Article Text

Download PDFPDF
Improving the diagnosis of central nervous system infections in adults through introduction of a simple lumbar puncture pack
  1. Benedict Daniel Michael1,2,
  2. Graham Powell2,
  3. Sarah Curtis3,
  4. Lisa Bailey3,
  5. Solomon Almond4,
  6. Fiona McGill1,
  7. David Cousins5,
  8. Ian J Hart6,
  9. Michael Griffiths1,
  10. Rachel Kneen1,7,
  11. Tom Solomon1,2
  1. 1Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
  2. 2Department of Neuroscience, The Walton Centre Neurology NHS Foundation Trust, Liverpool, UK
  3. 3Department of Clinical Biochemistry, Royal Liverpool and Broadgreen NHS Foundation Trust, Liverpool, UK
  4. 4Department of Acute Medicine, Royal Liverpool and Broadgreen NHS Foundation Trust, Liverpool, UK
  5. 5National Patient Safety Agency, Patient Safety for Medication and Medical Devices, London, UK
  6. 6Liverpool Specialist Virology Laboratory, Royal Liverpool and Broadgreen NHS Foundation Trust, Liverpool, UK
  7. 7The Alder Hey Children's NHS Foundation Trust, Liverpool, Liverpool, UK
  1. Correspondence to Dr Benedict Daniel Michael, Institute of Infection and Global Health, University of Liverpool, West Derby Street, Liverpool L69 7BE, UK; benedict.michael{at}


Background Acute central nervous system (CNS) infections, such as meningitis and encephalitis, are neurological emergencies for which accurate diagnosis and prompt treatment improve the outcome. Analysis of the cerebrospinal fluid (CSF) obtained at lumbar puncture (LP) is pivotal to establishing the diagnosis and guiding management. PCR analysis of the CSF is an important method to identify the pathogen. However, recent studies have demonstrated that many patients have inadequate CSF sample collection and analysis.

Aims To increase the proportion of patients having an LP for a suspected CNS infection for whom the appropriate samples are taken. Secondary aims included to increase the proportion of patients for whom a pathogen was identified.

Methods The authors developed an LP pack for patients with a suspected CNS infection. They also assessed its impact on diagnosis by comparing practice 6 months before and after its introduction to the medical admissions unit of a large inner city teaching hospital.

Results The authors found that the LP pack reduced major errors in CSF sample collection and improved the diagnosis of acute CNS infections; among those patients who had a CSF pleocytosis, the proportion with a viral or bacterial pathogen identified by PCR was increased after introduction of the pack.

Discussion This study has demonstrated that the introduction of a simple low-cost LP pack into a busy acute medical setting can improve the diagnosis of CNS infections and, thus, guide treatment. Further work is needed to see if these results are more widely reproducible, and to examine the clinical, health and economic impact on overall management of patients with suspected CNS infections.

  • Lumbar puncture
  • cerebrospinal fluid
  • central nervous system
  • meningitis
  • encephalitis
  • neurology
  • headache
  • infection
  • infectious diseases
  • management
  • emergency department management
  • epilepsy
  • toxicology
  • thromboembolic disease
  • psychological conditions
  • medicolegal
  • respiratory
  • acute medicine other

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This article presents independent work, which received support from the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0108-10048).

  • Competing interests BDM is an NIHR Doctoral Research Fellow; TS is an MRC Senior Clinical Fellow; the authors have no conflicts of interest to declare.

  • Ethics approval This was a retrospective review of anonymised data from internal laboratory records for quality improvement analysis of the clinical service and therefore did not require ethical approval. All data were handled in line with national guidelines.

  • Provenance and peer review Not commissioned; externally peer reviewed.