Cerebrospinal Fluid Protein as a Prognostic Marker in Neonatal Meningitis: A Prospective Study from Nepal

Background Acute meningitis is a major contributor to neurodevelopmental morbidity and death among newborns. In a resource limited setting, where cerebrospinal fluid (CSF) culture yield is often low, early identification of neonates at risk of poor neurological outcomes is challenging. This study aimed to evaluate the prognostic utility of routinely sent CSF marker in predicting short term neurological outcome among neonates who are being treated as meningitis in such settings. Methods This prospective study included 54 neonates being treated for meningitis at a tertiary level pediatric referral center in Nepal. Neonatal meningitis was defined as either a positive CSF culture, or the presence of CSF pleocytosis (≥ 20 WBCs/µL) accompanied by elevated protein (≥ 150 mg/dL preterm; ≥100 mg/dL term) or low glucose (< 30 mg/dL). CSF protein level at diagnosis was the primary exposure. The primary outcome was poor short-term neurological status (defined by residual sequelae or death) at discharge. Statistical analysis included the Mann-Whitney U test, Fisher’s exact test for the ≥ 200 mg/dL cutoff, and logistic regression adjusted for gestational age. Results Among the 54 neonates, most neonates were term (70.4%) and males predominated (59.3%). Fever or hypothermia and refusal to suck were the most common presenting features, each observed in 55.6% of cases. Cerebrospinal fluid culture was positive in 5.6% of neonates, predominant yield being Klebsiella species. At discharge, 12 (22.2%) neonates had a poor neurological outcome. Median CSF protein was 239mg/dL (IQR 253.3) in the poor outcome group vs. 120mg/dL (IQR 44.0) in the good outcome group (p < 0.001). CSF protein ≥ 200 mg/dL had a sensitivity of 91.7% and specificity of 92.9% for predicting poor outcome. The adjusted odds ratio for poor outcome with CSF protein ≥ 200 mg/dL was 141.9 (95% CI: 13.0–1545.8). Conclusion Elevated CSF protein is a strong predictor of adverse short-term outcomes in neonates being treated as meningitis in resource limited settings.