1
|
Pei PP, Fitzmaurice KP, Le MH, Panella C, Jones ML, Pandya A, Horsburgh CR, Freedberg KA, Weinstein MC, Paltiel AD, Reddy KP. The Value-of-Information and Value-of-Implementation from Clinical Trials of Diagnostic Tests for HIV-Associated Tuberculosis: A Modeling Analysis. MDM Policy Pract 2023; 8:23814683231198873. [PMID: 37743931 PMCID: PMC10517616 DOI: 10.1177/23814683231198873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives. Conventional value-of-information (VOI) analysis assumes complete uptake of an optimal decision. We employed an extended framework that includes value-of-implementation (VOM)-the benefit of encouraging adoption of an optimal strategy-and estimated how future trials of diagnostic tests for HIV-associated tuberculosis could improve public health decision making and clinical and economic outcomes. Methods. We evaluated the clinical outcomes and costs, given current information, of 3 tuberculosis screening strategies among hospitalized people with HIV in South Africa: sputum Xpert (Xpert), sputum Xpert plus urine AlereLAM (Xpert+AlereLAM), and sputum Xpert plus the newer, more sensitive, and costlier urine FujiLAM (Xpert+FujiLAM). We projected the incremental net monetary benefit (INMB) of decision making based on results of a trial comparing mortality with each strategy, rather than decision making based solely on current knowledge of FujiLAM's improved diagnostic performance. We used a validated microsimulation to estimate VOI (the INMB of reducing parameter uncertainty before decision making) and VOM (the INMB of encouraging adoption of an optimal strategy). Results. With current information, adopting Xpert+FujiLAM yields 0.4 additional life-years/person compared with current practices (assumed 50% Xpert and 50% Xpert+AlereLAM). While the decision to adopt this optimal strategy is unaffected by information from the clinical trial (VOI = $ 0 at $3,000/year-of-life saved willingness-to-pay threshold), there is value in scaling up implementation of Xpert+FujiLAM, which results in an INMB (representing VOM) of $650 million over 5 y. Conclusions. Conventional VOI methods account for the value of switching to a new optimal strategy based on trial data but fail to account for the persuasive value of trials in increasing uptake of the optimal strategy. Evaluation of trials should include a focus on their value in reducing barriers to implementation. Highlights In conventional VOI analysis, it is assumed that the optimal decision will always be adopted even without a trial. This can potentially lead to an underestimation of the value of trials when adoption requires new clinical trial evidence. To capture the influence that a trial may have on decision makers' willingness to adopt the optimal decision, we also consider value-of-implementation (VOM), a metric quantifying the benefit of new study information in promoting wider adoption of the optimal strategy. The overall value-of-a-trial (VOT) includes both VOI and VOM.Our model-based analysis suggests that the information obtained from a trial of screening strategies for HIV-associated tuberculosis in South Africa would have no value, when measured using traditional methods of VOI assessment. A novel strategy, which includes the urine FujiLAM test, is optimal from a health economic standpoint but is underutilized. A trial would reduce uncertainties around downstream health outcomes but likely would not change the optimal decision. The high VOT (nearly $700 million over 5 y) lies solely in promoting uptake of FujiLAM, represented as VOM.Our results highlight the importance of employing a more comprehensive approach for evaluating prospective trials, as conventional VOI methods can vastly underestimate their value. Trialists and funders can and should assess the VOT metric instead when considering trial designs and costs. If VOI is low, the VOM and cost of a trial can be compared with the benefits and costs of other outreach programs to determine the most cost-effective way to improve uptake.
Collapse
Affiliation(s)
- Pamela P. Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mylinh H. Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle L. Jones
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - C. Robert Horsburgh
- School of Public Health and School of Medicine, Boston University, Boston, MA, USA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - A. David Paltiel
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT, USA
| | - Krishna P. Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
2
|
So C, Ling L, Wong WT, Zhang JZ, Ho CM, Ng PY, Shum HP, Yeung AWT, Sin KC, Chan J, Au KF, Liong T, Ho E, Chow FL, Ho L, Chan KM, Joynt GM. Population study on diagnosis, treatment and outcomes of critically ill patients with tuberculosis in Hong Kong (2008-2018). Thorax 2022:thorax-2022-218868. [PMID: 35981883 DOI: 10.1136/thorax-2022-218868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/17/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tuberculosis (TB) is a preventable and curable disease, but mortality remains high among those who develop sepsis and critical illness from TB. METHODS This was a population-based, multicentre retrospective cohort study of patients admitted to all 15 publicly funded Hong Kong adult intensive care units (ICUs) between 1 April 2008 and 31 March 2019. 940 adult critically ill patients with at least one positive Mycobacterium tuberculosis (MTB) culture were identified out of 133 858 ICU admissions. Generalised linear modelling was used to determine the impact of delay in TB treatment on hospital mortality. Trend of annual Acute Physiology and Chronic Health Evaluation (APACHE) IV-adjusted standardised mortality ratio (SMR) over the 11-year period was analysed by Mann-Kendall's trend test. RESULTS ICU and hospital mortality were 24.7% (232/940) and 41.1% (386/940), respectively. Of those who died in the ICU, 22.8% (53/232) never received antituberculosis drugs. SMR for ICU patients with TB remained unchanged over the study period (Kendall's τb=0.37, p=0.876). After adjustment for age, Charlson comorbidity index, APACHE IV, albumin, vasopressors, mechanical ventilation and renal replacement therapy, delayed TB treatment was directly associated with hospital mortality. In 302/940 (32.1%) of patients, TB could only be established from MTB cultures alone as Ziehl-Neelsen staining or PCR was either not performed or negative. Among this group, only 31.1% (94/302) had concurrent MTB PCR performed. CONCLUSIONS Survival of ICU patients with TB has not improved over the last decade and mortality remains high. Delay in TB treatment was associated with higher hospital mortality. Use of MTB PCR may improve diagnostic yield and facilitate early treatment.
