provide the reader with all the elements needed to adequately approach a patient with a central nervous system infection. Mycobacterium tuberculosis infection, Cryptococcus spp. infection and vaccines are not within the scope of this article.

Pediatric central nervous system infections in the Amazon: clinical and laboratory profiles

Background

Central nervous system (CNS) infections are important causes of mortality and morbidity in children, and they are related to severe problems such as hearing loss, neurological sequelae, and death. The objective was to describe clinical and laboratory exam profiles of children who were diagnosed with CNS infections.

Methods

We conducted a cross-sectional study based on medical records, which included pediatric patients aged from 3 months to 15 years, with a clinical suspicion of CNS infection between January 2014 to December 2019. The pathogens were confirmed in cerebrospinal fluid (CSF) samples using Gram staining, cell culture, molecular diagnostics (PCR and qPCR), and serology.

Results

Out of the 689 enrolled patients, 108 (15.6%) had laboratory-confirmed infections in CSF. The most common bacterial pathogens isolated from the culture were Neisseria meningitidis serogroup C in 19, Streptococcus pneumoniae in 11, and Haemophilus influenzae in seven samples. The viruses identified were Enterovirus, Cytomegalovirus, Varicella-zoster virus, Epstein-Barr virus, and arbovirus. No patient was found to be positive for Herpes simplex virus 1 and 2. Patients with viral infections showed altered levels of consciousness (p = 0.001) when compared to bacterial infections.

Conclusion

This study shows the presence of important vaccine-preventable pathogens, and different families of viruses causing CNS infections in the pediatric patients of Manaus.

Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients

BACKGROUND

Meningitis is a life-threatening clinical condition associated with high mortality and morbidity. Early diagnosis and specific treatment may improve outcomes. Lack of specific clinical signs or tests make the diagnosis challenging.

AIM

To assess the efficacy of cerebrospinal fluid (CSF) lactate in diagnosing meningitis in critically ill patients.

METHODS

A prospective, observational cohort study was carried out in a neuro-medical intensive care unit (ICU) over a 22 mo period. Adult patients, with suspected meningitis admitted in ICU, were serially recruited. Patients who refused consent, those with peripheral sensorineural deficit, or with any contraindication to lumber puncture were excluded. CSF cytology, bio-chemistry, lactates, culture and polymerase chain reaction based meningo-encephalitis panel were evaluated. Patients were divided in two groups based on clinical diagnosis of meningitis. The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests.

RESULTS

Seventy-one patients were included and 23 were diagnosed with meningitis. The mean values of CSF total leucocyte count (TLC), proteins and lactates were significantly higher in meningitis group. There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel. CSF lactate (> 2.72 mmol/L) showed good accuracy in diagnosing meningitis with an area under the curve of 0.81 (95% confidence interval: 0.69-0.93), sensitivity of 82.6%, and specificity 72.9%. These values were comparable to those of CSF TLC and protein. Twelve patients with bacterial meningitis had significantly higher CSF lactate (8.9 ± 4.7 mmol/L) than those with non-bacterial meningitis (4.2 ± 3.8 mmol/L), P = 0.006.

CONCLUSION

CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients. CSF lactate (> 2.72 mmol/L) showed good accuracy, sensitivity, and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis.

Etiology, Clinical Phenotypes, Epidemiological Correlates, Laboratory Biomarkers and Diagnostic Challenges of Pediatric Viral Meningitis: Descriptive Review

Meningitis is an inflammation of the brain and spinal cord meninges caused by infectious and non-infectious agents. Infectious agents causing meningitis include viruses, bacteria, and fungi. Viral meningitis (VM), also termed aseptic meningitis, is caused by some viruses, such as enteroviruses (EVs), herpesviruses, influenza viruses, and arboviruses. However, EVs represent the primary cause of VM. The clinical symptoms of this neurological disorder may rapidly be observed after the onset of the disease, or take prolonged time to develop. The primary clinical manifestations of VM include common flu-like symptoms of headache, photophobia, fever, nuchal rigidity, myalgia, and fatigue. The severity of these symptoms depends on the patient's age; they are more severe among infants and children. The course of infection of VM varies between asymptomatic, mild, critically ill, and fatal disease. Morbidities and mortalities of VM are dependent on the early recognition and treatment of the disease. There were no significant distinctions in the clinical phenotypes and symptoms between VM and meningitis due to other causative agents. To date, the pathophysiological mechanisms of VM are unclear. In this scientific communication, a descriptive review was performed to give an overview of pediatric viral meningitis (PVM). PVM may occasionally result in severe neurological consequences such as mental retardation and death. Clinical examinations, including Kernig's, Brudzinski's, and nuchal rigidity signs, were attempted to determine the clinical course of PVM with various success rates revealed. Some epidemiological correlates of PVM were adequately reviewed and presented in this report. They were seen depending mainly on the causative virus. The abnormal cytological and biochemical features of PVM were also discussed and showed potentials to distinguish PVM from pediatric bacterial meningitis (PBM). The pathological, developmental, behavioral, and neuropsychological complications of PVM were also presented. All the previously utilized techniques for the etiological diagnosis of PVM which include virology, serology, biochemistry, and radiology, were presented and discussed to determine their efficiencies and limitations. Finally, molecular testing, mainly PCR, was introduced and showed 100% sensitivity rates.

