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

2. 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

3. 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 ?

4. 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

5. 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

6. 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

7. 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

8. CSF culture samples in 2010

9. 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.

10. 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

11. 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 ?