Collapse
Affiliation(s)
- Christina So
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Jack Zhenhe Zhang
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Chun Ming Ho
- Department of Intensive Care, Tuen Mun Hospital, Hong Kong, China.,Department of Intensive Care, Pok Oi Hospital, New Territories, Hong Kong SAR, China
| | - Pauline Yeung Ng
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.,Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - Hoi Ping Shum
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Alwin Wai Tak Yeung
- Department of Medicine and Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals, Hong Kong SAR, China
| | - Kai Cheuk Sin
- Department of Intensive Care, Queen Elizabeth Hospital, Hong Kong, China
| | - Jacky Chan
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong, China
| | - Ka Fai Au
- Department of Intensive Care, Kwong Wah Hospital, Hong Kong, China
| | - Ting Liong
- Department of Intensive Care, United Christian Hospital, Hong Kong, China
| | - Eunise Ho
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong, China.,Department of Intensive Care, Yan Chai Hospital, Hong Kong, Hong Kong, China
| | - Fu Loi Chow
- Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong, China
| | - Laptin Ho
- Department of Intensive Care, North District Hospital, Hong Kong, China
| | - Kai Man Chan
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| |
Collapse
|
3
|
Said B, Nuwagira E, Liyoyo A, Arinaitwe R, Gitige C, Mushagara R, Buzaare P, Chongolo A, Jjunju S, Twesigye P, Boulware DR, Conaway M, Null M, Thomas TA, Heysell SK, Moore CC, Muzoora C, Mpagama SG. Early empiric anti- Mycobacterium tuberculosis therapy for sepsis in sub-Saharan Africa: a protocol of a randomised clinical trial. BMJ Open 2022; 12:e061953. [PMID: 35667721 PMCID: PMC9171283 DOI: 10.1136/bmjopen-2022-061953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa shoulders the highest burden of global sepsis and associated mortality. In high HIV and tuberculosis (TB) prevalent settings such as sub-Saharan Africa, TB is the leading cause of sepsis. However, anti-TB therapy is often delayed and may not achieve adequate blood concentrations in patients with sepsis. Accordingly, this multisite randomised clinical trial aims to determine whether immediate and/or increased dose anti-TB therapy improves 28-day mortality for participants with HIV and sepsis in Tanzania or Uganda. METHODS AND ANALYSIS This is a phase 3, multisite, open-label, randomised controlled clinical 2×2 factorial superiority trial of (1) immediate initiation of anti-TB therapy and (2) sepsis-specific dose anti-TB therapy in addition to standard of care antibacterials for adults with HIV and sepsis admitted to hospital in Tanzania or Uganda. The primary endpoint is 28-day mortality. A sample size of 436 participants will provide 80% power for testing each of the main effects of timing and dose on 28-day mortality with a two-sided significance level of 5%. The expected main effect for absolute risk reduction is 13% and the expected OR for risk reduction is 1.58. ETHICS AND DISSEMINATION This clinical trial will determine the optimal content, dosing and timing of antimicrobial therapy for sepsis in high HIV and TB prevalent settings. The study is funded by the National Institutes of Health in the US. Institutional review board approval was conferred by the University of Virginia, the Tanzania National Institute for Medical Research, and the Uganda National Council for Science and Technology. Study results will be published in peer-reviewed journals and in the popular press of Tanzania and Uganda. We will also present our findings to the Community Advisory Boards that we convened during study preparation. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT04618198).
