Intensive Care Med (2006) 32:1272–1273
DOI 10.1007/s00134-006-0210-x
Burke A. Cunha
Distinguishing bacterial from
viral meningitis: the critical
importance of the CSF lactic
acid levels
Accepted: 26 April 2006
Published online: 13 June 2006
© Springer-Verlag 2006
An author’s reply to this comment is
available at: http://dx.doi.org/10.1007/
s00134-006-0211-9
Sir: I read with interest the article
by Brivet et al. [1] describing a mul-
tivariate approach to differentiate
bacterial from viral meningitis. It
has long been known that combining
clinical presentation with the clinical
severity is helpful in distinguishing
bacterial from viral meningitis [2].
A multivariate analysis is unnecessary
to make this clinical distinction. Bac-
teria are the usual pathogens in acute
bacterial meningitis, whereas viruses
are the usual pathogens of aseptic
meningitis, meningoencephalitis, or
encephalitis. Meningoencephalitis is
rare with bacterial neuropathogens
but may occur with Mycoplasma or
Listeria and some viruses.
The definitive diagnosis of menin-
gitis depends on CSF analysis. CSF
pleocytosis is relatively insensitive
in differentiating bacterial from
viral meningitis. HSV-1 and WNE
meningitis, meningoencephalitis,
and encephalitis are not infrequently
associated with a marked CSF pleo-
cytosis. As the authors correctly point
out, an initial PMN predominance
may occur early in tuberculous,
fungal, luetic, and viral meningitis.
The percentage of CSF PMNs
helps to differentiate bacterial from
CORRESPONDENCE
viral meningitis. With the excep-
tion of HSV-1, a proportion greater
than 90% PMNs in the initial LP is
helpful in differentiating viral from
nonviral meningitis. HSV-1 is the
only CNS viral pathogen presenting
with ≥ 90% PMNs in CSF. Therefore
an absolute CSF white blood cell
count of more than 1,000/mm3 is
unhelpful in differentiating bacterial
from viral meningitis. Even if clinical
severity is combined with degree
of CSF pleocytosis, the clinician
still may be misled, particularly by
HSV-1 [2].
The authors mention the CSF
glucose as unhelpful in differentiating
bacterial from viral meningitis. It
is true that the CSF glucose below
the authors’ cutoff of 2 µg/ml may
occur in tuberculous and in fungal
and bacterial meningitis, but most
bacterial pathogens with the excep-
tion of Streptococcus pneumoniae do
not usually decrease the CSF glucose
to such low levels [2].
In my experience, the best CFS
parameter to differentiate bacterial
from viral meningitis is the CSF
lactic acid. Because enteroviruses,
LCM, and HSV-1 may decrease the
CSF glucose, meningitis caused by
these viral pathogens if accompanied
by a white blood cell count greater
than 1,000/mm3 are easily confused
with bacterial meningitis. The CSF
lactic acid readily differentiates
bacterial (< 6 mmol/l), from partially
treated (4–6 mmol/l), from viral
meningitis (> 2 mmol/l), regardless
of CSF glucose determinations.
The authors excluded “partially
treated meningitis” from their
series, but the CSF lactic acid
can readily identify this patient
subset, who often have a negative
CSF Gram stain and culture and
variable CSF pleocytosis. CSF lactic
acid levels, in the absence of red
blood cells, is an underutilized and
accurate test that readily differentiate
bacterial from viral meningitis [3].
The authors state that the CSF
Gram stain, when positive, is 100%
predictive of bacterial meningitis.
This is true, excluding causes of
“pseudomeningitis” with bacteria
on the Gram stain but not cultured,
or that are not causing infection. In
critically ill patients, bacterial menin-
gitis occasionally may present with
a turbid CSF/negative Gram stain,
particularly with Neisseria menin-
gitidis or S. pneumoniae; the Gram
stain is not infrequently uncommon in
Listeria meningitis [4].
Meningitis is a clinical diagnosis
but depends on CSF analysis. Clin-
icians must be wary of relying on
the degree of pleocytosis, the pro-
portion of PMNs, and CSF glucose
to differentiate bacterial from viral
meningitis. The best single CSF test
to differentiate bacterial from viral
meningitis is the CSF lactic acid
level. The CSF lactic acid levels are
particularly helpful when the CSF
Gram stain is negative, and there is
a PMN predominance with a low
glucose [5]. Normal CSF lactic acid
levels (> 2 mmol/l) could have elim-
inated the need for repeat lumbar
puncture done in this study. Another
important advantage of unelevated
CSF lactic acid levels is that it
eliminates the need for empiric an-
tibiotic coverage pending CSF culture
results.
References
1. Brivet FG, Ducuing S, Jacobs F,
Chary I, Pompier R, Prat D,
Grigoriu BD, Nordmann P (2005)
Accuracy of clinical presentation for
differentiating bacterial from viral
meningitis in adults: a multivari-
ate approach. Intensive Care Med
31:1654–1660

2. Durand ML, Calderwood SB, We-
ber DJ, Miller SI, Southwick FS,
Caviness VS, Swartz MN (1993)
Acute bacterial meningitis in adults.
A review of 493 episodes. N Engl J
Med 328:21–28
3. Bailey EM, Domenico P, Cunha BA
(1990) Bacterial vs viral meningi-
tis—the importance of CSF lactic acid.
Postgrad Med 88:217–223
1273
4. Latcha S, Cunha BA (1994) B. A. Cunha (u)
Listeria monocytogenes meningoence- Infectious Disease Division,
phalitis—the diagnostic importance Winthrop-University Hospital,
of the CSF lactic acid. Heart Lung Mineola N.Y., USA
23:177–179 Tel.: +1-516-6632505
5. Cunha BA (2004) The usefulness of Fax: +1-516-6632753
CSF lactic acid levels in central nervous
system infections with decreased cere- B. A. Cunha
brospinal fluid glucose. Clin Infect Dis State University of New York, School of
38:1260–1261 Medicine,
Stony Brook N.Y., USA