Atormac
Neurology India
Open access journal indexed with Index Medicus
  Users online: 4760  
 Home | Login 
About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (802 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Patients and Methods
 » Results
 » Discussion
 »  Limitations of O...
 » Conclusions
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed35    
    Printed0    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
ORIGINAL ARTICLE
Year : 2018  |  Volume : 66  |  Issue : 3  |  Page : 722-725

Prognostic value of cerebrospinal fluid lactate in meningitis in postoperative neurosurgical patients


Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication15-May-2018

Correspondence Address:
Dr. Barada Prasad Sahu
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.232330

Rights and Permissions

 » Abstract 


Objective: To evaluate the prognostic usefulness of cerebrospinal fluid (CSF) lactate in postoperative bacterial meningitis (POBM) and to establish the optimal CSF lactate cut-off values in our population to identify POBM in neurosurgical patients.
Patients and Methods: A prospective study of postoperative neurosurgical patients with presumed and established bacterial meningitis in the Department of Neurosurgery, NIMS, Hyderabad, India, from September 2012 to December 2014. The diagnostic and prognostic values of CSF lactate have been evaluated and compared with other well-established CSF markers. All the patients who have undergone intradural cranial surgery with features of meningism have been included.
Results: The study included 37 patients. The CSF value of the first lumbar puncture (LP) was taken to evaluate the diagnostic value of CSF lactate. Twenty three corresponded to Group A, and 14 to Group B. The mean CSF lactate in Group A was 5.94 ± 2.36, and in Group B 4.60 ± 2.31. Subsequent LPs were performed and CSF analyzed to evaluate the prognostic value of CSF lactate. The CSF markers like neutrophil count (P = 0.003), CSF/blood glucose ratio (P = 0.012), CSF lactate (P = 0.024), lymphocyte count (P = 0.046), leukocyte count (P = 0.047) have shown their prognostic value in a descending order. CSF markers like the presence of red blood cells (P = 0.540) and proteins (P = 0.757) did not show prognostic significance. The decline in CSF lactate (content and concentration) after initiation of antibiotics correlated with subsidence of fever (P = 0.0001), decrease in neck rigidity (P = 0.022) and improvement in sensorium. They were also correlated improvement in CSF/blood glucose ratio and CSF white blood cell counts.
Conclusions: In our study, CSF lactate was noted to have a dependable prognostic value in POBM. As routine CSF markers can be ambiguous in POBM, CSF lactate can be considered a better alternative for both establishing the diagnosis and prognostication.


Keywords: Bacterial meningitis, cerebrospinal fluid, lactate, postoperative
Key Messages:
Serial cerebrospinal fluid lactate estimation is a good marker for the diagnosis and prognostication of postoperative bacterial meningitis, especially when routine CSF markers like glucose level, leucocytic or lymphocytic count, or the presence of red blood cells in CSF have not provided an unequivocal evidence of the presence of bacterial meningitis following surgery.


How to cite this article:
Sumanth Kumar A S, Sahu BP, Kumar A. Prognostic value of cerebrospinal fluid lactate in meningitis in postoperative neurosurgical patients. Neurol India 2018;66:722-5

How to cite this URL:
Sumanth Kumar A S, Sahu BP, Kumar A. Prognostic value of cerebrospinal fluid lactate in meningitis in postoperative neurosurgical patients. Neurol India [serial online] 2018 [cited 2018 May 20];66:722-5. Available from: http://www.neurologyindia.com/text.asp?2018/66/3/722/232330




Bacterial meningitis (BM) is not so common in an elective neurosurgery setting and it is a serious nosocomial infection that complicates intradural procedures. It has an incidence of 2.2% and a mortality of 5%.[1] It increases the length of intensive care and hospital stay and increases the overall cost of hospital care. The diagnosis is sometimes difficult to establish due to the masked clinical signs and alteration in cerebrospinal fluid (CSF) values because of the presence of blood in CSF. Diagnosis is often assumptive because patients are on broad-spectrum antibiotics per-operatively and for prevention of other co-infections. In the last few years, CSF lactate level has proven to be a valid ancillary test for the diagnosis of postoperative BM (POBM) due to the ease, precision, and rapidity with which it may be measured in the clinical laboratory.[2],[3]