Collapse
Affiliation(s)
- Bibie Said
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Edwin Nuwagira
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Alphonce Liyoyo
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Rinah Arinaitwe
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Catherine Gitige
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Rhina Mushagara
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Buzaare
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anna Chongolo
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| | - Samuel Jjunju
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Precious Twesigye
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David R Boulware
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - Mark Conaway
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Megan Null
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher C Moore
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Conrad Muzoora
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stellah G Mpagama
- Department of Medicine, Kibong'oto Infectious Diseases Hospital, Sanya Juu, United Republic of Tanzania
| |
Collapse
|
4
|
Bresges C, Wilson D, Fielding K, Corbett EL, Del-Greco F, Grint D, Peters J, Gupta-Wright A. Early Empirical Tuberculosis Treatment in HIV-Positive Patients Admitted to Hospital in South Africa: An Observational Cohort Study. Open Forum Infect Dis 2021; 8:ofab162. [PMID: 34327252 PMCID: PMC8314941 DOI: 10.1093/ofid/ofab162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Empirical tuberculosis (TB) treatment in human immunodeficiency virus (HIV)-positive inpatients is common and may undermine the impact of new diagnostics. We sought to describe empirical TB treatment and compare characteristics and outcomes with patients treated for TB after screening. METHODS This was a retrospective observational cohort study of HIV-positive inpatients treated empirically for TB prior to TB screening. Data on clinical characteristics, investigations, and outcomes were collected from medical records. Comparison cohorts with microbiologically confirmed or empirical TB treatment after TB screening with Xpert MTB/RIF and urine lipoarabinomannan assays were taken from South African Screening for Tuberculosis to Reduce AIDS-Related Mortality in Hospitalized Patients in Africa (STAMP) trial site. In-hospital mortality was compared using a competing-risks analysis adjusted for age, sex, and CD4 cell count. RESULTS Between January 2016 and September 2017, 100 patients excluded from STAMP were treated for TB empirically prior to TB screening. After enrollment in STAMP and TB screening, 240 of 1177 (20.4%) patients received TB treatment, of whom 123 had positive TB tests and 117 were treated empirically. Characteristics were similar among early empirically treated patients and those treated after TB screening. 50% of early empirical TB treatment was based on radiological investigations, 22% on cerebrospinal or pleural fluid testing, and 28% on clinical features alone. Only 11 of 100 empirically treated patients had subsequent microbiological confirmation. In-hospital mortality was lower in patients with microbiologically confirmed TB compared to those treated empirically (adjusted subdistribution hazard ratio, 0.5 [95% confidence interval, .3-.9). CONCLUSIONS Empirical TB treatment remains common in severely ill HIV-positive inpatients. These patients may benefit from TB screening using existing rapid diagnostics, both to improve confirmation of TB disease and reduce overtreatment for TB.
Collapse
Affiliation(s)
- Carolin Bresges
- Global Health and Infection Department, Brighton and Sussex Medical School, Brighton, United Kingdom.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizabeth L Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Fabrizia Del-Greco
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel Grint
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jurgens Peters
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Institute for Global Health, University College London, London, United Kingdom
| |
Collapse
|
5
|
Reddy KP, Denkinger CM, Broger T, McCann NC, Gupta-Wright A, Kerkhoff AD, Pei PP, Shebl FM, Fielding KL, Nicol MP, Horsburgh CR, Meintjes G, Freedberg KA, Wood R, Walensky RP. Cost-effectiveness of a novel lipoarabinomannan test for tuberculosis in patients with HIV. Clin Infect Dis 2020; 73:e2077-e2085. [PMID: 33200169 PMCID: PMC8492225 DOI: 10.1093/cid/ciaa1698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/13/2020] [Indexed: 02/03/2023] Open
Abstract
Background A novel urine lipoarabinomannan assay (FujiLAM) has higher sensitivity and higher cost than the first-generation AlereLAM assay. We evaluated the cost-effectiveness of FujiLAM for tuberculosis testing among hospitalized people with human immunodeficiency virus (HIV), irrespective of symptoms. Methods We used a microsimulation model to project clinical and economic outcomes of 3 testing strategies: (1) sputum Xpert MTB/RIF (Xpert), (2) sputum Xpert plus urine AlereLAM (Xpert+AlereLAM), (3) sputum Xpert plus urine FujiLAM (Xpert+FujiLAM). The modeled cohort matched that of a 2-country clinical trial. We applied diagnostic yields from a retrospective study (yields for Xpert/Xpert+AlereLAM/Xpert+FujiLAM among those with CD4 <200 cells/µL: 33%/62%/70%; among those with CD4 ≥200 cells/µL: 33%/35%/47%). Costs of Xpert/AlereLAM/FujiLAM were US$15/3/6 (South Africa) and $25/3/6 (Malawi). Xpert+FujiLAM was considered cost-effective if its incremental cost-effectiveness ratio (US$/year-of-life saved) was <$940 (South Africa) and <$750 (Malawi). We varied key parameters in sensitivity analysis and performed a budget impact analysis of implementing FujiLAM countrywide. Results Compared with Xpert+AlereLAM, Xpert+FujiLAM increased life expectancy by 0.2 years for those tested in South Africa and Malawi. Xpert+FujiLAM was cost-effective in both countries. Xpert+FujiLAM for all patients remained cost-effective compared with sequential testing and CD4-stratified testing strategies. FujiLAM use added 3.5% (South Africa) and 4.7% (Malawi) to 5-year healthcare costs of tested patients, primarily reflecting ongoing HIV treatment costs among survivors. Conclusions FujiLAM with Xpert for tuberculosis testing in hospitalized people with HIV is likely to increase life expectancy and be cost-effective at the currently anticipated price in South Africa and Malawi. Additional studies should evaluate FujiLAM in clinical practice settings.
Collapse
Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Nicole C McCann
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Ankur Gupta-Wright
- Division of Infection and Immunity, University College London, London, United Kingdom.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Pamela P Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark P Nicol
- Infection and Immunity, University of Western Australia, Perth, Australia
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Graeme Meintjes
- Department of Medicine, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Chopra A, Avadhani V, Tiwari A, Riemer EC, Sica G, Judson MA. Granulomatous lung disease: clinical aspects. Expert Rev Respir Med 2020; 14:1045-1063. [PMID: 32662705 DOI: 10.1080/17476348.2020.1794827] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Granulomatous lung diseases (GLD) are heterogeneous group of diseases that can be broadly categorized as infectious or noninfectious. This distinction is extremely important, as the misdiagnosis of a GLD can have serious consequences. In this manuscript, we describe the clinical manifestations, histopathology, and diagnostic approach to GLD. We propose an algorithm to distinguish infectious from noninfectious GLD. AREAS COVERED We have searched PubMed and Medline database from 1950 to December 2019, using multiple keywords as described below. Major GLDs covered include those caused by mycobacteria and fungi, sarcoidosis, hypersensitivity pneumonitis, and vasculidities. EXPERT OPINION The cause of infectious GLD is usually identified through microbiological culture and molecular techniques. Most noninfectious GLD are diagnosed by clinical and laboratory criteria, often with exclusion of infectious pathogens. Further understanding of the immunopathogenesis of the granulomatous response may allow improved diagnosis and treatment of GLD.
