Pediatric lumbar puncture rates in urban tertiary hospitals in Africa participating in the SURE pediatric tuberculous meningitis treatment trial

Lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis are essential for the diagnosis and management of central nervous system (CNS) infections, but LP is underutilised in pediatric patients in high burden settings. As part of the pre-screening and screening procedures of the SURE+DP diagnostic sub-study of the SURE pediatric tuberculous meningitis randomised control trial we identified this as a key clinical issue and quantified how often pediatric lumbar puncture was performed at recruiting African hospitals and implemented a package of interventions to increase LP rates. Methods: We evaluated the frequency of pediatric CSF sampling of children aged 28 days to 18 years at four urban tertiary hospitals in Kampala, Lusaka and Harare. We developed a family-facing educational video to support LP consent discussions. In Zambia and Zimbabwe, healthcare workers received training sessions including mannequin-based LP simulation, with knowledge, confidence, experience and perceived barriers assessed before and after training. We assessed the effect of healthcare worker LP training on confidence and LP performance and explored reported barriers to pediatric LP. Results: Median weekly pediatric CSF samples were 1 at both Sally Mugabe and Parirenyatwa hospitals in Harare, 6 at University Teaching Hospital in Lusaka, and 4 at Mulago Hospital in Kampala. Training significantly improved healthcare-worker self-reported confidence to assist (p-value <0.001) and perform pediatric LP (p-value <0.001). At the Zambian site, the proportion of children with coded diagnoses compatible with consideration of LP who had CSF samples increased by 7% in the six months after training compared with the preceding six months (p=0.002). In Zimbabwe, there was an increase in LP activity the week following training, which was not subsequently sustained. Healthcare workers identified parental refusal, limited procedural confidence, delays obtaining consent from male family decision makers, fear of complications, and consumables availability as barriers. Discussion: Pediatric LP was performed infrequently across these tertiary hospitals, and improved healthcare worker confidence following training did not consistently translate into sustained increases in LP performance. Multifaceted sustained approaches combining healthcare worker training with caregiver engagement, system level support and improved resources are needed to improve diagnostic LP use for children with suspected CNS infections.