Suspected Meningitis Age > 56 days Clinical Pathway — Emergency Department, Inpatient and ICU

Assess Patient Characteristics Prior to Performing Lumbar Puncture (LP)

Consider the following guidance and evaluate the risk-benefit ratio for individual patients.

Concern for increased intracranial pressure
Consider obtaining non-contrast head CT prior to LP in patients who have symptoms/signs concerning for elevated ICP, such as:

  • Markedly depressed mental status
  • Focal or lateralizing neurologic signs, including new onset focal seizure
  • Papilledema
  • Known intracranial space occupying lesion
  • Hydrocephalus
  • Recent neurosurgical procedure or presence of CSF shunt
  • Recent traumatic injury to the brain or spine
  • Immunocompromise
    Consider imaging given risk of infectious mass lesions, but immunocompromised status is not an absolute contraindication to LP by itself.
  • Congenital heart disease with right-to-left shunt
  • Consider imaging to evaluate for brain abscess
  • Significant coagulopathy
  • Active bleeding
  • Current anti-coagulation therapy
  • Congenital bleeding disorder
  • Platelet count less than 50,000/uL (Consider Heme consult if plt count 30,000-50,000/uL)
  • INR > 1.4
  • Soft tissue or epidural infection at the puncture site
  • Concerns for Clinical Instability
  • In patients with hemodynamic or respiratory concerns, it may be appropriate to delay LP