Collapse
Affiliation(s)
- Amit Chopra
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center , NY, USA
| | - Vaidehi Avadhani
- Department of Pathology and Laboratory Medicine, Emory University , Atlanta, USA
| | - Anupama Tiwari
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center , NY, USA
| | - Ellen C Riemer
- Department of Pathology, Medical University of South Carolina , SC, USA
| | - Gabriel Sica
- Department of Pathology and Laboratory Medicine, Emory University , Atlanta, USA
| | - Marc A Judson
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center , NY, USA
| |
Collapse
|
7
|
Kebede W, Abebe G, Gudina EK, De Vos E, Riviere E, Van Rie A. Role of empiric treatment in hospitalized patients with Xpert MTB/RIF-negative presumptive pulmonary tuberculosis: A prospective cohort study. Int J Infect Dis 2020; 97:30-37. [PMID: 32526390 DOI: 10.1016/j.ijid.2020.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The ability of clinical algorithms to identify tuberculosis disease and the impact of empiric treatment on survival in people with a negative Xpert MTB/RIF (Xpert) result remains poorly documented. METHODS Hospitalized Xpert-negative patients (125 initiated on empiric tuberculosis treatment based on a clinical algorithm and 125 in whom tuberculosis treatment was not started) were enrolled. Sputum samples were evaluated for Mycobacterium tuberculosis by culture. All study participants were followed up for 6 months. RESULTS Xpert-negative inpatients in whom empiric tuberculosis treatment was initiated were more likely to have microbiological confirmed tuberculosis compared to those in whom empiric tuberculosis treatment was not started (24.8% vs 6.4%, p=0.0001). Six-month risk of death was 5.2%, but the risk was twice as high in people with bacteriological confirmation of TB (10.3% vs 4.3%, p=0.12). Cardinal symptoms of TB were associated with bacteriological confirmation and a decision to start empiric treatment. The positive predictive value of the clinical algorithm was 24.8% and empiric treatment did not affect 6-month risk of death (5.6% vs 4.8%, p=0.78). CONCLUSIONS Clinical algorithm identifies the majority of confirmed tuberculosis cases among Xpert-negative inpatients. Empiric treatment did not impact survival and resulted in substantial overtreatment. The more sensitive Xpert Ultra assay should be used to eliminate the need for empiric tuberculosis treatment.
Collapse
Affiliation(s)
- Wakjira Kebede
- Mycobacteriology Research Center, Jimma University, Ethiopia; School of Medical Laboratory Science, Institute of Health, Jimma University, PO Box 378, Ethiopia; Department of Epidemiology and Social Medicine, Faculty of Medicine and Health sciences, University of Antwerp, Antwerp, Belgium.
| | - Gemeda Abebe
- Mycobacteriology Research Center, Jimma University, Ethiopia; School of Medical Laboratory Science, Institute of Health, Jimma University, PO Box 378, Ethiopia.
| | - Esayas Kebede Gudina
- Department of Internal Medicine, Jimma University Medical Center, Jimma University, Ethiopia.
| | - Elise De Vos
- Department of Epidemiology and Social Medicine, Faculty of Medicine and Health sciences, University of Antwerp, Antwerp, Belgium.
| | - Emmanuel Riviere
- Department of Epidemiology and Social Medicine, Faculty of Medicine and Health sciences, University of Antwerp, Antwerp, Belgium.
| | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, Faculty of Medicine and Health sciences, University of Antwerp, Antwerp, Belgium.
| |
Collapse
|
8
|
Moore CC, Jacob ST, Banura P, Zhang J, Stroup S, Boulware DR, Scheld WM, Houpt ER, Liu J. Etiology of Sepsis in Uganda Using a Quantitative Polymerase Chain Reaction-based TaqMan Array Card. Clin Infect Dis 2020; 68:266-272. [PMID: 29868873 DOI: 10.1093/cid/ciy472] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/31/2018] [Indexed: 01/08/2023] Open
Abstract
Background Knowledge of causes of sepsis in sub-Saharan Africa is limited. A better understanding of the microbiology of bloodstream infections could improve outcomes. Methods We used a quantitative polymerase chain reaction (qPCR)-based TaqMan Array Card (TAC) to directly test for 43 targets from whole blood. We analyzed 336 cryopreserved specimens from adult Ugandans with sepsis enrolled in a multisite study; 84% were infected with human immunodeficiency virus. We compared qPCR TAC results with blood culture and determined the association of qPCR with study participant outcomes using logistic regression. Results The most frequently detected targets were cytomegalovirus (CMV, n = 139, 41%), Mycobacterium tuberculosis (TB, n = 70, 21%), Plasmodium (n = 35, 10%), and Streptococcus pneumoniae (n = 31, 9%). Diagnostic performance varied by target with qPCR sensitivity averaging 61 ± 28% and specificity 98 ± 3% versus culture. In multivariable analysis, independent factors associated with in-hospital mortality included CMV viremia (adjusted odds ratio [aOR] 3.2, 95% confidence interval [CI], 1.8-5.5; p < .01) and TB qPCR-positivity, whether blood culture-positive (aOR 4.6, 95% CI, 2.1-10.0; p < .01) or blood culture-negative (aOR 2.9, 95% CI, 1.2-6.9; p = .02). Conclusions Using qPCR TAC on direct blood specimens, CMV and TB were the most commonly identified targets and were independently associated with increased in-hospital mortality. qPCR TAC screening of blood for multiple targets may be useful to guide triage and treatment of sepsis in sub-Saharan Africa.
