Contamination of CSF Cultures in Children After Spinal Tap Procedure Dr. Amal Al-Maani Pediatric Infectious Disease and Infection Control Fellow

Case Presentation 4 days old baby girl brought to ER with history of stiffness for past 6 hours and poor feeding since birth No h/o fever Physical exam was unremarkable and no documented fever LP was done to R/O meningitis and baby admitted pending 48hours cultures result and for observation Started on IV Cefotaxim and Ampicillin Blood and Urine cultures were negative

Baby had PICL inserted and needed 3 weeks course of Meropenem CSF : 5 WBC , 0 RBC, normal glucose and protein. Gram stain : numerous gram negative bacilli Culture: Enterobacter cloacae and Enterococcus Baby had PICL inserted and needed 3 weeks course of Meropenem Questions : Did this baby come with meningitis? Did we give this baby meningitis by inoculating stool into CSF space? Is this a patient safety concern ?

Background Lumbar puncture (LP) has been used for more than a century and it remains one of the most commonly performed diagnostic procedures in Children. CSF culture contaminants are threefold more common than true pathogens. Iatrogenic meningitis is a concern with LP procedure as result of introducing organisms into subarachnoid space Organisms can be blood-borne organisms in bacteremic patients or skin flora secondary to inadequate disinfection when performing procedure. Clinical follow-up of patients with CSF contaminants: Costly for health system Time-consuming Can result in unnecessary exposure to procedures , imaging and medication for the patient Can result in unnecessary anxiety for patient and family. M. M. Boysen et al

Objectives of project: Definition : CSF culture is considered a contaminant if the cell count doesn’t support diagnose of bacterial meningitis for children with exclusion of Immunocompromised individuals Objectives of project: Determine how common CSF contamination from LP process in our institute. Identify if existing controls are adequate to ensure safety of LP process. Put recommendation and suggestions for improvement Setting: The Hospital of Sick Children M. M. Boysen et al The Journal of Emergency Medicine, Vol. 37, No. 3, pp. 251–256, 2009

Methods: Review microbiology data to identify rate of CSF culture contamination in our institute (1st Jan 2010 to 31 December 2010): All positive CSF cultures will be reviewed excluding: Cultures from immunocompromised children CSF samples obtained by methods other than spinal tap (eg. From VP shunt or CNS reservoir ) Look into available education materials for HCW and trainee about LP Check available documentation modalities of LP Consent Procedure notes Adverse events reporting

Results : Educational and training materials: See one , Do one , teach One ??? Is this enough Half day procedures workshop for Pediatrics residents annually ED web site for procedures has link to LP Hardly any one know it exist Video of procedure not working Policy and Procedure related to LP in Hem/Onc patients for nurses No standard documentation method for procedure No standard written consent

CSF culture samples in 2010

Gram negative cocobacilli in 1 day old baby from NICU Excluded Samples Organisms Grown in CSF samples 1 with positive gram stain but didn’t grow in culture Gram negative cocobacilli in 1 day old baby from NICU 5 samples were not obtained by LP: 2 from Shunt (neurosurgical patients) 1 from nose of patient with CSF leak 1 was path specimen 1 from subgaleal collection True positives: 4 samples grew GBS 3 samples grew E.coli 1 sample grew Staph.aureus 1 sample grew N.meningitidis Contaminant: 2 samples grew CNST 1 sample grew Bacillus cerus 2 samples grew Enterococcus and one of them had also Enterobacter.

Suggestions: Lumber puncture check-List: Procedure steps and enforce aseptic techniques Procedure documentation (Standardized) Adverse event reporting  help with prospective data collection. Presenting result of this project to residents & HCW from different departments Work on existing ER module: Awareness of its existence Add video or edit existing one Create a standard consent form for LP

Questions for the Group : Do you agree on importance of CSF culture contamination as a safety issue ? Is a check-list a good quality improvement strategy for LP process ? Where should the check-list go ? What is experience with LP safety issues in other institutes? Any recommendation on how to improve safety of this procedure in general ?