Study of cerebrospinal fluid levels of lactate, lactate dehydrogenase and adenosine deaminase in the diagnosis and outcome of acute meningitis

BACKGROUND

Meningitis is a serious clinical health issue in most developing countries. Late diagnosis and treatment result in significant morbidity and mortality. This research aims to study the utility of CSF lactate, lactate dehydrogenase (LDH), and adenosine deaminase (ADA) as diagnostic markers in acute meningitis, and to differentiate among varied aetiologies of acute meningitis and their outcomes.

METHOD

A cross-sectional observational case-control study was conducted in 30 patients of suspected meningitis of varied aetiologies and 30 controls without any pre-existing neurological disorder and who underwent lumbar puncture during spinal anesthesia. A fresh CSF sample was collected in a heparinized vial following an aseptic lumbar puncture. The levels of lactate, LDH and ADA were estimated and recorded.

RESULT

CSF lactate was significantly elevated in bacterial meningitis (BM) and cryptococcal meningitis, with 100% sensitivity when compared to controls. Elevated LDH was found only in BM, hence elevated LDH levels may strongly signify bacterial etiology. Significantly elevated ADA levels were noted in tuberculous meningitis. Significantly elevated levels of lactate and ADA were suggestive of slower clinical recovery and a prolonged hospital stay (p < 0.001).

CONCLUSION

Estimation of CSF lactate, LDH, and ADA levels is a rapid, inexpensive and simple procedure and can play a major role in the early differentiation of bacterial, viral, tuberculous, and fungal meningitis. This would facilitate the initiation of appropriate treatment as early as possible, thereby decreasing mortality and complications.

Metabolomic Characterization of Cerebrospinal Fluid from Intracranial Bacterial Infection Pediatric Patients: A Pilot Study

Intracranial bacterial infection remains a major cause of morbidity and mortality in neurosurgical cases. Metabolomic profiling of cerebrospinal fluid (CSF) holds great promise to gain insights into the pathogenesis of central neural system (CNS) bacterial infections. In this pilot study, we analyzed the metabolites in CSF of CNS infection patients and controls in a pseudo-targeted manner, aiming at elucidating the metabolic dysregulation in response to postoperative intracranial bacterial infection of pediatric cases. Untargeted analysis uncovered 597 metabolites, and screened out 206 differential metabolites in case of infection. Targeted verification and pathway analysis filtered out the glycolysis, amino acids metabolism and purine metabolism pathways as potential pathological pathways. These perturbed pathways are involved in the infection-induced oxidative stress and immune response. Characterization of the infection-induced metabolic changes can provide robust biomarkers of CNS bacterial infection for clinical diagnosis, novel pathways for pathological investigation, and new targets for treatment.

Challenges in the Management of Gram-Negative Bacterial Infections in Patients With Ventriculoperitoneal Shunt

Gram-negative bacterial infections of the central nervous system (CNS) have worse clinical outcomes. The most common bacteria include Escherichia Coli, Citrobacter species, Enterobacter species, Serratia species, and Pseudomonas aeruginosa. There are multiple risk factors for CNS infection after shunt insertion, including younger age, obstructive hydrocephalus, shunt revision surgery, and trauma. The clinical presentation of a ventriculoperitoneal (VP) shunt infection includes the signs and symptoms of meningitis to fever with abdominal pain and peritonitis. Apart from cerebrospinal fluid (CSF) analysis, microbiological cultures and radiological studies are key diagnostic tools. Initial empirical intravenous antimicrobial therapy is preferably broad spectrum with appropriate coverage for resistant Gram-negative pathogens and the duration of treatment depends upon pathogenesis, host factors, and clinical response to the therapy.