Collapse
Affiliation(s)
- Christopher C Moore
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | | | - Patrick Banura
- Ministry of Health, National Disease Control Department, Kampala, Uganda
| | - Jixian Zhang
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Suzanne Stroup
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis
| | - W Michael Scheld
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| |
Collapse
|
9
|
Griesel R, Stewart A, van der Plas H, Sikhondze W, Rangaka MX, Nicol MP, Kengne AP, Mendelson M, Maartens G. Optimizing Tuberculosis Diagnosis in Human Immunodeficiency Virus-Infected Inpatients Meeting the Criteria of Seriously Ill in the World Health Organization Algorithm. Clin Infect Dis 2019; 66:1419-1426. [PMID: 29126226 DOI: 10.1093/cid/cix988] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/03/2017] [Indexed: 11/15/2022] Open
Abstract
Background The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill human immunodeficiency virus (HIV)-infected patients lacks a firm evidence base. We aimed to develop a clinical prediction rule for the diagnosis of tuberculosis and to determine the diagnostic utility of the Xpert MTB/RIF assay in seriously ill HIV-infected patients. Methods We conducted a prospective study among HIV-infected inpatients with any cough duration and WHO-defined danger signs. Culture-positive tuberculosis from any site was the reference standard. A priori selected variables were assessed for univariate associations with tuberculosis. The most predictive variables were assessed in a multivariate logistic regression model and used to establish a clinical prediction rule for diagnosing tuberculosis. Results We enrolled 484 participants. The median age was 36 years, 65.5% were female, the median CD4 count was 89 cells/µL, and 35.3% were on antiretroviral therapy. Tuberculosis was diagnosed in 52.7% of participants. The c-statistic of our clinical prediction rule (variables: cough ≥14 days, unable to walk unaided, temperature >39°C, chest radiograph assessment, hemoglobin, and white cell count) was 0.811 (95% confidence interval, .802-.819). The classic tuberculosis symptoms (fever, night sweats, weight loss) added no discriminatory value in diagnosing tuberculosis. Xpert MTB/RIF assay sensitivity was 86.3% and specificity was 96.1%. Conclusions Our clinical prediction rule had good diagnostic utility for tuberculosis among seriously ill HIV-infected inpatients. Xpert MTB/RIF assay, incorporated into the updated 2016 WHO algorithm, had high sensitivity and specificity in this population. Our findings could facilitate improved diagnosis of tuberculosis among seriously ill HIV-infected inpatients in resource-constrained settings.
Collapse
Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, University of Cape Town, South Africa
| | - Annemie Stewart
- Division of Clinical Pharmacology, University of Cape Town, South Africa
| | - Helen van der Plas
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, South Africa
| | - Welile Sikhondze
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, South Africa
| | - Molebogeng X Rangaka
- Department of Medicine, University of Cape Town, South Africa.,Institute of Global Health, Department of Infection and Population Health, University College London, United Kingdom.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service of South Africa, Cape Town, South Africa
| | - Andre P Kengne
- Department of Medicine, University of Cape Town, South Africa.,Medical Research Council, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, University of Cape Town, South Africa
| |
Collapse
|
10
|
Marcy O, Borand L, Ung V, Msellati P, Tejiokem M, Huu KT, Do Chau V, Ngoc Tran D, Ateba-Ndongo F, Tetang-Ndiang S, Nacro B, Sanogo B, Neou L, Goyet S, Dim B, Pean P, Quillet C, Fournier I, Berteloot L, Carcelain G, Godreuil S, Blanche S, Delacourt C. A Treatment-Decision Score for HIV-Infected Children With Suspected Tuberculosis. Pediatrics 2019; 144:e20182065. [PMID: 31455612 DOI: 10.1542/peds.2018-2065] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Diagnosis of tuberculosis should be improved in children infected with HIV to reduce mortality. We developed prediction scores to guide antituberculosis treatment decision in HIV-infected children with suspected tuberculosis. METHODS HIV-infected children with suspected tuberculosis enrolled in Burkina Faso, Cambodia, Cameroon, and Vietnam (ANRS 12229 PAANTHER 01 Study), underwent clinical assessment, chest radiography, Quantiferon Gold In-Tube (QFT), abdominal ultrasonography, and sample collection for microbiology, including Xpert MTB/RIF (Xpert). We developed 4 tuberculosis diagnostic models using logistic regression: (1) all predictors included, (2) QFT excluded, (3) ultrasonography excluded, and (4) QFT and ultrasonography excluded. We internally validated the models using resampling. We built a score on the basis of the model with the best area under the receiver operating characteristic curve and parsimony. RESULTS A total of 438 children were enrolled in the study; 251 (57.3%) had tuberculosis, including 55 (12.6%) with culture- or Xpert-confirmed tuberculosis. The final 4 models included Xpert, fever lasting >2 weeks, unremitting cough, hemoptysis and weight loss in the past 4 weeks, contact with a patient with smear-positive tuberculosis, tachycardia, miliary tuberculosis, alveolar opacities, and lymph nodes on the chest radiograph, together with abdominal lymph nodes on the ultrasound and QFT results. The areas under the receiver operating characteristic curves were 0.866, 0.861, 0.850, and 0.846, for models 1, 2, 3, and 4, respectively. The score developed on model 2 had a sensitivity of 88.6% and a specificity of 61.2% for a tuberculosis diagnosis. CONCLUSIONS Our score had a good diagnostic performance. Used in an algorithm, it should enable prompt treatment decision in children with suspected tuberculosis and a high mortality risk, thus contributing to significant public health benefits.
