No lumbar puncture in the evaluation for early neonatal sepsis: will meningitis be missed?

OBJECTIVE: We performed this investigation to assess whether selective approaches to performing lumbar puncture (LP) in the early neonatal period will result in a missed or delayed diagnosis of bacterial meningitis.

DESIGN: A retrospective review was conducted of the medical records of all neonates born in US Army hospitals from 1988 through 1992 who developed culture-positive meningitis during the first 72 hours of life.

RESULTS: In total, 169,849 infants were born during the 5-year study period. The incidence of meningitis in the first 72 hours of life was 0.25 per 1000 live births. Forty-three infants had organisms isolated from their cerebrospinal fluid (30, group B streptococcus; 10, Escherichia coli; 1, Listeria monocytogenes; 1, Streptococcus pneumoniae; and 1, Citrobacter diversus). The median age of infants at evaluation was 12 hours, and the mean gestational age was 38.8 weeks (7 < 37 weeks), whereas mean birth weight was 3163 g (7 < 2500 g). If we had used currently advocated selective criteria as the basis for not performing an LP, the diagnosis of bacterial meningitis would have been missed or delayed in 16 of 43 infants (37%): 5 infants born prematurely with suspected respiratory distress syndrome, 3 asymptomatic infants born at term with positive blood cultures, and 8 infants born at term with no central nervous system symptoms and negative blood cultures.

CONCLUSIONS: If LPs are omitted as part of the early neonatal sepsis evaluation, the diagnosis of bacterial meningitis occasionally will be delayed or missed completely.