Enhancing meningitis diagnosis: a diagnostic stewardship workflow in a resource-limited setting

Area of Science:

• Neurology
• Infectious Diseases
• Clinical Diagnostics

Background:

• Central nervous system (CNS) infections are a major cause of illness and death, particularly in low- and middle-income countries.
• Existing diagnostic methods in resource-limited settings often lack efficiency and comprehensive pathogen detection.

Purpose of the Study:

• To develop and evaluate a diagnostic stewardship workflow (DSW) to enhance pathogen detection and diagnostic efficiency for meningitis in resource-limited settings.
• To compare the DSW's performance against standard of care (SoC) in terms of pathogen identification and cost-effectiveness.

Main Methods:

• A prospective cross-sectional study was conducted in Lima, Peru, involving 103 adults with suspected meningitis.
• Cerebrospinal fluid specimens were analyzed using both the hospital's standard of care (SoC) and the newly developed DSW at an independent reference laboratory.
• Statistical comparisons, including McNemar's and Cochran's Q tests with Holm-Bonferroni correction, were used to evaluate diagnostic yield and cost simulations were performed.

Main Results:

• The DSW achieved a significantly higher pathogen detection rate (97.7%) compared to SoC.
• The DSW demonstrated substantial incremental yield over SoC, particularly for tuberculous meningitis (+36%), bacterial meningitis (+67%), and viral encephalitis (+100%).
• A cost simulation indicated that the DSW could reduce diagnostic expenditure by approximately 61%.

Conclusions:

• The diagnostic stewardship workflow substantially increases pathogen detection for CNS infections, especially for viral and difficult-to-culture bacteria.
• The DSW offers a practical approach to streamline diagnostics, reduce unnecessary testing, and lower costs in resource-limited settings.
• Implementing the DSW provides guidance to clinicians, improving the efficiency of diagnostic care for meningitis.