Point-of-Care Approaches for Meningitis Diagnosis in a Low-Resource Setting (Southwestern Uganda): Observational Cohort Study Protocol of the "PI-POC" Trial

Clinical utility of the FilmArray® meningitis/encephalitis panel in children with suspected central nervous system infection in a low-resource setting - a prospective study in Southwestern Uganda

BACKGROUND

In low-resource settings, limited laboratory capacity adds to the burden of central nervous system (CNS) infections in children and spurs overuse of antibiotics. The commercially available BioFire® FilmArray® Meningitis/Encephalitis Panel (FA-ME) with its capability to simultaneously detect 14 pathogens in cerebrospinal fluid (CSF), could potentially narrow such a diagnostic gap.

METHODS

In Mbarara, Uganda, we compared clinical utility (clinical turnaround time [cTAT], microbial yield, and influence on patient outcome and antibiotic exposure) of FA-ME with bacterial culture, in children 0-12 years with suspected CNS infection.

RESULTS

Of 212 enrolled children, CSF was sampled from 194. All samples underwent bacterial culture, of which 193 also underwent FA-ME analyses. FA-ME analyses prospectively influenced care for 169 of the 193 patients, and they constituted an 'Index group'. The remaining 43/212 patients constituted a 'Reference group'. Of all 194 CSF-sampled patients, 87% (168) had received antibiotics before lumbar puncture. Median cTAT for FA-ME was 4.2 h, vs. two days for culture. Bacterial yield was 12% (24/193) and 1.5% (3/194) for FA-ME and culture, respectively. FA-ME viral yield was 12% (23/193). Fatality rate was 14% in the Index group vs. 19% in the Reference group (P = 0.20). From clinician receival of FA-ME results, median antibiotic exposure was 6 days for bacteria-negative vs. 13 days for bacteria-positive patients (P = 0.03). Median hospitalization duration was 7 vs. 12 days for FA-ME negative and positive patients, respectively (P < 0.01).

CONCLUSIONS

In this setting, clinical FA-ME utility was found in a higher and faster microbial yield and shortened hospitalization and antibiotic exposure of patients without CSF pathology. More epidemiologically customized pathogen panels may increase FA-ME utility locally, although its use in similar settings would require major cost reductions.

TRIAL REGISTRATION

The trial was registered with clinicaltrials.gov (NCT03900091) in March 2019, and its protocol was published in November 2020.

A DAMP-Based Assay for Rapid and Affordable Diagnosis of Bacterial Meningitis Agents: Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae

The rapid and accurate diagnosis of meningitis is critical for preventing severe complications and fatalities. This study addresses the need for accessible diagnostics in the absence of specialized equipment by developing a novel diagnostic assay. The assay utilizes dual-priming isothermal amplification (DAMP) with unique internal primers to significantly reduce non-specificity. For fluorescence detection, the dye was selected among Brilliant Green, Thioflavin T, and dsGreen. Brilliant Green is preferred for this assay due to its availability, high fluorescence level, and optimal sample-to-background (S/B) ratio. The assay was developed for the detection of the primary causative agents of meningitis (Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae), and tested on clinical samples. The developed method demonstrated high specificity, no false positives, sensitivity comparable to that of loop-mediated isothermal amplification (LAMP), and a high S/B ratio. This versatile assay can be utilized as a standalone test or an integrated assay into point-of-care systems for rapid and reliable pathogen detection.

Innovative strategies for the surveillance, prevention, and management of pediatric infections applied to low-income settings

INTRODUCTION

Infectious diseases still cause a significant burden of morbidity and mortality among children in low- and middle-income countries (LMICs). There are ample opportunities for innovation in surveillance, prevention, and management, with the ultimate goal of improving survival.

AREAS COVERED

This review discusses the current status in the use and development of innovative strategies for pediatric infectious diseases in LMICs by focusing on surveillance, diagnosis, prevention, and management. Topics covered are: Minimally Invasive Tissue Sampling as a technique to accurately ascertain the cause of death; Genetic Surveillance to trace the pathogen genomic diversity and emergence of resistance; Artificial Intelligence as a multidisciplinary tool; Portable noninvasive imaging methods; and Prognostic Biomarkers to triage and risk stratify pediatric patients.

EXPERT OPINION

To overcome the specific hurdles in child health for LMICs, some innovative strategies appear at the forefront of research. If the development of these next-generation tools remains focused on accessibility, sustainability and capacity building, reshaping epidemiological surveillance, diagnosis, and treatment in LMICs, can become a reality and result in a significant public health impact. Their integration with existing healthcare infrastructures may revolutionize disease detection and surveillance, and improve child health and survival.

Aseptic Meningitis and Its Viral Etiologies, Clinical Characteristics and Management Practices in Children: A Retrospective Hospital-Based Study From Jordan

Purpose In this study, we aimed to describe the clinical characteristics, laboratory findings, aetiologies, and role of PCR in the decision on the management plan and duration of hospital stay in Jordanian children diagnosed with aseptic meningitis. Methods This retrospective observational cohort study included children diagnosed with meningitis who were admitted to the paediatric ward at Jordan University Hospital (JUH) during the period from January 2016 to August 2020. Patients were identified through the ICD9 discharge code of meningitis. Patients diagnosed with aseptic meningitis (defined as a patient with signs and symptoms of meningitis with a cerebrospinal fluid (CSF) white cell count of >5 cells/mm3, and a negative CSF Gram stain) were included, while patients who had low CSF glucose (<50% of serum) positive cerebrospinal fluid Gram stain and/or culture for bacterial meningitis were excluded. Files were reviewed to collect data on the clinical picture, viruses identified by the CSF viral polymerase chain reaction (PCR) panel, duration of medication, and hospital stay in patients with identified virus versus those with negative viral PCR. Results One hundred and thirty-one patients were included: 87 males (66.4%) and 44 females (33.5%). Fever was the most common presenting symptom, followed by headache, vomiting, and excessive sleep in 48.0%, 42.7%, and 35.8% of the patients, respectively. Prior oral antibiotic use was reported in 48/125 (38.4%) patients. White blood cell count (WBC) ranged from 4.800 to 22.000. cells/mL, 45 patients (34.3%) had counts above 15.000 cells/mL. C-reactive protein level was high in 61/103 (59.2%) patients. CSF WBC count was <100 in 62 (47.3%) patients while neutrophils predominance of >70% was present in 27 (20.6%) patients. Viral panel PCR was done for 100/131 (76.3%) patients and was positive in 66/100 (66%) patients; with enterovirus being the most common identified viruses (60/100; 60%). The average duration of hospital stay was 5.9 and 5.5 days for those with negative and positive PCR respectively. Ten (7.6%) patients had seizures upon presentation. None of the patients had any neurological sequel related to his meningitis. Conclusion Enteroviruses are the most common identified cause of paediatric aseptic meningitis in Jordan. Although PCR revealed an identified virus in around half of the patients, nevertheless, there was no adjustment in the management plan regarding duration of empirical antibiotic use and hospital stay. Increasing knowledge and awareness among clinicians on viral meningitis' lab characteristics might have great impact on duration of hospital stay and thus would be reflected on the patient and the healthcare system as well.