Incidence of Meningococcal Meningitis Undetected by Culture in New York City

1. Incidence of Meningococcal Meningitis Undetected by Culture in New York City Arianne Ramautar, MPH New York City Department of Health and Mental HygieneBureau of Communicable Disease 2012 CSTE Annual Conference (Breakout Presentation) Omaha, Nebraska, June 5, 2012

2. Meningitis is the inflammation of the lining surrounding the brain and spinal cord • Most often caused by an infectious agent • Can be: • Bacterial • Viral • Fungal • Parasitic • Common Symptoms • Fever • Headache • Neck rigidity • Altered Mental Status • Photophobia • Sepsis/Shock • Petechiae • Purpura fulminans Background- Meningitis

3. One of the more common causes: • Neisseria meningitidis(Nm) • Can progresses rapidly • Over 13 serogroups • A, B, C, W-135, X, Y, Z • Prompt administration of antibiotics is key to survival • Nm is communicable person to person • Potential to cause outbreaks • Prophylaxis provided to exposed contacts to prevent secondary cases Purpura Fulminans Background- Neisseria meningiditis

4. NYC: 60-80 rule-out Nm reports a year, about half are actually Nm and meningitis occurs in ≈ 33% • New York City (NYC) case fatality rate has been higher than the national average (19% v. ~10%) • One theory for the higher CFR is that there exist unreported, culture negative cases of Nm Background- Meningococcal meningitis in NYC

5. NYC Health Code and Universal reporting form Meningitis can be reported as bacterial, aseptic/viral or invasive meningococcal disease

6. Objectives • Primary Objective • To assess if NYC is missing cases of Nm meningitis • Testing culture negative reported cases of bacterial or aseptic meningitis • Secondary Objective • Assess the utility of nucleic acid testing on CSF • Describe and compare the bacterial organisms identified by culture vs. nucleic acid tests

7. Inclusion criteria: • All reports of bacterial meningitis (MEX) and a sample of aseptic meningitis (MAS) submitted to DOHMH between March 2011 and March 2012 • Available cerebrospinal fluid (CSF)specimen Transport of CSF to Wadsworth Center State Public Health Laboratory (WC) Nucleic Acid Testing performed Confirm CSF specimen availability Methods- Study Design • Reporting hospital final culture results were obtained • Culture confirmed cases of Nm meningitis were included for PCR quality assurance

8. Wadsworth Center Algorithm

9. Real-time Polymerase Chain Reaction (PCR) • Amplifies a specific DNA sequence • Rapid method for bacterial identification • Effective after prior antibiotic therapy 16S rRNA gene sequencing • 16S is a universal gene in bacteria • Sequencing is performed then compared to a database • There are over 90,000 nucleotide sequences known for the 16S gene Nucleic Acid Amplification Process

10. Descriptive statistics • Comparison of available CSF samples versus unavailable • Independent T-test • Chi Square test • Detection of Nm in CSF samples • Calculate sensitivity and specificity for real-time PCR • Where antibiotics were administered: • Prior to lumbar puncture • After lumbar puncture • Describe and explore organisms detected • Calculate sensitivity for real-time PCR on confirmed cases of Nm Statistical Methods

11. Results * One sample was lost during transport

12. Comparison of sample characteristics

13. Results * One sample was lost during transport No Neisseria meningitidiswasidentified!

14. LP after antibiotic therapy • Examined cases where LP followed antibiotic therapy • PCR was positive LP hours after antibiotics PCR (+) Culture (+) ≤ 12 hours 9/31 (29%) 5/31 (16%) > 12 hours 5/16 (31%) 7/16 (44%)* *Where the hospital identified an organism when LP was >24 hours after start of antibiotics (PCR and 16S both negative): • Pseudomonas aeruginosa • Corynebacterium • Enterobacter Suspected contaminants

15. We used cases where LP preceded antibiotic therapy • Culture is the “gold standard” Culture & PCR found same organism Culture (-) PCR (+) LP before antibiotic therapy: PCR Sensitivity and Specificity Culture & PCR negative Culture (+) PCR (-)

