Syndromic Testing for Meningitis/Encephalitis: A Game Changer

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Time frame for results can shift from days to hours.

***This article was written by one of EPM’s advertising partners as a promotional supplement.***

Syndromic testing is a symptom-driven, broad grouping of probable pathogens into a single, rapid diagnostic test. When a patient is suspected of meningitis/encephalitis, traditional CSF culture methods can take up to three days to produce pathogen-specific results.


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The BioFire® FilmArray® Meningitis/Encephalitis (ME) Panel is a syndromic test. Using multiplex PCR technology, the BioFire ME Panel takes a small sample of CSF and simultaneously tests it for a panel of 14 bacterial and viral targets in about an hour. It can dramatically reduce the turnaround time from lumbar puncture to definitive diagnosis.

Emergency physicians have always known that time is of the essence in cases of myocardial infarction (“Time is Muscle”) and stroke (“Time is Brain”). In both instances, EPs have been able to provide optimized treatment quickly. Until now, however, we had to treat meningitis/encephalitis shotgun style, covering all the potential pathogens with broad spectrum antibiotics until the cause of infection was known, which could take days. With the BioFire ME Panel, that’s no longer the case.

The sample volume required by the BioFire ME Panel is dramatically reduced compared to traditional testing methods. Most EPs still use these methods, which require obtaining multiple CSF tubes for cell count, differential, glucose and protein.


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Juggling several tubes can risk contamination and other complications related to the mechanics of multi-stage lumbar puncture. The BioFire ME Panel requires just 0.2 mL of CSF to provide a result on 14 meningitis/encephalitis pathogens. CSF will still need to be cultured to fine-tune specific drug sensitivities.

In today’s environment of pay-for-value, every hospital is looking for ways to safely decrease length-of-stay and unnecessary antibiotic utilization. A yearlong French study evaluated the use of syndromic testing in several countries and found that it contributed to a significant reduction in time to microbiologic diagnoses. The study also noted earlier discontinuation of antibiotics in about one-third of patients and decreased hospital length-of-stay in about one-fifth of patients.[1]

United States researchers have come to similar conclusions. While the BioFire ME Panel is more expensive than traditional methods, the higher cost can be offset by the savings from decreased drug utilization and hospital length-of-stay. When these savings are multiplied across a large number of patients, the overall decrease in cost of care is significant.

Another benefit of rapid syndromic ME testing: the ability to rule out life-threatening bacterial meningitis. Dr. Sean-Xavier Neath, an emergency physician researcher from the University of California, San Diego and a clinical consultant for BioFire, related a recent case involving a young college student. The patient presented to the emergency department with a fever, headache and mild neck stiffness.


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Dr. Neath’s clinical suspicion was that the student’s condition was viral in nature. But if a bacterial etiology could not be ruled out, the patient could have exposed other students in her dormitory to bacterial meningitis, many of whom would then have to be tested and placed on quarantine until a pathogen was identified.

Considering the panic that can stem from news of communicable disease outbreaks at schools, the university would need to become involved, perhaps including the Dean of the patient’s college. Meanwhile, the patient’s parents were preparing to fly to San Diego from the east coast.

Using the BioFire ME Panel, Dr. Neath was able to confirm a benign viral etiology in just two hours. He was able to provide reassurance to the patient, her close contacts in the dorm, and her parents. Dr. Neath and the BioFire ME Panel were certainly the heroes that day.

“BioFire technology has been at my institution for a number of years,” said Dr. Neath. “Our laboratories system — including our micro labs — is very forward-thinking, but evaluates new technology carefully and cautiously. At the beginning, the use of [the BioFire® FilmArray® Respiratory (RP) Panel] was limited to certain high-risk cancer and immunocompromised populations before we recognized its broad applicability across our tertiary care patient population. That’s what we call the RPNA (Respiratory Pathogen Nucleic Acid test). That’s the first test that substantially changed our management of respiratory infections.”

The BioFire® FilmArray® Gastrointestinal (GI) Panel was adopted next, transforming how acute diarrheal illnesses were diagnosed and treated. “It’s been very educational for me,” said Dr. Neath. “And I would say that these panels have contributed to antibiotic stewardship significantly. [The BioFire ME Panel] came along shortly after the [BioFire] Respiratory and GI Panels. Each time it’s gone in with a good deal of validation in our population with appropriate education to a cross-sectional group of laboratory medicine, infectious disease, hospital medicine and emergency clinicians.”

As any new diagnostic test brings in new costs, having a clinical champion is key. “It usually takes an interest from the people in laboratory medicine, and depending on your hospital system, some interest at the level of the C-suite,” said Dr. Neath. “Usually in cases like this, pharmacy is becoming increasingly important in helping to analyze and adopt these tests. They have to see that this test is going to help decrease length-of-stay or that this test is going to help our antibiotic budget.”

The adoption of new processes like syndromic testing requires a champion who will bring the potential benefits and cost effectiveness to the attention of the right people. Emergency physicians are uniquely capable of being those champions and helping bring this novel diagnostic tool into mainstream use.

REFERENCES

[1] Cailleaux M, et al. 2020. Eur J Clin Micro Infect Dis. 39(2):293

ABOUT THE AUTHOR

FOUNDER / EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

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