Abstract

Objective: This study aimed to assess the clinical assessment and documentation of the suspected cases of central nervous system (CNS) infection during 6 years (20172022).
Methods: This was a retrospective quality audit study, conducted at King Fahad Specialist Hospital, between January 2017 and December 2022. Adult patients who had a lumbar puncture (LP) due to suspected CNS infection were included. The electronic medical records were analyzed using a pre-tested abstraction tool that evaluated four areas: documentation completeness, timeliness of care, microbiological evaluation, and congruence with Centers for Disease Control and Prevention/National Healthcare Safety Network definitions.
Results: A total of 76 patients were included. There was also a high level of documentation gaps, especially in cerebrospinal fluid (CSF) opening pressure (98.7%), CSF red blood cell count (90.8%), and respiratory rate (55.3%). Although CSF glucose and protein levels were mostly complete, inflammatory markers (CRP, 56.6% missing, and ESR, 42.1% missing) were often missing. Only 38.2% of patients underwent LP on the day of admission, whereas 26.3% experienced delays of ≥4 days. Microbiological yield was poor, with only one positive CSF culture and limited viral testing. In about half of the cases, empiric antimicrobials were used. Overall, 75% of patients did not meet standardized CNS infection criteria, primarily due to incomplete documentation.
Conclusion: This audit identified major gaps in documentation, timeliness of diagnosis, and compliance with standardized definitions in the process of assessing suspected CNS infections. These loopholes had significant consequences on patient care, clinical decision-making, and epidemiological surveillance.

Key words: Central nervous system infections, epidemiology, Saudi Arabia, retrospective study, data completion, timeliness, quality audit