CSF Testing for Neuroinvasive West Nile Virus and Measures to Improve Guideline Adherence

Diagnosis of West Nile virus (WNV) neuroinvasive disease, an important cause of neurologic disability in endemic areas, requires appropriate testing given its often nonspecific presentation. Guidelines recommend CSF testing of WNV-specific immunoglobulin M (IgM) in all patients, with additional reverse transcription-polymerase chain reaction (RT-PCR) testing only in those who are unable to mount a humoral response due to significant immunosuppression. WNV testing is known to be underused, but real-world guideline adherence has not been described.

We analyzed testing patterns for suspected neuroinvasive WNV in a retrospective analysis of 1,304 adult patients in a Boston hospital network who underwent CSF testing for WNV-specific IgM or WNV RNA using RT-PCR between 2016 and 2023. Both CSF IgM and RT-PCR were available to order during the duration of the study. Relevant clinical, laboratory, and demographic data were extracted from the electronic health record.

The median age in our cohort was 63 years, and 46% of patients were female. Sole testing with CSF RT-PCR was performed in 73% of patients, and WNV testing guidelines were adhered to in only 25% of cases. Elevated CSF protein, CSF lymphocytic pleocytosis, admission to a neurology service, immunocompetence, race, and hospital site were significantly associated with improved adherence. WNV tests were positive in 26 patients, and patients whose CSF testing patterns adhered to guidelines were 12 times more likely to receive a WNV diagnosis.

The existence of guidelines for appropriate diagnostic testing may not be sufficient to encourage appropriate CSF WNV IgM testing when the RT-PCR test, which is not recommended in immunocompetent patients, remains readily available for ordering. Differential guideline adherence based on institutional factors suggests that systems-level changes may play an important role in shaping provider behavior regarding appropriate use of diagnostic testing.