CSF lactate is produced largely by the brain during normal anaerobic glycolysis by inter-conversion from pyruvate via the action of lactate dehydrogenase (LDH). In BM, there will be influx of inflammatory cells leading to global cerebral edema and hypoperfusion secondary to vasospasm, and loss of autoregulatory mechanism further leading to ischemia and anaerobic metabolism. In addition, the elevated CSF lactate level that commonly accompanies a low CSF glucose level strongly suggests that increased anaerobic metabolism contributes to these changes. Varying amount of lactate is produced by the bacteria itself accounting for 10% of total CSF lactate.[4],[5],[6],[7]

In our study, we aimed to evaluate the prognostic value of CSF lactate by assessing its serial values and by comparing them with the clinical improvement of patients. This would enable us to obtain important information regarding the response to antibiotics and guide us to timely change the antibiotics, whenever required.


 » Patients and Methods Top


This is a prospective study of patients with suspected BM following intradural cranial procedures, from September 2012 to December 2014, in the Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India. All the patients were started on preoperative antibiotics. The antibiotics were continued until 3–5 days after the postoperative period. The indication for lumbar puncture (LP) for CSF analysis was 'suspected BM', characterized by new onset of fever, altered mental status, seizures and neck rigidity, or any other signs of meningism. The CSF collected was subjected to analysis for cell counts (leukocytes, neutrophils, and erythrocytes), routine biochemistry (glucose and protein), and microbiological examination (gram stain and cultures). The blood sugar levels were checked at the time of LP. For estimation of lactate, the CSF was sent to another facility about 0.5 km from the primary hospital.

All infective pathologies such as cerebral abscess, empyema, epidural abscess; the presence of an immunocompromised patient; and/or the presence of a patient with signs of systemic infection, were excluded from the study. The mean day of performing the first, second, and third LP was the 6th, 11th, and 16th postoperative day, respectively. The patients who underwent the first LP were categorized into Group A and Group B. Group A included patients with leukocytes >250/cumm or neutrophils >50% (favoring BM).[8],[9] Rest were included in Group B (not favoring BM). Subsequent LPs were performed to evaluate the prognostic value of CSF lactate and the values obtained were compared with other markers.

Statistical analysis

Data were entered into the Microsoft Excel spreadsheet, and descriptive statistical analysis was done using SPSS (Statistical Package for Social Sciences) version 20. Results on continuous measurements were presented as mean and standard deviation. Results on categorical measurements were presented as percentages. Significance was assessed at 5% level of significance. The chi-square test was used to assess the significance of the study parameters on a categorical scale between the groups. The analysis of variance (ANOVA) test was used to assess the significance of the study parameters on a continuous scale between the groups. Receiver operating characteristic (ROC) curves were used for the diagnostic test evaluation of the CSF markers.


 » Results Top


A total of 37 patients were included in the study. The patient demographics such as the age, sex, diagnosis, and the categorized groups are shown in [Table 1]. The first LP was performed, and CSF analysis was done for evaluating the diagnostic values of the markers. According to the preset criteria, 23 patients corresponded to Group A, and 14 to Group B. The mean CSF lactate in Group A was 5.94 ± 2.36, and in Group B, 4.60 ± 2.31 (P = 0.1 [not significant, NS]). There was no significant difference noted between the two groups [Table 2].
Table 1: Patient characteristics

Click here to view
Table 2: CSF marker values

Click here to view


The diagnostic value of CSF lactate was evaluated by ROC analysis by taking Group A as the positive control [Figure 1] and [Table 3]. The value of ROC was 0.67, considered to have a poor diagnostic accuracy (excellent: 0.90–1.00; good: 0.80–0.89; fair: 0.70–0.79; poor: 0.60–0.69; failure: 0.50–0.59). The sensitivity was 73.91% and the specificity was 28.57%. The cut-off value of 5.2 was derived based on the highest point of sensitivity and specificity on the ROC curve.
Figure 1: Receiver operating characteristic curve for cerebrospinal fluid lactate (Group A as positive control)

