Title: Development and Implementation of a Point-of-Care Pharmacogenetic Test to Avoid Antibiotic Related Hearing Loss in Neonates
Funder: Department of Health and Social Care

Abstract: This 24 month project will encompass two stages (Figure 1): an analytical validation of the point of care test (POCT) before a clinical implementation of the technology. Pre-Clinical Stage The genetic PoCT that we have designed to detect the mitochondrial variant associated with antibiotic hearing loss is based on a similar CE marked product developed by our industry partner, Genedrive which predicts response to hepatitis treatment. We have developed a prototype assay which uses asymmetrical PCR to amplify the target before identifying genotype status via melt-curve analysis. Initial validation indicates that this PoCT can generate a result in Year one of the project will focus on the refinement and analytical validation of the assay and include; Lyophilisation. Our prototype uses wet reagents. The lyophilisation process provides standardisation of the assay and ensures stability of the reagents, allowing the products to be stored on a ward at room temperature for a protracted period. Validate the assay against our &ldquo;Gold-Standard&rdquo; pyrosequencing methodology. We can source multiple &ldquo;positive&rdquo; samples from our patient cohort. We have extensive experience of validating rare genetic variant tests for diagnostic use and led the European guidance on this validation. Stability testing. Ensuring that the product remains robust across a protracted time at different temperatures. Modification of the Genedrive unit, allowing patient identifiers to be inputted, ensuring that the product is compatible with NHS PoCT guidelines. CE Marking. The above data will be used to achieve CE marking by the completion of year 1. Clinical Stage The assay will be validated in year 1 before being implemented into clinical practice in year 2. During year 1, we will design guidelines for use of the system and seek approval for retrospective consent given the emergency setting for the assay use. A &ldquo;positive&rdquo; result should change prescribing behaviour and it is critical that systems are in place to ensure alternative antibiotic guidelines are readily available and genetic follow up for extended family members is provided. Training to use the PoCT will be provided and all NICU clinicians and nurses will be involved in this programme. Multiple Genedrive units will be placed at the two NICU sites and the assay will be undertaken on babies during the admission process. As the assay will have been validated in year 1, we would use an effectiveness trial design. We will measure uptake and implementation of the assay, monthly for the first two months then bi-monthly thereafter. Specifically, we will undertake; Analysis of Genedrive Data. We will assess the results from the Genedrive units, determining the number of patients who are tested as a proportion of the NICU population. Direct Observation. A research nurse will be employed as part of the project who will directly observe use of the assay in the NICU and post-natal ward. Formalised Questionnaires and Interviews. We will ask staff to complete standardised questionnaires at 0, 2 and 6 months of the clinical stage to assess their understanding and familiarity with use of the technology. Formalised interviews will also be completed to understand how the assay is being used. We will collect use and outcome data to inform an economic cost consequences analysis. All the above measures will be used to inform continuing improvement of the assay and its utilisation in an iterative process. After 18 months, we expect to have a robust PoCT to detect the m.1555A>G variant validated and integrated within the admission process at two large NICUs. The final 6 months will be used to draw up guidelines for clinical implementation and undertake a program of dissemination and engage with commissioners and stakeholders.

Lay abstract: The problem: Gentamicin is an antibiotic that is routinely used to treat or protect against infection in over 95% of babies admitted to special care baby units within one hour of arrival. Some children have a genetic change that means they will suffer severe hearing loss or total deafness after a single dose of gentamicin. Approximately 1 in 500 people have this genetic change. Groups with a higher risk of repeated chest infections throughout their lives i.e. people with cystic fibrosis, are routinely tested for this genetic change. The current test takes at least three days for results. Newborn babies need to be treated with antibiotics within one hour of arriving in the special care baby unit. The current genetic test that checks their risk of hearing loss associated with gentamicin treatment is therefore unsuitable. The need is therefore to identify a more immediate way of checking genetic susceptibility. A possible solution: We have developed a quicker way to test for the defective gene. This new test involves swabbing the inside of the cheek and it can be done on newborn babies. The test can deliver a reliable test result in 40 minutes. However more extensive checks need to be done before it can be used more widely. The research study therefore aims to test the new genetic sampling methodology and the equipment in two large special care baby units. The aim is to improve the test so it can be used with newborn babies as quickly as possible to give reliable and accurate results that will indicate if the child can or cannot (a safe alternative can be used) be treated with gentamicin, and therefore reduce the risk of deafness. Impact: This test will ensure that no baby will go deaf unnecessarily due to inappropriate antibiotic treatment.

Research activity codes: 4.1 DISCOVERY AND PRECLINICAL TESTING OF MARKERS AND TECHNOLOGIES;4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: INFECTION;EAR;REPRODUCTIVE HEALTH AND CHILDBIRTH