FilmArray Meningitis/Encephalitis (ME) panel in the diagnosis of bacterial meningitis

brazjinfectdis2019;23(6):468–470

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Brief

communication

FilmArray

Meningitis/Encephalitis

(ME)

panel

in

the

diagnosis

of

bacterial

meningitis

Renan

Barros

Domingues

,

Márcio

Vega

dos

Santos,

Fernando

Brunale

Vilela

de

Moura

Leite,

Carlos

Senne

SenneLíquorDiagnóstico,SãoPaulo/SP,Brazil

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t

i

c

l

e

i

n

f

o

Articlehistory:

Received8July2019 Accepted20October2019

Availableonline16November2019

Keywords:

Meningitis

FilmArrayMeningitis/Encephalitis Cerebrospinalfluid

Polymerasechainreaction

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Theprecisediagnosisofbacterialmeningitisisessential.Cytologicalandbiochemical exam-inationofcerebrospinalfluid(CSF)arenot specific.Conventionalmethodsforbacterial meningitislacksensitivityortaketoolongforafinalresult.Therefore,othermethodsfor rapidandaccuratediagnosisofcentralnervoussysteminfectionsarerequired.FilmArray meningitis/encephalitis(ME)panelisaPCRmultiplexforsimultaneousandrapid identi-ficationof14pathogens,including6bacteria,7viruses,andCryptococcus.Weevaluated 436CSFsamplessubmittedtoFilmArrayMEPanel.Amongthem,25caseswerepositivefor bacteria,beingStreptococcuspneumoniathemostfrequent(48%).Amongpositivecases forbacteria,60%werepositiveonlywithFilmArray.Allthebacterialmeningitiscasesin whichtheonlypositivetestwasFilmArrayhadCSFfindingssuggestiveofbacterial menin-gitis,includingneutrophilicpleocytosis,increasedCSFproteinandlactate,anddecreased CSFglucose.ThesefindingssuggestthatFilmArraymayincreasethediagnosticsensitivity forbacterialmeningitis.

©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Bacterial meningitis infections are potentially fatalcentral nervous system(CNS) diseases.1 _{Theempiricmanagement}

ofpatientswithbacterialmeningitisisfrequentlycarriedout withoutaprecisedefinitionoftheetiologicalagentsince iden-tification of the causative microorganism is often difficult. Cerebrospinalfluid(CSF)analysisisofgreatimportancebut cytologicalandbiochemicalanalysisarenotentirelyspecific. Conventionalmicrobiologicalmethods,includingGramstain, antigendetection,andcultureareeitherpoorlysensitiveor takealongtimeforafinalresult.1,2_{Theuseofmolecular}

biol-∗ _{Correspondingauthor.}

E-mailaddress:[email protected](R.B.Domingues).

ogymethodshascontributedtoimprovethisscenariowith moresensitiveandrapiddiagnoses.3

FilmArray meningitis/encephalitis(ME) panelisa multi-plexpolymerasechainreaction(PCR)forrapididentification of14pathogensfromCSF:Streptococcuspneumoniae, Streptococ-cusagalactiae,EscherichiacoliK1,Haemophylusinfluenza,Listeria monocytogenes,cytomegalovirus,enterovirus,herpessimplex 1and2,humanherpesvirus6,humanparechovirus, varicella-zoster virus, and Cryptococcus neoformans/gattii (bioMérieux S.A.,Marcyl’Étoile,France).4 _{TheCSFvolumeused ineach}

https://doi.org/10.1016/j.bjid.2019.10.008

1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

brazj infect dis.2019;23(6):468–470

469

Table1–CytologicalandbiochemicalresultsinCSFsamplesobtainedfrompatientswithmeningitisinwhichtheonly positivemicrobiologicalresultwasachievedwithFilmArray.

FilmArray WBCa_{count Neutrophils(%) Protein(mg/dl) Glucose(mg/dl) Lactate(mg/dl)}

S.Pneumoniae 970 70 140 27 63,7 S.Pneumoniae 8000 86 513 5 138,6 S.Pneumoniae 8789 77 475 32 144 S.Pneumoniae 18000 95 229 5 122,7 S.Pneumoniae 250 62 417 62 102 S.Pneumoniae 280 58 427 49 100,7 S.Pneumoniae 110 79 77 51 28,4 S.Pneumoniae 14080 92 270 16 167,9 N.meningitidis 410 38 95 23 24,6 N.meningitidis 6800 89 330 5 96,9 N.meningitidis 6160 75 166 56 70,4 L.monocytogenes 874 42 42 32 69.3 H.influenzae 1706 74 74 75 51.3 H.influenzae 2960 90 90 5 68.5 H.influenzae 5413 80 80 5 110

a _{Whitebloodcells(/mm}3_).

reactionis200␮L,andtherunturnaroundtimeisaboutone hour.Inthepresentstudy wedescribetheresultsobtained withtheuseofFilmArrayMEpanelincasesinwhichbacteria wereidentifiedwiththismethod.