Click here to view
Table 3: Diagnostic value of CSF lactate (Group A taken as positive control)

Click here to view


Subsequent LPs were performed, and the CSF was analyzed to evaluate the prognostic value of CSF lactate [Table 4] and [Figure 2]. For P values, the mean and standard deviation of the first and second LP CSF analyses were compared. The CSF markers such as neutrophil count (P = 0.003), CSF/blood glucose ratio (P = 0.012), CSF lactate (P = 0.024), lymphocyte count (P = 0.046), and leukocyte count (P = 0.047) were shown to have a good prognostic value in a descending order of significance. CSF markers such as red blood cell (RBC) (P = 0.540) and protein (P = 0.757) did not show any prognostic significance.
Table 4: CSF markers - prognostic significance

Click here to view
Figure 2: Cerebrospinal fluid markers - - prognostic significance

Click here to view


Along with other CSF markers, the decline of CSF lactate with initiation of antibiotics was correlating with clinical improvement of patients with regard to fever (P = 0.0001) and neck rigidity (P = 0.022) [Table 5].
Table 5: Clinical assessment

Click here to view



 » Discussion Top


An early diagnosis of BM in the postoperative neurosurgical patients is crucial in reducing the morbidity by the timely initiation of appropriate antibiotics. Due to many factors (preoperative antibiotics, steroids, surgical manipulation, etc.), the conventional markers (CSF glucose, CSF/plasma glucose ratio, CSF protein, and CSF total number of leukocytes) are less dependable in a postoperative setting. In two different meta-analyses, it was revealed that CSF lactate has an excellent overall diagnostic accuracy compared to other conventional markers [10] and has a high sensitivity and specificity in differentiating bacterial versus aseptic meningitis, both in adults and children.[11],[12] Many studies have shown the benefits of CSF lactate in meningitic patients [Table 6]. Maskin et al., in their largest prospective study, have confirmed the sensitivity of CSF lactate levels even in patients receiving antibiotic treatment.[13] Conduction of the LP procedure in irritable and uncooperative patients can result in the collection of blood-stained CSF, and in these patients, the usual markers (especially the cell counts) are not dependable, whereas CSF lactate does not alter significantly with a changing plasma lactate level or CSF neutrophil and RBCs count.[14] In addition to its diagnostic value, CSF lactate is also helpful as a good prognostic indicator, showing a rapid decline after the initiation of antibiotics.[15],[16]
Table 6: Values of CSF lactate in various studies

Click here to view


In our study, we have taken the cut-off value of 4 mmol for CSF lactate and evaluated its diagnostic value by comparing this value with the the CSF lactate values obtained in Group A patients (meningitis group). Our results have shown the poor diagnostic accuracy of CSF lactate, contrary to the findings of a few other studies. Apart from the diagnostic aspect, we have evaluated CSF lactate for its prognostic significance by comparing the subsequent serial LP CSF analysis with the clinical improvement of the patient, which has shown that CSF lactate has got a significant prognostic value that is comparable to other conventional markers.


 » Limitations of Our Study Top


We had less number of cases to derive an appropriate cut-off value. Also, CSF lactate was performed at another facility due to which there might be a time difference between the sample collection and the analysis of CSF lactate in each case.


