Improving diagnosis of brain infections in Indonesia using novel and established molecular diagnostic tools.

与其他地方一样，脑感染，如脑膜炎和脑炎，是印度尼西亚发病率和死亡率的一个重要原因，给家庭、保健和社会造成了相当大的代价。早期患者管理的关键步骤是区分需要立即抗生素治疗的细菌性病因和许多不需要抗生素治疗的临床类似病因，如病毒性脑膜炎。鉴别两者的金标准是腰椎穿刺，其次是显微镜检查和脑脊液（CSF）培养。然而，培养结果往往是延迟的或不确定的。因此，在排除细菌性脑膜炎诊断之前，许多患者接受了不必要的抗生素治疗，这加剧了抗菌素耐药性的负担。在利物浦，我们开发了转录物来识别细菌性脑膜炎（TRIM）测试。这是一种基于宿主转录的诊断性血液测试。我们已经证明，它在区分成人细菌性脑膜炎和类似物（病毒性脑膜炎或脑膜炎[患者有脑膜炎的临床症状，但脑脊液中白细胞的数量没有升高]）方面具有高灵敏度（100%）、特异性（90%）和阴性预测值（100%）。TRIM测试的一个关键优势是，从样品到达实验室开始，可以快速获得结果（在四小时内）。作为一种快速、准确和低成本（每位患者的目标成本低于10英镑）的血液检测，TRIM检测可以更好地排除细菌性脑感染，加强患者管理并促进停止不必要的抗菌药物使用。与印度尼西亚Gadjah Mada大学（UGM）合作，初步工作评估了UGM的TRIM测定，表明它在区分患有脑膜炎或脑炎症状/体征的印度尼西亚儿童和成人患者的细菌感染和模拟物方面保持了很高的准确性（100%）。我们的第二种诊断方法是使用病原体特异性聚合酶链反应（PCR）和抗体测试；通过这些措施，我们通过对脑脊液进行系统检测的试点，将UGM疑似脑膜炎儿童的病原体检出率提高了30%以上（从11%提高到42%）。在这项为期三年的研究中，我们将通过与UGM和印度尼西亚大学相关的医院招募更大的印度尼西亚疑似脑膜脑炎患者队列，评估TRIM测试的准确性。此外，我们将通过在这些位点进行病原体特异性PCR和抗体检测来增加病原体检测。为了改进我们的病原体特异性PCR小组，我们将在印度尼西亚的Eijkman研究所对未检测到病原体的脑脊液样本进行下一代测序。已鉴定病原体的序列信息将用于PCR检测设计。我们将与华威大学合作，评估将这些诊断工具引入印度尼西亚医院对疑似脑感染患者的常规临床护理的成本效益。本研究将在印度尼西亚脑感染患者中评估和实施新的和已建立的诊断工具。从长期来看，这些工具将支持对印度尼西亚患者的脑部感染进行更适当的治疗，加强当地的研究能力以及英国和印度尼西亚之间的合作。

Brain infections, such as meningitis and encephalitis, are a significant cause of morbidity and mortality in Indonesia, as elsewhere, with considerable costs to families, health care and society.The key step in early patient management is to distinguish bacterial causes, which need immediate antibiotic treatment, from the many clinical mimics, such as viral meningitis, which do not. The gold standard for distinguishing the two is lumbar puncture, followed by microscopy and culture of the cerebrospinal fluid (CSF). However, culture results are often delayed, or inconclusive. Many patients are therefore treated with unnecessary antibiotics until a diagnosis of bacterial meningitis is excluded, contributing to the burden of antimicrobial resistance.In Liverpool, we have developed the TRanscripts to Identify bacterial Meningitis (TRIM) test. It is a host transcript-based diagnostic blood test. We have shown it exhibits high sensitivity (100%), specificity (90%) and negative predictive value (100%) in distinguishing adult bacterial meningitis from mimics (viral meningitis or meningism [where patients have clinical symptoms of meningitis but the number of white blood cells in the CSF is not raised]). A key advantage of the TRIM test is that results can be rapidly available (in under four hours) from sample arrival in the laboratory. As a rapid, accurate and low cost (target cost under £10 per patient) blood test, the TRIM test offers improved rule-out of bacterial brain infections, enhancing patient management and promoting cessation of unnecessary antimicrobial use. In partnership with Universitas Gadjah Mada (UGM), Indonesia, preliminary work assessing the TRIM assay at UGM indicate it maintains high accuracy (100%) in distinguishing bacterial infection from mimics among child and adult Indonesian patients with symptoms/signs of meningitis or encephalitis.Our second diagnostic approach is to use pathogen-specific polymerase chain reaction (PCR) and antibody tests; through these we have increased pathogen detection among children with suspected meningo-encephalitis at UGM by over 30 percent (from 11% to 42%), through a pilot of systematic testing of CSF. In this three year study, we will assess the accuracy of the TRIM test in a larger cohort of Indonesian patients with suspected meningo-encephalitis, recruited through hospitals linked to UGM and Universitas of Indonesia. Alongside, we will increase pathogen detection through pathogen-specific PCR and antibody testing at these sites. To improve our pathogen-specific PCR panel, we will perform next generation sequencing, at the Eijkman Institute, Indonesia, on CSF samples where no pathogen has been detected. Sequence information from identified pathogens will be used to inform PCR test design.Linking with the University of Warwick, we will evaluate the cost-effectiveness of introducing these diagnostic tools into routine clinical care for suspected brain infection patients in Indonesian hospitals.This study will assess and implement novel and established diagnostic tools among Indonesian brain infection patients. In the longer-term, these tools will support more appropriate treatment of brain infections among Indonesian patients, strengthen local research capacity and collaboration between UK and Indonesia.