Blood culture-PCR to optimise typhoid fever diagnosis after controlled human infection identifies frequent asymptomatic cases and evidence of primary bacteraemia

• Published in: The Journal of infection Vol. 74; no. 4; pp. 358 - 366
• Main Authors: Darton, Thomas C, Zhou, Liqing, Blohmke, Christoph J, Jones, Claire, Waddington, Claire S, Baker, Stephen, Pollard, Andrew J
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.04.2017; W.B. Saunders
• Subjects: Adolescent; Adult; Asymptomatic Infections - epidemiology; Bacteremia - classification; Bacteremia - diagnosis; Bacteremia - microbiology; Blood Culture; Controlled human infection model; Culture Media - chemistry; Diagnostics; DNA, Bacterial - blood; Febrile disease; Female; Fever - etiology; Fever - microbiology; Healthy Volunteers; Humans; Infectious Disease; Male; Middle Aged; Polymerase chain reaction; Polymerase Chain Reaction - methods; Salmonella Typhi; Salmonella typhi - isolation & purification; Sensitivity and Specificity; Typhoid fever; Typhoid Fever - blood; Typhoid Fever - diagnosis; Young Adult; Polymerase chain reaction; Typhoid fever; Diagnostics; Febrile disease; Salmonella Typhi; Controlled human infection model
• ISSN: 0163-4453; 1532-2742
• DOI: 10.1016/j.jinf.2017.01.006

Summary Background Improved diagnostics for typhoid are needed; a typhoid controlled human infection model may accelerate their development and translation. Here, we evaluated a blood culture-PCR assay for detecting infection after controlled human infection with S . Typhi and compared test performance with optimally performed blood cultures. Methodology/Principal findings Culture-PCR amplification of blood samples was performed alongside daily blood culture in 41 participants undergoing typhoid challenge. Study endpoints for typhoid diagnosis (TD) were fever and/or bacteraemia. Overall, 24/41 (59%) participants reached TD, of whom 21/24 (86%) had ≥1 positive blood culture (53/674, 7.9% of all cultures) or 18/24 (75%) had ≥1 positive culture-PCR assay result (57/684, 8.3%). A further five non-bacteraemic participants produced culture-PCR amplicons indicating infection; overall sensitivity/specificity of the assay compared to the study endpoints were 70%/65%. We found no significant difference between blood culture and culture-PCR methods in ability to identify cases (12 mismatching pairs, p  = 0.77, binomial test). Clinical and stool culture metadata demonstrated that additional culture-PCR amplification positive individuals likely represented true cases missed by blood culture, suggesting the overall attack rate may be 30/41 (73%) rather than 24/41 (59%). Several participants had positive culture-PCR results soon after ingesting challenge providing new evidence for occurrence of an early primary bacteraemia. Conclusions/Significance Overall the culture-PCR assay performed well, identifying extra typhoid cases compared with routine blood culture alone. Despite limitations to widespread field-use, the benefits of increased diagnostic yield, reduced blood volume and faster turn-around-time, suggest that this assay could enhance laboratory typhoid diagnostics in research applications and high-incidence settings.