 » Conclusions Top


CSF lactate has been proven to be a good diagnostic marker in establishing POBM by other studies. In our study, CSF lactate was noted to have a dependable prognostic value in POBM. As routine CSF markers can often be inconclusive in POBM, CSF lactate can be considered a better alternative for both its diagnosis and prognostication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Srinivas D, Veena Kumari HB, Somanna S, Bhagavatula I, Anandappa CB. The incidence of postoperative meningitis in neurosurgery: An institutional experience. Neurol India 2011;59:195-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Wang KW, Chang WN, Huang CR, Tsai NW, Tsui HW, Wang HC, et al. Post-neurosurgical nosocomial bacterial meningitis in adults: Microbiology, clinical features, and outcomes. J Clin Neurosci 2005;12:647-50.  Back to cited text no. 2
[PUBMED]    
3.
Brown EM. Infections in neurosurgery: Using laboratory data to plan optimal treatment strategies. Drugs 2002;62:909-13.  Back to cited text no. 3
[PUBMED]    
4.
Fishman RA. Cerebrospinal Fluid in Diseases of the Nervous System. 2nd ed. Philadelphia: W.B. Saunders; 1992.  Back to cited text no. 4
    
5.
Salord F, Boussaid O, Eynard N, Perret C, Grando J, Chacornac R. Value of D(-) lactate determination for the fast diagnosis of meningitis after craniotomy. An initial study. Ann Fr Anesth Reanim 1994;13:647-53.  Back to cited text no. 5
[PUBMED]    
6.
Leib SL, Kim YS, Black SM, Tureen JH, Täuber MG. Inducible nitric oxide synthase and the effect of aminoguanidine in experimental neonatal meningitis. J Infect Dis 1998;177:692-700.  Back to cited text no. 6
    
7.
Abro AH, Abdou AS, Ustadi AM, Saleh AA, Younis NJ, Doleh WF. CSF lactate level: A useful diagnostic tool to differentiate acute bacterial and viral meningitis. J Pak Med Assoc 2009;59:508-11.  Back to cited text no. 7
[PUBMED]    
8.
Leib SL, Boscacci R, Gratzl O, Zimmerli W. Predictive value of cerebrospinal fluid (CSF) lactate level versus CSF/blood glucose ratio for the diagnosis of bacterial meningitis following neurosurgery. Clin Infect Dis 1999;29:69-74.  Back to cited text no. 8
[PUBMED]    
9.
Grille P, Torres J, Porcires F, Bagnulo H. Value of cerebrospinal fluid lactate for the diagnosis of bacterial meningitis in postoperative neurosurgical patients. Neurocirugia (Astur) 2012;23:131-5.  Back to cited text no. 9
[PUBMED]    
10.
Huy NT, Thao NT, Diep DT, Kikuchi M, Zamora J, Hirayama K. Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: A systemic review and meta-analysis. Crit Care 2010;14:R240.  Back to cited text no. 10
[PUBMED]    
11.
Sakushima K, Hayashino Y, Kawaguchi T, Jackson JL, Fukuhara S. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: A meta-analysis. J Infect 2011;62:255-62.  Back to cited text no. 11
[PUBMED]    
12.
Viallon A, Desseigne N, Marjollet O, Birynczyk A, Belin M, Guyomarch S, et al. Meningitis in adult patients with a negative direct cerebrospinal fluid examination: Value of cytochemical markers for differential diagnosis. Crit Care 2011;15:R136.  Back to cited text no. 12
[PUBMED]    
13.
Maskin LP, Capparelli F, Mora A, Hlavnicka A, Orellana N, Díaz MF, et al. Cerebrospinal fluid lactate in post-neurosurgical bacterial meningitis diagnosis. Clin Neurol Neurosurg 2013;115:1820-5.  Back to cited text no. 13
    
14.
Tavares WM, Machado AG, Matushita H, Plese JP. CSF markers for diagnosis of bacterial meningitis in neurosurgical postoperative patients. Arq Neuropsiquiatr 2006;64:592-5.  Back to cited text no. 14
[PUBMED]    
15.
Yerramilli A, Mangapati P, Prabhakar S, Sirimulla H, Vanam S, Voora Y. A study on the clinical outcomes and management of meningitis at a tertiary care centre. Neurol India 2017;65:1006-12  Back to cited text no. 15
    
16.
Genton B, Berger JP. Cerebrospinal fluid lactate in 78 cases of adult meningitis. Intensive Care Med 1990;16:196-200.  Back to cited text no. 16
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow