Diagnostic and Prognostic Biomarkers for Childhood Bacterial Pneumonia

Diagnostic and Prognostic Biomarkers for Childhood Bacterial Pneumonia in Sub-Saharan Africa

Clinical pneumonia is a leading cause of pediatric hospitalization. The etiology is generally bacterial or viral. Prompt and optimal treatment of pneumonia is critical to reduce mortality. However, adequate pneumonia management is hampered by: a) the lack of a diagnostic tool that can be used at point-of-care (POC) and promptly and accurately allow the diagnosis of bacterial disease and b) lack of a prognostic POC test to help triage children in need of intensive assistance. Antibiotic therapy is frequently overprescribed as a result of suspected bacterial infections resulting in development of antibiotic resistance. Conversely, in malaria-endemic areas, antibiotics may also be "underprescribed" and children with bacterial pneumonia sent home without antibiotic therapy, when the clinical pneumonia is mistakenly attributed to a co-existing malaria infection.

The investigators previously identified combinations of protein with 96% sensitivity and 86% specificity for detecting bacterial disease in Mozambican children with clinical pneumonia. The investigators' prior work showed that it is possible to identify biosignatures for diagnosis and prognosis using few proteins. Recently, other authors also identified different accurate biosignatures (e.g., IP-10, TRAIL and CRP).

In this study, the investigators propose to validate and improve upon previous biosignatures by testing prior combinations and seeking novel combinations of markers in 900 pediatric inpatients aged 2 months to 5 years with clinical pneumonia in The Gambia. The investigators will also use alternative case criteria and seek diagnostic and prognostic combination of markers. This study will be conducted in Basse, rural Gambia, in two hospitals associated with the Medical Research Council Unity The Gambia (MRCG). Approximately 900 pediatric patients with clinical pneumonia aged 2 months to 5 years of age will be enrolled. Patients will undergo standard of care test and will have blood proteins measured through Luminex®-based immunoassays.

Results of this study may ultimately support future development of an accurate point-of-care test for bacterial disease to guide clinicians in choices of treatment and to assist in the prioritization of intensive care in resource-limited settings.

Study Overview

• Status: Completed
• Conditions: Pneumonia, Bacterial; Malaria; Plasmodium Falciparum Malaria; Viral Infection; Infections, Respiratory; Clinical Pneumonia

• Study Type: Observational
• Enrollment (Actual): 837

Contacts and Locations

Study Locations

• Gambia
  • URR
    • Basse Santa Su, URR, Gambia
      • Basse Field Station, Medical Research Council Gambia Unit
• Netherlands
  • Utrecht, Netherlands, 3584
    • Laboratory of Transnational Immunology, UMC Utrecht
• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02118
      • Boston University School of Public Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 2 months to 5 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

This study will be enrolling children 2 month-5 years of age who seek treatment for clinical pneumonia at two hospitals in rural Gambia: Basse and Bansang hospitals

Description

Inclusion criteria Clinical Pneumonia Patients

In order to be eligible to participate in this study, an individual must meet all of the following criteria:

• Pediatric patients aged between 2 months and 5 years presenting at the screening sites with respiratory symptoms, i.e. cough or difficulty breathing AND
• One of the following: Increased respiratory rate for age OR indrawing OR SaO2 < 93% OR grunting OR MUAC < 11.5 if child is greater or equal than 6 months of age OR visible wasting AND
• Referred to clinician review for probable admission

Definition of increased respiratory rate (rr) for age based on the WHO criteria: respiratory rate (rr) > > 50 for 2-11 month old; rr > 40 for 1-5 years old.

Inclusion criteria Healthy Controls

• No symptoms or signs of any disease
• No malaria infection as detected by microscopy or RDT
• No history of clinical pneumonia or hospital admission

Exclusion criteria Clinical Pneumonia Patients

An individual who meets any of the following criteria will be excluded from participation in this study:

• Suspected tuberculosis based on history of cough lasting > 2 weeks
• Hospital admission in the previous 2 weeks.
• Children that show any evidence of other conditions that could be worsened by blood collection will be further excluded from this study.

Exclusion criteria Healthy Controls

• Having received a vaccine within the prior 4 weeks

Study Plan

How is the study designed?

Design Details

• Observational Models: Case-Control
• Time Perspectives: Prospective

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort
BA Group; The bacterial group: Patients will be assorted to this group if he/she has a bacterial pathogen culture of fluid from a normally sterile site (e.g. blood, pleural fluid)
VI Group; The viral group: Patients will be assigned to this group if they have negative bacteria microbiological tests, negative malaria blood slides, X-rays without "endpoint pneumonia", no evidence of fungal infection, and positive PCR for a viral pathogen from nasopharyngeal swabs.
MA Group; The malarial group: Patients will be assigned to this group if they have normal X-rays, no bacterial infection and >0 asexual P. falciparum parasites if they are aged < 1 year, or > 2,500 asexual parasites/µl of blood if they are aged > 1 year

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Definitive diagnosis of an invasive bacterial disease (versus viral and malarial infection)	A patient will be assigned to the bacterial (BA) group if he/she has a bacterial pathogen culture of fluid from a normally sterile site (e.g. blood, pleural fluid). Patients will be assigned to the viral (VI) group if they have negative bacteria microbiological tests, negative malaria blood slides, X-ray without "endpoint pneumonia" (consolidation or pleural effusion50), no evidence of fungal infection, and positive PCR for a viral pathogen from nasopharyngeal swabs. Patients will be assigned to the malarial (MA) group if they have normal X-ray (with neither infiltrates nor endpoint pneumonia), no bacterial infection and > 0 asexual P. falciparum parasites if they are aged < 1 year, or > 2,500 asexual parasites/µl of blood if they are aged > 1 year. Patients who are admitted with viral infections but who develop bacterial pneumonia during hospitalization will be excluded from VI	At admission
Poor prognosis of clinical pneumonia	Patients will be categorized in the following three groups based on a review of clinical records: a) children who die during or within the first 30 days from admission (all children that meet this criteria), b) children with prolonged hospital stay or who need to have antibiotic therapy changed within 48 hours of admission or who were re-admitted within 30 days from the first admission; and c) children discharged well within 3 days of admission and without the need for a change in antibiotic therapy after admission.	30 days from admission

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Probable bacterial pneumonia (versus viral pneumonia or severe malaria)	Based on the review of data by an expert panel, patients will be assigned to either: a) the probable bacterial group (BA) or the b) non bacterial group. Data to be reviewed by the panel will include chest X-ray, complete blood cell counts, other laboratory results, the clinical course during admission and following discharge. Children will be assigned to the non bacterial group (i.e, VI or MA) if they have X-ray without endpoint pneumonia, pleural effusion or infiltrates, do not have bacterial infection as per the algorithm for definitive diagnosis and are not classified as bacterial infection by the expert panel.	At admission
Oxygen saturation curve	Area under the first five days of the oxygen saturation curve. Oxygen saturation will be recorded daily in the morning in a follow-up form	Within the first 5 days of admission
Need to switch antibiotic therapy	All patients will be classified as either needing or not needing to switch within the first three days of hospitalization their antibiotic therapy prescribed at admission based on a follow-up form	Within the first 3 days of admission
Duration of hospital admission	The total length of hospital admission will be calculated in days for each patient based on the difference between the dates of discharge and admission.	Within 3 days of hospital discharge
Time to start feeding well	Time to feed well will be defined based on the child examination in the morning within the first 5 days of follow-up that will be recorded in a follow-up form	Within the first 5 days of admission

Collaborators and Investigators

• Sponsor: Boston University
• Collaborators: National Institute of Allergy and Infectious Diseases (NIAID); Medical Research Council Unit, The Gambia, LSTMH; Laboratory of Transnational Immunology, UMC Utrecht
• Investigators: Principal Investigator: Clarissa Valim, MD ScD, Boston University; Principal Investigator: Patricia Hibberd, MD PhD, Boston University

Study record dates

Study Major Dates

• Study Start (Actual): February 11, 2019
• Primary Completion (Actual): April 10, 2021
• Study Completion (Actual): April 10, 2021

Study Registration Dates

• First Submitted: June 20, 2019
• First Submitted That Met QC Criteria: June 23, 2019
• First Posted (Actual): June 25, 2019

Study Record Updates

• Last Update Posted (Actual): May 31, 2022
• Last Update Submitted That Met QC Criteria: May 26, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Keywords: Children; Sub-Saharan Africa; Point-of-care test; Prognostic Biomarkers; Biosignature proteins; Luminex®-based immunoassays; Diagnostic Biomarkers; Mediators of Inflammation
• Additional Relevant MeSH Terms: Pathologic Processes; Respiratory Tract Diseases; Lung Diseases; Disease Attributes; Vector Borne Diseases; Bacterial Infections; Bacterial Infections and Mycoses; Parasitic Diseases; Protozoan Infections; Infections; Communicable Diseases; Virus Diseases; Pneumonia; Malaria; Respiratory Tract Infections; Pneumonia, Bacterial; Malaria, Falciparum
• Other Study ID Numbers: H-38462; R21AI140258-01 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No