ThisstudywasconductedbetweenOctober2018andMay 2019 and included all cases of suspected meningitis and encephalitiswithinflammatoryCSFthatwerecollectedin pri-vatehospitalsinSãoPaulo,Brazil,andsenttoSenneLíquor DiagnósticoforCSFanalysis. All sampleswere obtainedin emergence rooms. During this period oftime all the sam-plesfromsuspectedcommunity-acquiredCNSinfectioncases withatleast10cells/mm3_{weresystematicallysubmittedto}

FilmArray. Age and sex were recorded. CSF data included leukocytes count, protein, glucose, and lactate determina-tion. Conventional microbiological analysis included Gram stain,bacterialculture,andantigendetection.Theresultsare reportedaspercentagesormean±SD.

Four hundred thirty-six CSF samples from 436 patients weresubmittedtoFilmArray.Twenty-fivecases(5.7%)were positiveforbacteria.Themeanagewas32.7±29.4years,13 (52%) females.Streptococcuspneumoniae, the mostfrequent bacterium,wasidentifiedbyFilmArrayin12cases(48%), fol-lowedbyNeisseriameningitidisin7(28%), andHaemophylus influenza in4 (16 %).E. coli and Listeria monocytogeneswere identifiedin onecaseeach and no caseswere positive for

Streptococcusagalactiae.Eigthcases(66.6%)identifiedas Strep-tococcus pneumoniae were positive only with FilmArray and were negativewithGram stain,cultureand antigen detec-tion.ThreecasesidentifiedasNeisseria meningitidis(42.8 %) were positiveonly withFilmArray. Three (75%) Haemophy-lus influenza out of the four positive cases with FimArray werenegativewithothermicrobiologicalmethods.TheListeria monocytogenescasewaspositiveonlywithFilmArray,whereas theE.colicasewaspositivewithFilmArrayandculture.CSF cytologicalandbiochemicalresultsofcasesinwhich FilmAr-raywastheonlypositivemethodforbacteriaidentification are shown in Table 1. All these cases had CSF cytological andbiochemicalresultscompatiblewithbacterial meningi-tis.Ten(40 %)out ofthe 25 FilmArraypositive caseswere

positivewithatleastoneoftheconventional microbiology tests. Culturewaspositivein24%and bacterioscopyin25 % of those cases. One hundred seventy-four (40 %) of the 436sampleswerepositiveforvirus,beingenterovirus-77%, HHV-6-9 %,HSV-2-6 %,VZV-5 %, HSV-1-2%,and CMV-1 %. OnesamplewaspositiveforC.neoformans.Dataonvirusand fungalinfectionswerenotanalyzedindetailinthepresent study.

The present data suggest that FilmArray enhances the sensitivityforthediagnosisofbacterialmeningitis.An alter-nativeexplanationisthatcasesthatwerepositiveonlywith FilmArray are indeedfalsepositive. Infact, thisisunlikely sinceall the15 casespositive withFilmArray andnegative withothermicrobiologicalmethodshadCSFgeneral analy-sis suggestive ofbacterial etiology.Itcould be argued that thelowculturesensitivityisduetopreviousantibioticuse. Althoughwedonothavedetailedclinicalinformationabout the patients’ treatments, all of the sampleswere obtained inemergenceroomsandthereforelikelybeforeinitiationof antibiotics.Another possibilityforthelowsensitivitycould bepoorqualityoftheconventionalmicrobiologicalanalysis. However,thisisunlikelysincethesesampleswereprocessed inalaboratoryspecializedinCSF,withallthecertificationsto carryouthighstandardmicrobiologicalanalysiswithqualified personnel.

Ourresultsareinlinewithpreviouspublications.Ithas beenshownthatFilmArrayenhancespathogenidentification inpatientswithmeningitiswithnegativeGramstain.5

FilmAr-raywasshowntobeefficatiousindetectingbacterialetiology inmeningitiscasesinwhichCSFculturewasnegative.6,7 _A

previous reportshowed rapiddetectionofListeria monocyto-genesinapatientinwhichCSFGranstainandculturewere negative,asoccurred inacaseinourseries.8_Alargestudy

showedhighsensitivityandspecificitylevels.Thesensitivity was85.7%forHHV-6,95.7%forenterovirusand100%forall theother agents.Thespecificitywasabove99%forall the 14agents.9_{SomestudieshaveshowedthatFilmArrayis}

cost-effectivewithareductioninhospitalizationtimeduetorapid identificationofetiologicagent.10–12

470

Our study has limitations that deserve to be men-tioned.Thestudywasnotdesignedtoassesssensitivityand specificity.Ourdatadonotallowustoconcludeabout cost-effectivenessaswellaslengthofhospitalstay.Therefore,we werenotabletoassesstheoverallimpactoftheutilization ofFilmArray.However,wecoulddetecttheimportanceof Fil-mArrayinindividualcases,asillustratedinthecaseinwhich

Listeriamonocytogeneswasidentifiedandcouldbetreatedwith aspecificantibioticregimenthankstoFilmArray identifica-tion.Incaseslike this,itisreasonabletosupposethatthe useofthistest,whichcostsaroundUS350–400,maybecost effective.

Inconclusion,FilmArraymayallowforarapiddiagnosisof bacterialmeningitis,beingpossiblymoresensitivethan con-ventionalmethodsforidentifyingthebacteriatestedinthe panel.

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