CT before lumbar puncture in suspected meningitis in Botswana: how established guidelines may not apply

ABSTRACT

Introduction:According to established guidelines from high-income countries; computed tomography of the head (CT) is indicated before lumbar puncture (LP) in the evaluation of suspected meningitis in HIV patients. In Botswana; meningitis in HIV-infected patients is common but CT is not widely available.Objective:Develop a rational; evidence-based approach to CT use in the emergency evaluation of suspected meningitis in a population with high HIV prevalence.Methods:Emergency center (EC) staff at Princess Marina Hospital in Gaborone; Botswana; reviewed indications for CT and LP in suspected meningitis. The authors considered existing evidence for CT before LP (mostly from high-income countries) and considered the epidemiology of central nervous system infections in Southern Africa. Draft guidelines were circulated to emergency center doctors and nurses; and to specialists in other hospital departments for review and comment before finalization. Result: Available literature seems to indicate that in Botswana it would be possible to significantly limit the use of head CT before LP in HIV positive patients without increasing the incidence or risk of herniation. The guideline includes scenarios where an LP might be indicated in the presence of focal neurological findings and in the absence of a CT; in contradiction to established guidelines. Discussion: The applicability of established guidelines for CT use in suspected meningitis is dependent on local epidemiology and resources