16. LP before antibiotic therapy: PCR Sensitivity and Specificity • Includes PCR for Streptococcus pneumoniae, Streptococcus agalactiae, Haemophilusinfluenzae, and Methicillin-resistant Staphylococcus aureus Real-time PCR yielded: • Sensitivity: 80% • Specificity: 89% Hospital Culture (+) Culture (-) PCR (+) WadsworthCenter PCR (-)

17. 135 Samples Obtained Tube Broken 1 Fungus/Virus 10 Concordant 96 Bacterial Organisms 23 Negative 73

18. 135 Samples Obtained Tube Broken 1 Fungus/Virus 10 Concordant 96 Bacterial Organisms 23 Negative 73

19. Hospital identified bacterial organisms detected by WC: Real-time PCR & 16S rRNA results

20. 135 Samples Obtained Tube Broken 1 Fungus/Virus 10 Discordant 28 Hosp (+) WC (+) 2 Hosp (+) WC (-) 12 Hosp (-) WC (+) 14

21. 135 Samples Obtained Tube Broken 1 Fungus/Virus 10 Discordant 28 Hosp (+) WC (+) 2 Hosp (+) WC (-) 12 Hosp (-) WC (+) 14

22. WC identified bacteria undetected by hospital culture

23. 135 Samples Obtained Tube Broken 1 Fungus/Virus 10 Discordant 28 Hosp (-) WC (+) 14 Hosp (+) WC (+) 2 Hosp (+) WC (-) 12

24. Hospital identified bacteria undetected by WC

25. 135 Samples Obtained Tube Broken 1 Fungus/Virus 10 Discordant 28 Hosp (-) WC (+) 14 Hosp (+) WC (+) 2 Hosp (+) WC (-) 12

26. Hospital and WC conflicting identifications

27. Confirmed cases of Nm during the interval were also sent for real-time PCR testing For confirmed cases of Nm • Real-timePCR yielded a sensitivity of 100% PCR (+) PCR (-) Culture (+) For other bacterial organisms • Real-timePCR yielded a sensitivity of 89% PCR Sensitivity PCR (+) PCR (-) Culture (+)

28. Nm was not found in any culture negative specimens • Bacterial organisms that were identified in this study • PCR sensitivity was: • 100% for confirmed Nm • 89% for other organisms Summary

29. PCR sensitivity and specificity for detecting organisms after antibiotic therapy • Length of time on antibiotics? Not enough samples> 24 hours to evaluate (n=10). • Contaminant species were suspected where the hospital positively identified an organism >24 hours • 16S rDNA sequencing • Is useful in identifying unusual organisms • 6 organisms identified by WC that hospital did not detect Discussion

30. Sample size • CSF availability & volume • Tube sent for PCR and 16S rRNA gene may not have been same as for culture • Specimen quality • Degradation of sample during transport to WC • 16S rRNA gene sequencing is usually performed on cultures • Performed on primary specimens; novel application of method Limitations

31. New York City’s surveillance system is effective at capturing cases of Nm meningitis • Due to the severe nature of the disease Nmdiagnoses should be rapid and comprehensive • The “gold standard” for Nm confirmation is a positive culture • However, can take 24 hours or longer for results • PCR testing is an effective method that could be utilized routinely Conclusion

32. PCR is currently available in research and state laboratories • Useful in cases where culture and Gram stain are negative or inconclusive • There is room for expansion of test in clinical settings • Further studies in a clinical setting need to be undertaken to establish real-time PCR and 16S rRNA gene: • Cost-effectiveness • Clinical utility Conclusion

33. Acknowledgements • Sally Slavinski • Anna Smorodina • James Yea • Alice Yeung • Tanya Halse • Kimberlee Musser • Lillian Lee • Jennifer Rakeman • Nellie Dumas • Elizabeth Nazarian • Danielle Wrobleowski • Michelle Dickinson • Don Weiss • Lola Arakaki • Linda Steiner-Sichel • Erlinda Amoroso • Mike Antwi • Paula Del Rosso • Marie Dorsinville • Prabhu Gounder • Marci Layton • Lan Li • Laura Miller

34. Thank you! Contact Information: Arianne Ramautar ar2568@nyu.edu