Should unmasked anaesthetists be given benefit of the doubt?

With flawless logic Dr Hutter concludes that some mothers will be bacteraemic during insertion of a spinal anaesthetic and therefore the case of streptococcus viridans meningitis described by Drs Sprigge and Harpers should not necessarily be laid at the door of the bare faced anaesthetist who performed the block [1, 2]. We would like to describe a recent case of meningitis in one of our patients following combined spinal and epidural which has made us even more convinced of the necessity of keeping the mouth and nose covered, not just for the anaesthetist but also anyone assisting. A young nulliparous lady requested regional analgesia 7 h after spontaneous rupture of membranes. She was apyrexial and very distressed. The anaesthetist wore a mask, sterile gown and gloves. 0.5% chlorhexidine in 70% alcohol solution was allowed to dry before applying a sterile fenestrated drape. Insertion of a needle-through-needle combined spinal and epidural was noted to be straightforward. After 12 h the patient vomited and complained of severe headache and photophobia. She remained apyrexial with no abnormal neurological signs. Her symptoms improved with administration of intravenous fluids, paracetamol and ondansetron. Six hours later a second combined spinal and epidural was sited in theatre, using the same aseptic precautions, following failure to extend the block sufficiently for Caesarean delivery. The procedure was again uncomplicated and cerebrospinal fluid was noted to be clear. Co-amoxiclav 1.2 g was given peri-operatively. On the third postoperative day she developed a severe, generalised, non-positional headache with neck pain and vomiting. Her temperature was 38 °C, with a positive Kernig’s sign. C-reactive protein was 216 mg.l−1 with a white cell count of 10.2 × 109.l−1 and neutrophilia. The diagnosis of meningitis was confirmed by lumbar puncture and culture of the cerebrospinal fluid which showed a scanty growth of Streptococcus salivarius. After 3 days’ treatment with ceftriaxone, vancomycin and ampicillin her symptoms improved. She was discharged home 10 days after surgery and has remained well. We would like to highlight several features of interest in this case: We believe (with hindsight) that this woman developed meningitis during labour and the dose of co-amoxiclav may have suppressed her symptoms and delayed the diagnosis. Although our policy is that both the anaesthetist and their assistant should wear face masks, the need to use a fresh mask on each occasion and to cover both mouth and nose was not explicitly stated. We have rectified this omission and also specify that the back should be sprayed twice to enhance disinfection [3]. For the past 14 years we have routinely performed combined spinal and epidurals in labour [4]. We have had three cases of meningitis, including this case, one of which was probably due to chemical contamination and one involved multiple needling including a blood patch [5]. We recommend that multiple puncture be avoided if possible. Bouhemad et al. [6] have also described a case of Streptococcus salivarius meningitis following combined spinal and epidural in labour. Face masks costs just six pence and only takes 10 s to tie in place. We feel this is a small inconvenience and cost to minimise the risk of further cases, of what must be assumed to be iatrogenic meningitis until proven otherwise. We will of course continue to warn parturients of the (as yet unquantified) risk of infection.