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An Electronic Health Record Intervention to Limit Viral Testing of Cerebrospinal Fluid

Kyle A Lyman1, Evan Madill1, Prateek Thatikunta1

  • 1Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.

The Neurohospitalist
|April 17, 2023
PubMed

Insights

Implementing a stepwise cerebrospinal fluid (CSF) testing algorithm significantly reduced low-yield viral polymerase chain reaction (PCR) tests for meningitis and encephalitis. This optimized diagnostic approach improved resource utilization without compromising patient care.

Area of Science:

  • Neurology
  • Infectious Diseases
  • Clinical Diagnostics

Background:

  • Meningitis and encephalitis are critical neurologic emergencies necessitating prompt treatment.
  • Current guidelines recommend broad-spectrum antimicrobials, but cerebrospinal fluid (CSF) testing algorithms lack standardization, leading to resource inefficiencies and potential false positives.
  • Lumbar punctures (LPs) are often performed for noninfectious indications, complicating diagnostic strategies.

Purpose of the Study:

  • To analyze the diagnostic utility of CSF testing in a large academic medical center.
  • To evaluate the frequency of low-yield viral polymerase chain reaction (PCR) tests, particularly for Herpes Simplex Virus (HSV) meningoencephalitis.
  • To design and implement a systems-level intervention to optimize CSF testing algorithms and reduce unnecessary diagnostic procedures.

Main Methods:

  • Retrospective analysis of CSF diagnostic testing in hospitalized patients undergoing LP.
  • Assessment of viral PCR test ordering patterns, including duplicate testing and multiplex panels.
  • Implementation of a revised, stepwise CSF testing algorithm aimed at minimizing low-yield tests.

Main Results:

  • A low rate of positive virus-specific PCR tests was observed, with many cases of HSV meningoencephalitis diagnosed by non-neurologists.
  • Viral PCR tests were frequently ordered redundantly alongside multiplex meningitis/encephalitis (M/E) panels.
  • The implemented intervention significantly decreased the number of low-yield virus-specific PCR tests ordered.

Conclusions:

  • A stepwise CSF testing algorithm can effectively reduce unnecessary viral PCR testing.
  • Optimizing diagnostic pathways enhances resource conservation in managing suspected meningitis and encephalitis.
  • Tailoring CSF testing to clinical context is crucial for efficient and accurate diagnosis of neurologic emergencies.
Keywords:
biostatistics < techniquesmeningoencephalitis < central nervous system infectionsneurocritical care < clinical specialtyneurohospitalist < clinical specialtyquality < techniques

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