Collapse
Affiliation(s)
- Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia;
- Centre INSERM U1219, Bordeaux Population Health, University of Bordeaux, Bordeaux, France
| | - Laurence Borand
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Vibol Ung
- Tuberculosis and HIV Department, National Pediatric Hospital, Phnom Penh, Cambodia
- University of Health Sciences, Phnom Penh, Cambodia
| | - Philippe Msellati
- UMI 233-U1175 TransVIHMI, IRD, Université de Montpellier, Montpellier, France
| | - Mathurin Tejiokem
- Service d'Epidémiologie et de Santé Publique, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon
| | - Khanh Truong Huu
- Infectious Disease Department, Pediatric Hospital Nhi Dong 1, Ho Chi Minh City, Vietnam
| | - Viet Do Chau
- Infectious Disease Department, Pediatric Hospital Nhi Dong 2, Ho Chi Minh City, Vietnam
| | - Duong Ngoc Tran
- Pediatric Department, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | | | | | - Boubacar Nacro
- Service de Pédiatrie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Bintou Sanogo
- Service de Pédiatrie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
| | | | - Sophie Goyet
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Bunnet Dim
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Polidy Pean
- Immunology Laboratory, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Catherine Quillet
- ANRS Research Site, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | | | | | - Guislaine Carcelain
- Immunologie Biologique, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | - Sylvain Godreuil
- Département de Bactériologie-Virologie, Hôpital Arnaud de Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Stéphane Blanche
- Unité d'Immunologie Hématologie Rhumatologie Pédiatrique, Hôpital Necker Enfants Malades and
| | | |
Collapse
|
11
|
Prabhu S, Harwell JI, Kumarasamy N. Advanced HIV: diagnosis, treatment, and prevention. Lancet HIV 2019; 6:e540-e551. [PMID: 31285181 DOI: 10.1016/s2352-3018(19)30189-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/06/2019] [Accepted: 05/17/2019] [Indexed: 11/25/2022]
Abstract
Substantial progress has been made this century in bringing millions of people living with HIV into care, but progress for early HIV diagnosis has stalled. Individuals first diagnosed with advanced HIV have higher rates of mortality than those diagnosed at an earlier stage even after starting antiretroviral therapy (ART), resulting in substantial costs to health systems. Diagnosis of these individuals is hindered because many patients are asymptomatic, despite being severely immunosuppressed. Baseline CD4 counts and screening for opportunistic infections, such as tuberculosis and cryptococcus, is crucial because of the high mortality associated with these co-infections. Individuals with advanced HIV should have rapid ART initiation (except when found to have symptoms, signs, or a diagnosis of cryptococcal meningitis) and those in treatment failure should switch treatment. Overcoming barriers to testing and adherence through the development of differentiated care models and providing psychosocial support will be key in reaching populations at high risk of presenting with advanced HIV.
Collapse
Affiliation(s)
- Sandeep Prabhu
- University of California, San Diego School of Medicine, La Jolla, CA, USA
| | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, Voluntary Health Services, Chennai, India.
| |
Collapse
|
12
|
Hazard RH, Kagina P, Kitayimbwa R, Male K, McShane M, Mubiru D, Welikhe E, Moore CC, Abdallah A. Effect of Empiric Anti- Mycobacterium tuberculosis Therapy on Survival Among Human Immunodeficiency Virus-Infected Adults Admitted With Sepsis to a Regional Referral Hospital in Uganda. Open Forum Infect Dis 2019; 6:ofz140. [PMID: 31024977 PMCID: PMC6475587 DOI: 10.1093/ofid/ofz140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background Mycobacterium tuberculosis is the leading cause of bloodstream infection among human immunodeficiency virus (HIV)–infected patients with sepsis in sub-Saharan Africa and is associated with high mortality rates. Methods We conducted a retrospective study of HIV-infected adults with sepsis at the Mbarara Regional Referral Hospital in Uganda to measure the proportion who received antituberculosis therapy and to determine the relationship between antituberculosis therapy and 28-day survival. Results Of the 149 patients evaluated, 74 (50%) had severe sepsis and 48 (32%) died. Of the 55 patients (37%) who received antituberculosis therapy, 19 (35%) died, compared with 29 of 94 (31%) who did not receive such therapy (odds ratio, 1.34; 95% confidence interval [CI], .56–3.18; P = .64). The 28-day survival rates did not differ significantly between these 2 groups (log-rank test, P = .21). Among the 74 patients with severe sepsis, 9 of 26 (35%) who received antituberculosis therapy died, versus 23 of 48 (48%) who did not receive such therapy (odds ratio, 0.58; 95% CI, .21–1.52; P = .27). In patients with severe sepsis, antituberculosis therapy was associated with an improved 28-day survival rate (log-rank test P = .01), and with a reduced mortality rate in a Cox proportional hazards model (hazard ratio, 0.32; 95% CI, .13–.80; P = .03). Conclusions Empiric antituberculosis therapy was associated with improved survival rates among patients with severe sepsis, but not among all patients with sepsis.