Considering the importance of this disease and associated clinical outcomes, in this review article, we have summarized the epidemiology, clinical features, management, and prevention of Gram-negative VP shunt infections in adults.

The Epidemiology and Outcomes of Meningitis among Iranian Children in a Period of 10 Years

Background:

One of the important causes of childhood febrile illness is meningitis. It causes bacterial, viral, fungal, parasitic, and non-infectious agents. Pediatric bacterial meningitis is one of the most important causes of infant mortality, especially in premature infants. This study aimed to identify the outcome and mortality of children with meningitis.

Methods and Materials:

All children with meningitis in the Pediatric Department of Rasool Akram Hospital from December 23, 2007, to December 16, 2017, were included. Signs and symptoms (fever, consciousness, neck rigidity, and seizure) were collected and Cerebrospinal fluid analysis in children was made. Based on these findings, patients were divided into two groups, which include bacterial and non-bacterial meningitis. Then we recalled all families and examined them to discover the child’s outcome and complications at least after two years.

Results:

During the ten-year study period, 202 children were included in the study. Patients aged less than 12 months were found to be more frequently affected. Fever was the most common presentation (83.4%) followed by seizure (51.5%) and vomiting (49%). 119 (58.9%) of the patients were male and 83 (41.1%) were female. Definite bacterial meningitis was the final diagnosis in 35.6% (72) of patients (mean age 34.1± 48.3 months), and non-bacterial meningitis was diagnosed in 64.4% (130) of cases (mean age 46.3± 52.4 months). The most common organism in bacterial meningitis (by all methods) was Streptococcus pneumonia. Among children, 187 (92.1%) were survivors and 15 (%7.9) were non-survivors. Neurological sequelae such as motor deficit and epilepsy were identified in 9 (4.8%) and 5 (2.6%) subjects, respectively, and that they were all caused by bacterial meningitis. There was no death or neurological sequelae observed during follow-up in children with non-bacterial meningitis. Gender, age, signs and symptoms of patients at the time of admission were not significantly different between the bacterial and non-bacterial meningitis groups (p>0.05). Hydrocephalus, CSF characteristic, morbidity and mortality were significantly different between the bacterial and non-bacterial meningitis groups.

Conclusion:

This study showed that elevated LDH and low glucose levels in CSF are characteristic of bacterial meningitis. Increased LDH is significantly related to death in children (P-value > 0.001) with meningitis. Beneficial empirical antibiotics and sufficient follow-up by parents cause good prognosis in children with meningitis. Also in a child with fever and seizure, we should think of meningitis, even though in the absence of positive neurological examinations. It seems that increased CSF LDH, elevated CSF protein and age under one year are significant mortality risk factors in children with meningitis.

A Mitocentric View of the Main Bacterial and Parasitic Infectious Diseases in the Pediatric Population

Infectious diseases occur worldwide with great frequency in both adults and children. Both infections and their treatments trigger mitochondrial interactions at multiple levels: (i) incorporation of damaged or mutated proteins to the complexes of the electron transport chain, (ii) mitochondrial genome (depletion, deletions, and point mutations) and mitochondrial dynamics (fusion and fission), (iii) membrane potential, (iv) apoptotic regulation, (v) generation of reactive oxygen species, among others. Such alterations may result in serious adverse clinical events with great impact on children's quality of life, even resulting in death. As such, bacterial agents are frequently associated with loss of mitochondrial membrane potential and cytochrome c release, ultimately leading to mitochondrial apoptosis by activation of caspases-3 and -9. Using Rayyan QCRI software for systematic reviews, we explore the association between mitochondrial alterations and pediatric infections including (i) bacterial: M. tuberculosis, E. cloacae, P. mirabilis, E. coli, S. enterica, S. aureus, S. pneumoniae, N. meningitidis and (ii) parasitic: P. falciparum. We analyze how these pediatric infections and their treatments may lead to mitochondrial deterioration in this especially vulnerable population, with the intention of improving both the understanding of these diseases and their management in clinical practice.

Distinguishing bacterial versus non-bacterial causes of febrile illness - A systematic review of host biomarkers

BACKGROUND

Acute febrile illnesses (AFIs) represent a major disease burden globally; however, the paucity of reliable, rapid point-of-care testing makes their diagnosis difficult. A simple tool for distinguishing bacterial versus non-bacterial infections would radically improve patient management and reduce indiscriminate antibiotic use. Diagnostic tests based on host biomarkers can play an important role here, and a target product profile (TPP) was developed to guide development.

