The Department of Endocrinology, 
A multifaceted intervention to improve diagnosis and early management of hospitalised patients with suspected acute brain infections in Brazil, India, and Malawi: an international multicentre intervention study.
- Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
- Christian Medical College, Vellore, Tamil Nadu, India
- Liverpool School of Tropical Medicine, Liverpool, UK.
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
- Christian Medical College, Vellore, Tamil Nadu, India.
- National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India.
- Department of Sociology, Federal University of Pernambuco, Recife, Brazil
- Oswaldo Cruz Foundation Pernambuco, Recife, Brazil.
- Department of Clinical Medicine, Federal University of Pernambuco, Recife, Brazil
- Hospital das Clinicas, Recife, Brazil
- Autoimmune Research Institute, Recife, Brazil.
- Department of Neurology, Hospital da Restauração, Recife, Brazil.
- Institute of Population Health, University of Liverpool, Liverpool, UK.
- Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK.
- Department of Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India.
- National Institute of Health and Care Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK.
- Kamuzu University of Health Sciences, Blantyre, Malawi.
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi.
- National Institute of Health and Care Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- The Pandemic Institute, Liverpool, UK.
- Sri Devaraj Urs Academy of Higher Education and Research, Kolar, India
- Sri Devaraj Urs Medical College, Kolar, India
- R L Jalappa Hospital, Kolar, India.
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Psychiatry, University of Oxford, Oxford, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
- Laboratory of Arboviruses and Haemorrhagic Viruses, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
- Brain Health Unit, World Health Organization, Geneva, Switzerland.
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK.
- Hospital Correia Picanço, Recife, Brazil.
- Encephalitis International, Malton, UK.
- Liverpool School of Tropical Medicine, Liverpool, UK
- Alder Hey Children's Hospital, Liverpool, UK
- Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Bangor, UK.
- University of Birmingham, Birmingham, UK.
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- The Walton Centre NHS Foundation Trust, Liverpool, UK.
- Centre for Child and Adolescent Health Research, University of Sydney, Sydney, NSW, Australia.
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- The Pandemic Institute, Liverpool, UK. Electronic address: tsolomon@liverpool.ac.uk.
Lancet (London, England) Vol. 405 · Issue 10483 · pp. 991-1003
PMID 40081400 DOI 10.1016/s0140-6736(25)00263-6
Cite This Article
Bhagteshwar Singh, Gareth D Lipunga, Premkumar Thangavelu, Shalley Dhar, Lorena Ferreira Cronemberger, Kundavaram Paul Prabhakar Abhilash, Asha Mary Abraham, Carlos Alexandre Antunes de Brito, Maria Lúcia Brito Ferreira, Nagarathna Chandrashekar, Rui Duarte, Anna Fajardo Modol, Ben Chirag Ghale, Gagandeep Kang, Vykuntaraju K Gowda, Kevin Kuriakose, Suzannah Lant, Macpherson Mallewa, Emmie Mbale, Shona C Moore, Gloria Mwangalika, Prasanna B T Kamath, Patricia Navvuga, Alinane Linda Nyondo-Mipando, Tamara J Phiri, Camila Pimentel Lopes de Melo, B S Pradeep, Rebecca Rawlinson, Irene Sheha, Priya Treesa Thomas, Charles R Newton, Patricia Carvalho de Sequeira, James J Sejvar, Tarun Dua, Lance Turtle, Valsan Philip Verghese, Luciano Wagner de Melo Santiago Arraes, Nicola Desmond, Ava Easton, Jessica Anne Jones, Richard J Lilford, M Netravathi, Fiona McGill, Benedict D Michael, Victor Mwapasa, Michael J Griffiths, Christopher M Parry, Vasanthapuram Ravi, Girvan Burnside, Jennifer Cornick, Rafael Freitas de Oliveira França, Anita S Desai, Priscilla Rupali, Tom Solomon. A multifaceted intervention to improve diagnosis and early management of hospitalised patients with suspected acute brain infections in Brazil, India, and Malawi: an international multicentre intervention study. Lancet (London, England). 2025;405(10483):991-1003. doi:10.1016/s0140-6736(25)00263-6
Abstract
BACKGROUND: Brain infections pose substantial challenges in diagnosis and management and carry high mortality and morbidity, especially in low-income and middle-income countries. We aimed to improve the diagnosis and early management of patients admitted to hospital (adults aged 16 years and older and children aged >28 days) with suspected acute brain infections at 13 hospitals in Brazil, India, and Malawi.
METHODS: With hospital stakeholders, policy makers, and patient and public representatives, we co-designed a multifaceted clinical and laboratory intervention, informed by an evaluation of routine practice. The intervention, tailored for each setting, included a diagnostic and management algorithm, a lumbar puncture pack, a testing panel, and staff training. We used multivariable logistic regression and interrupted time series analysis to compare the coprimary outcomes-the percentage of patients achieving a syndromic diagnosis and the percentage achieving a microbiological diagnosis before and after the intervention. The study was registered at ClinicalTrials.gov (NCT04190303) and is complete.
FINDINGS: Between Jan 5, 2021, and Nov 30, 2022, we screened 10 462 patients and enrolled a total of 2233 patients at 13 hospital sites connected to the four study centres in Brazil, India, and Malawi. 1376 (62%) were recruited before the intervention and 857 (38%) were recruited after the intervention. 2154 patients (96%) had assessment of the primary outcome (1330 [62%] patients recruited pre-intervention and 824 [38%] recruited post-intervention). The median age across centres was 23 years (IQR 6-44), with 1276 (59%) being adults aged 16 years or older and 888 (41%) children aged between 29 days and 15 years; 1264 (59%) patients were male and 890 (41%) were female. Data on race and ethnicity were not recorded. 1020 (77%) of 1320 patients received a syndromic diagnosis before the intervention, rising to 701 (86%) of 813 after the intervention (adjusted odds ratio [aOR] 1·81 [95% CI 1·40-2·34]; p
INTERPRETATION: Diagnosis and management of patients with suspected acute brain infections improved following introduction of a simple intervention package across a diverse range of hospitals on three continents. The intervention is now being implemented in other settings as part of the WHO Meningitis Roadmap and encephalitis control initiatives.
FUNDING: UK National Institute for Health and Care Research.
Keywords
- Adolescent
- Adult
- Child
- Child
- Preschool
- Female
- Humans
- Infant
- Male
- Middle Aged
- Young Adult
- Acute Disease
- Brazil
- Hospitalization
- India
- Malawi
- Spinal Puncture
- Brain Diseases
- Interrupted Time Series Analysis
- Logistic Models
