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Applause to Kneen et al1 and Riordan and Cant2 for reminding us of the value of lumbar puncture in suspected meningitis. To their arguments I would add that, while the matter may end after seven days’ intravenous antibiotic treatment as far as the admitting paediatrician is concerned, it certainly does not for the child or parents of many children who have had meningitis, as recent data shows.3 To be discharged home in ignorance or confusion regarding the diagnosis, as is becoming the norm, does no favours either to the patient or to anyone attempting to manage late complications. In adopting the “treat and do a hearing test” approach we should consider whether we are really motivated by a desire to relieve the child of the risk and discomfort of the procedure or to relieve ourselves of the bother. Undoubted risk and discomfort does not seem to have put us off requesting large numbers of head CT scans (often without contrast—so they do not reliably exclude abscess) in this clinical situation, even though they do not tell us anything useful about raised intracranial pressure.
As both papers point out, the epidemiology and management of bacterial meningitis are changing fast. Has anyone paused to consider how, in the future, we will evaluate either its incidence or the effectiveness of our current management strategies if we can’t tell how many cases we have seen and who they were?
Clearly, it can be ill-advised to perform a lumbar puncture at the outset in seriously sick children—but there is always a time later on when the procedure can be done safely, and often also painlessly just before weaning from the ventilator.
As for the habit of replacing the LP (and other necessary investigations) with indiscriminate initiation of cephalosporin treatment in the mild to moderately ill febrile child, this simply encourages misdiagnosis and promotes development of antibiotic resistance.