OBJECTIVES

To qualitatively evaluate host biomarkers that can distinguish bacterial from non-bacterial causes of AFI.

DATA SOURCES

The PubMed database was systematically searched for relevant studies published between 2015 and 2019.

STUDY ELIGIBILITY CRITERIA

Studies comparing diagnostic performances of host biomarkers in patients with bacterial versus non-bacterial infections were included.

PARTICIPANTS

Studies involving human participants and/or human samples were included.

METHODS

We collected information following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A risk of bias assessment was performed, based on a modified QUADAS-2 (Quality Assessment of Diagnostic Accuracy Score 2).

RESULTS

We identified 1107 publications. Following screening, 55 publications were included, with 265 biomarker entries. Entries mostly comprised protein biomarkers (58.9%), followed by haematological, RNA, and metabolite biomarkers (15.5%, 8.7%, 12.5%). Sensitivity/specificity was reported for 45.7% of biomarker entries. We assessed a high overall risk of bias for most entries (75.8%). In studies with low/medium risk of bias, four biomarker entries tested in blood samples had sensitivity/specificity of more than 0.90/0.80. Only 12 additional biomarker entries were identified with sensitivity/specificity of more than 0.65/0.65.

CONCLUSIONS

Most recently assessed biomarkers represent well-known biomarkers, e.g. C-reactive protein and procalcitonin. Some protein biomarkers with the highest reported performances include a combined biomarker signature (CRP, IP-10, and TRAIL) and human neutrophil lipocalin (HNL). Few new biomarkers are in the pipeline; however, some RNA signatures show promise. Further high-quality studies are needed to confirm these findings.

Association between cerebrospinal fluid lactate concentration and central nervous system disease in dogs

BACKGROUND

Cerebrospinal fluid (CSF) analysis is a sensitive tool for evaluating patients with neurologic diseases but is rarely specific. Biomarkers can be measured from any bodily fluid and can be useful indicators for the presence, severity, and prognosis of diseases.

OBJECTIVES

This study was designed to evaluate if CSF lactate can be used as a biomarker in dogs with central nervous system disease.

METHODS

Peripheral venous blood and CSF were collected from 49 dogs with various intracranial diseases to evaluate correlations between blood and CSF lactate levels. Total nucleated cell count (TNCC) and CSF protein concentrations were also evaluated. All samples obtained were divided into normal (NG) and abnormal (AG) dogs based on a TNCC of ≤5 and >5 cells/μL and a protein concentration of ≤25 and >25 mg/dL, respectively. The AG dogs were further subdivided into those having <100 TNCCs/µL (AGL) and those having >100 TNCCs/µL (AGH). They were also subdivided into groups based on seizure activity (AGS), and inflammatory (AGI), or neoplastic diseases (AGN), and the respective lactate concentrations were then compared.

RESULTS

Lactate concentrations were significantly increased in CSF and venous blood samples in the AG compared with the NG dogs, but no differences were found among the individual disease processes. In all dogs, CSF lactate concentrations were higher than venous blood lactate levels; however, no direct correlation between CSF and blood lactate concentrations was identified.

CONCLUSIONS

Cerebrospinal fluid lactate can be used as a biomarker in clinical settings as it can be measured via a commercially available lactometer immediately after collection without the need for special instrumentation or laboratory personnel.

Management of Acute Bacterial Meningitis in Children

Acute community-acquired bacterial meningitis (ABM) in children continues to have high rates of neurological morbidity and mortality despite the overall declining rates of infection attributed to the use of vaccines and intrapartum Group B Streptococcus prophylaxis. Prompt diagnosis and early antibiotic therapy are crucial and should not be delayed to obtain cranial imaging. Differentiating bacterial from viral meningitis continues to be a clinical dilemma especially in patients with previous antibiotic exposure. Clinical models and inflammatory biomarkers can aid clinicians in their diagnostic approach. Multiplex polymerase chain reaction and metagenomic next-generation sequencing are promising tools that can help in early and accurate diagnosis. This review will present the epidemiology of ABM in children, indications of cranial imaging, role of different models and serum biomarkers in diagnosing ABM, and management including the use of adjunctive therapies and methods of prevention.

Diagnostic accuracy of cerebrospinal fluid lactate in confirmed cases of acute bacterial meningitis in children

Objective:

To determine the diagnostic accuracy of cerebrospinal fluid lactate level in confirmed cases of acute bacterial meningitis in children

Methods:

This cross sectional study was conducted in the Department of Paediatrics, King Edward Medical University/ Mayo Hospital, Lahore from January to December 2018. A total of 250 children, between two months - 12 years of age, of both the genders, with suspected acute bacterial meningitis were included by non-probability consecutive sampling. Each child was subjected to lumbar puncture for biochemistry, cytology, culture, and lactate level. CSF lactate level of 1.1-2.4 mmol/L was taken as normal, and >2.4 mmol/L was taken as cut off for acute bacterial meningitis. All collected data was entered and analyzed in SPSS version 22. A 2 x 2 table was made to calculate diagnostic accuracy, sensitivity, specificity, positive and negative predictive value for CSF Lactate.

Results:

The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of CSF lactate taking CSF culture as gold standard was 100%, 60.61%, 17.27%, 100% and 63.6% respectively, with kappa of 0.19 and p value of 0.000.

Conclusion:

At a cut off value of 2.4 mmol/L, cerebrospinal fluid lactate level has a high diagnostic accuracy for acute bacterial meningitis.

Comparison of Cerebrospinal Fluid Biomarkers for Differential Diagnosis of Acute Bacterial and Viral Meningitis with Atypical Cerebrospinal Fluid Characteristics

OBJECTIVE

Several cerebrospinal fluid (CSF) biomarkers are used to distinguish between acute bacterial meningitis (BM) and viral meningitis (VM). We compared the ability of lactate and glucose (GL) in CSF and the CSF/blood GL ratio to distinguish between acute BM and VM with typical and atypical CSF characteristics.

METHODS

Three hundred and twenty-four CSF reports were included, which were distributed as the acute BM, VM, and normal control groups (n = 63, 139, and 122, respectively).

RESULTS

Lactate level in the CSF of acute BM group was 4-fold higher than that in the acute VM and control groups (p < 0.0001). CSF lactate presented higher specificity (92%) and negative predictive value (94%) compared to CSF GL and CSF/blood GL ratio in distinguishing acute BM and VM. Definitive acute BM or VM with atypical CSF cell characteristics was observed in 23.2 and 21.6% of samples, respectively, and these groups showed reduced performance of characteristics of all CSF biomarkers. CSF lactate showed better operational characteristics than those of CSF GL and CSF/blood GL ratio, presenting the highest positive likelihood ratio, and thus aided in the differential diagnosis of VM with atypical CSF.

CONCLUSION

The CSF lactate assay can be routinely used in laboratories as a rapid, automated, and easy method that is independent of lactate blood levels.

Clinical characteristics and molecular epidemiology of children with meningitis in Tehran, Iran: a prospective study

The molecular epidemiology of meningitis in children is unclear in Iran, and data are scarce. We aimed to characterize its clinical and paraclinical features as well as to determine the distribution of genotype/capsular types of common bacterial meningitis agents in children in Iran. All children suspected to have meningitis aged 4 days to 15 years were enrolled onto a prospective cross-sectional study from January 2015 to September 2017. Diagnostic values of clinical features, cerebrospinal fluid and serum parameters were evaluated independently and in combination with each other by multivariate logistic regression to develop a diagnostic rule. Genotype/capsular types of all the isolates were determined by targeting serotype-specific genes with uniplex or multiplex PCR. Among 119 patients suspected of having meningitis, 43 had bacterial meningitis, 19 aseptic and one tuberculous; and there were 56 nonmeningitis cases (NMC). Presentation of four features at the same time-cerebrospinal fluid white blood cell count, protein, polymorphonuclear leukocytes and serum C-reactive protein-revealed 100% sensitivity and 86.4% specificity for diagnosis of bacterial meningitis. Haemophilus influenzae type b (60%), Streptococcus pneumoniae serotype 3 (28.5%) and Neisseria meningitidis B (63.5%) were the most prevalent serotypes. This study demonstrated that a well-designed combination of clinical and paraclinical features is useful, but these combinations are not good enough to be relied on as stand-alone exclusionary tests for the diagnosis of bacterial meningitis. In addition, public immunization of infants with the most prevalent bacterial meningitis serotypes is recommended.