Collapse
Affiliation(s)
- Riley H Hazard
- University of Melbourne, School of Population and Global Health, Australia
| | - Peninah Kagina
- Mbarara University of Science and Technology, Department of Medicine, Uganda
| | - Richard Kitayimbwa
- Mbarara University of Science and Technology, Department of Medicine, Uganda
| | - Keneth Male
- Mbarara University of Science and Technology, Department of Medicine, Uganda
| | - Melissa McShane
- Temple University, Department of Medicine, Division of Hematology and Oncology, Philadelphia, Pennsylvania.,University of Virginia, Department of Medicine, Division of Infectious Diseases, Charlottesville
| | - Dennis Mubiru
- Mbarara University of Science and Technology, Department of Medicine, Uganda
| | - Emma Welikhe
- Mbarara University of Science and Technology, Department of Medicine, Uganda
| | - Christopher C Moore
- Mbarara University of Science and Technology, Department of Medicine, Uganda.,University of Virginia, Department of Medicine, Division of Infectious Diseases, Charlottesville
| | - Amir Abdallah
- Mbarara University of Science and Technology, Department of Medicine, Uganda.,Mayo Clinic Phoenix, Department of Neurology, Arizona
| |
Collapse
|
13
|
Huerga H, Ferlazzo G, Wanjala S, Bastard M, Bevilacqua P, Ardizzoni E, Sitienei J, Bonnet M. Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis. BMC Infect Dis 2019; 19:132. [PMID: 30744603 PMCID: PMC6369550 DOI: 10.1186/s12879-019-3775-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/04/2019] [Indexed: 01/20/2023] Open
Abstract
Background Empirical treatment of tuberculosis (TB) may be necessary in patients with negative or no Xpert MTB/RIF results. In a context with access to Xpert, we assessed mortality in the 6 months after the initial TB consultation among HIV-positive and HIV-negative patients who received empirical TB treatment or TB treatment based on bacteriological confirmation and we compared it with the mortality among those who did not receive TB treatment. Methods This prospective cohort study included consecutively adult patients with signs and symptoms of TB attending an outpatient TB clinic in Western Kenya. At the first consultation, patients received a clinical exam and chest X-ray. Sputum was collected for microscopy, Xpert and Mycobacterium tuberculosis complex (MTB) culture. Patients not started on TB treatment were reassessed after 5 days. All patients bacteriologically confirmed (positive Xpert or culture) received TB treatment. Empirical treatment was defined as a decision to start TB treatment without bacteriological confirmation. Patients were reassessed after 6 months. Results Of 606 patients included, 344/606 (56.8%) were women. Median age was 35 years [Interquartile Range (IQR):27–47] and 398/594 (67.0%) were HIV-positive. In total, 196/606 (32.3%) patients were Xpert- or culture-positive and 331/606 (54.6%) started TB treatment. Overall, 100/398 (25.1%) HIV-positive and 31/196 (15.8%) HIV-negative patients received empirical treatment. Mortality in the 6 months following the first consultation was 1.6 and 0.8/100 patient-months among HIV-positive and HIV-negative patients respectively. In the multivariate analyses, TB treatment - whether empirical or based on bacteriological confirmation- was not associated with increased mortality among HIV-positive patients (aHR:2.51, 95%CI:0.79–7.90 and aHR:1.25, 95%CI:0.37–4.21 respectively). However, HIV-negative patients who received empirical treatment had a higher risk of mortality (aHR:4.85, 95%CI:1.08–21.67) compared to those not started on treatment. HIV-negative patients treated for TB based on bacteriological confirmation did not have a different risk of mortality (aHR:0.77, 95%CI:0.08–7.41). Conclusions Our findings suggest that in a context with access to Xpert, clinicians should continue using empirical TB treatment in HIV-positive patients with signs and symptoms of TB and negative Xpert results. However, differential diagnoses other than TB should be actively sought before initiating empirical TB treatment, particularly in HIV-negative patients.