Performance of lactate in discriminating bacterial meningitis from enteroviral meningitis

The cytological and biochemical examination of cerebrospinal fluid (CSF) has been used for the presumed diagnosis of bacterial meningitis until the final microbiological results are achieved. We assessed the ability of CSF lactate in comparison with other CSF parameters to discriminate bacterial and enteroviral community acquired meningitis. We included 1,187 CSF samples of acute community-acquired meningitis, being 662 cases of bacterial and 525 of enteroviral meningitis. Lactate concentration (mg/dL), leukocyte count/mm³, protein (mg/dL), and glucose (mg/dL) were compared between bacterial and viral meningitis. Receiver operator characteristic (ROC) curves were used to assess diagnostic performance. CSF leukocytes, CSF protein and CSF lactate were significantly higher in bacterial meningitis cases (P<0.0001). CSF glucose was significantly lower in bacterial meningitis cases (P<0.0001). CSF lactate showed the best predictive ability with an area under the curve of 0.944 (95% CI 0.929 – 0.959). Considering a cut off of CSF lactate of 30 mg/dL, the sensitivity and specificity for bacterial meningitis were 84.1% and 99%, respectively. In the cytological and biochemical CSF analysis, CSF lactate was the most accurate marker for bacterial meningitis.

Comparing Single vs. Combined Cerebrospinal Fluid Parameters for Diagnosing Full-Term Neonatal Bacterial Meningitis

Objectives: To identify and compare the cerebrospinal fluid (CSF) parameters that predict the presence of neonatal bacterial meningitis using optimal cutoff values, and to derive and compare predictive profiles based on a combination of individual parameters for the same purpose.

Study Design: The retrospective component of the Shanghai Neonate Meningitis Cohort included all term neonates who underwent lumbar puncture between 2000 and 2017. Those with severe neurological diseases, histories of ventricular drainage, or traumatic lumbar punctures were excluded. Reference ranges were determined for non-bacterial meningitis neonates based on the 5th, 25th, 50th, 75th, and 95th CSF parameter quantiles, and their relationships with age were calculated using generalized additive models that tested for linear relationships. The optimal cutoff value for each measured CSF parameter was calculated using receiver operating characteristic analysis and by deriving the Youden's index. Parameters with good diagnostic efficacies were combined to produce predictive profiles using logistic regression. The diagnostic efficacies of the single parameters and profiles were compared in neonates with confirmed bacterial meningitis.

Results: White blood cells (WBCs) in CSF showed a higher diagnostic ability for neonatal bacterial meningitis than CSF protein, glucose, lactate dehydrogenase, or chloride. The sensitivity and specificity of the diagnostic cutoff value for WBCs (20 × 10⁶/L) were 95.1 and 98.7%, respectively. Profiles based on CSF parameter combinations improved the specificities slightly to 99.0–99.7%. However, employing predictive profiles did not improve sensitivities, which remained at 95.1–96.0%.

Conclusions: Profiles for predicting neonatal bacterial meningitis improve the sensitivity and specificity of diagnosis slightly, although not appreciably, compared to the single parameter of CSF WBC alone.

The Diagnostic Dilemma of Traumatic Lumbar Puncture: Current Standing of Cerebrospinal Fluid Leukocyte Corrections and Our Experience With Cerebrospinal Fluid Biomarkers

OBJECTIVE

To assess the diagnostic efficiency of cerebrospinal fluid markers of procalcitonin, lactate, and cerebrospinal fluid/serum lactate ratio for detecting bacterial meningitis during traumatic lumbar puncture, and to compare these markers with routinely used uncorrected and corrected leukocyte measurements.

METHODS

Infants aged ≤90 days with traumatic lumbar puncture were prospectively studied. The diagnostic characteristics of cerebrospinal fluid assays of uncorrected and corrected leukocyte count, procalcitonin, lactate, and lactate ratio were described and compared.

RESULTS

Considering the area under the curve (95% CI) analysis and standard cutoff values, the lactate-ratio (0.985 [0.964-0.989] at cutoff 1.2) had the best test indexes for identifying meningitis, followed by lactate (0.964 [0.945-0.984] at cutoff 2.2 mmol/L) and procalcitonin (0.939 [0.891-0.986] at cutoff 0.33 ng/mL) measurement, whereas the corrected total leukocyte count assay (0.906 [0.850-0.962] at cutoff 350 cells/mm³) had diagnostic properties moderately superior to uncorrected total leukocyte count measurement (0.870 [0.798-0.943] at cutoff 430 cells/mm³).

CONCLUSION

Cerebrospinal fluid levels of procalcitonin, lactate, and lactate-ratio are reliable markers to diagnose bacterial meningitis in blood-contaminated cerebrospinal fluid.