Collapse
Affiliation(s)
| | | | | | | | | | - Elisa Ardizzoni
- Médecins Sans Frontières, Paris, France.,Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Maryline Bonnet
- Epicentre, Paris, France.,IRD UMI 233 TransVIHMI - UM - INSERM U1175, Montpellier, France
| |
Collapse
|
14
|
Maze MJ, Bassat Q, Feasey NA, Mandomando I, Musicha P, Crump JA. The epidemiology of febrile illness in sub-Saharan Africa: implications for diagnosis and management. Clin Microbiol Infect 2018; 24:808-814. [PMID: 29454844 PMCID: PMC6057815 DOI: 10.1016/j.cmi.2018.02.011] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/08/2018] [Accepted: 02/10/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fever is among the most common symptoms of people living in Africa, and clinicians are challenged by the similar clinical features of a wide spectrum of potential aetiologies. AIM To summarize recent studies of fever aetiology in sub-Saharan Africa focusing on causes other than malaria. SOURCES A narrative literature review by searching the MEDLINE database, and recent conference abstracts. CONTENT Studies of multiple potential causes of fever are scarce, and for many participants the infecting organism remains unidentified, or multiple co-infecting microorganisms are identified, and establishing causation is challenging. Among ambulatory patients, self-limiting arboviral infections and viral upper respiratory infections are common, occurring in up to 60% of children attending health centres. Among hospitalized patients there is a high prevalence of potentially fatal infections requiring specific treatment. Bacterial bloodstream infection and bacterial zoonoses are major causes of fever. In recent years, the prevalence of antimicrobial resistance among bacterial isolates has increased, notably with spread of extended spectrum β-lactamase-producing Enterobacteriaceae and fluoroquinolone-resistant Salmonella enterica. Among those with human immunodeficiency virus (HIV) infection, Mycobacterium tuberculosis bacteraemia has been confirmed in up to 34.8% of patients with sepsis, and fungal infections such as cryptococcosis and histoplasmosis remain important. IMPLICATIONS Understanding the local epidemiology of fever aetiology, and the use of diagnostics including malaria and HIV rapid-diagnostic tests, guides healthcare workers in the management of patients with fever. Current challenges for clinicians include assessing which ambulatory patients require antibacterial drugs, and identifying hospitalized patients infected with organisms that are not susceptible to empiric antibacterial regimens.
Collapse
Affiliation(s)
- M J Maze
- Centre for International Health, University of Otago, New Zealand; Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Q Bassat
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; ICREA, Pg. Lluís Companys 23, Barcelona, Spain; Paediatric Infectious Diseases Unit, Paediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
| | - N A Feasey
- Liverpool School of Tropical Medicine, Liverpool, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - I Mandomando
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - P Musicha
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - J A Crump
- Centre for International Health, University of Otago, New Zealand; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Tumaini University, Moshi, Tanzania
| |
Collapse
|
15
|
Griesel R, Stewart A, van der Plas H, Sikhondze W, Mendelson M, Maartens G. Prognostic indicators in the World Health Organization's algorithm for seriously ill HIV-infected inpatients with suspected tuberculosis. AIDS Res Ther 2018; 15:5. [PMID: 29433509 PMCID: PMC5808414 DOI: 10.1186/s12981-018-0192-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Criteria for the 2007 WHO algorithm for diagnosing tuberculosis among HIV-infected seriously ill patients are the presence of one or more danger signs (respiratory rate > 30/min, heart rate > 120/min, temperature > 39 °C, and being unable to walk unaided) and cough ≥ 14 days. Determining predictors of poor outcomes among HIV-infected inpatients presenting with WHO danger signs could result in improved treatment and diagnostic algorithms. METHODS We conducted a prospective cohort study of inpatients presenting with any duration of cough and WHO danger signs to two regional hospitals in Cape Town, South Africa. The primary outcome was all-cause mortality up to 56 days post-discharge, and the secondary outcome a composite of any one of: hospital admission for > 7 days, died in hospital, transfer to a tertiary level or tuberculosis hospital. We first assessed the WHO danger signs as predictors of poor outcomes, then assessed the added value of other variables selected a priori for their ability to predict mortality in common respiratory opportunistic infections (CD4 count, body mass index (BMI), being on antiretroviral therapy (ART), hypotension, and confusion) by comparing the receiver operating characteristic (ROC) area under the curve (AUC) of the two multivariate models. RESULTS 484 participants were enrolled, median age 36, 66% women, 53% had tuberculosis confirmed on culture. The 56-day mortality was 13.2%. Inability to walk unaided, low BMI, low CD4 count, and being on ART were independently associated with poor outcomes. The multivariate model of the WHO danger signs showed a ROC AUC of 0.649 (95% CI 0.582-0.717) for predicting 56-day mortality, which improved to ROC AUC of 0.740 (95% CI 0.681-0.800; p = 0.004 for comparison between the two ROC AUCs) with the multivariate model including the a priori selected variables. Findings were similar in sub-analyses of participants with culture-positive tuberculosis and with cough duration ≥ 14 days. CONCLUSION The study design prevented a rigorous evaluation of the prognostic value of the WHO danger signs. Our prognostic model could result in improved algorithms, but needs to be validated.
Collapse
Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Annemie Stewart
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Helen van der Plas
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Welile Sikhondze
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| |
Collapse
|
16
|
Sabur NF, Esmail A, Brar MS, Dheda K. Diagnosing tuberculosis in hospitalized HIV-infected individuals who cannot produce sputum: is urine lipoarabinomannan testing the answer? BMC Infect Dis 2017; 17:803. [PMID: 29282005 PMCID: PMC5745979 DOI: 10.1186/s12879-017-2914-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 12/13/2017] [Indexed: 12/03/2022] Open
Abstract
Background Up to one third of HIV-infected individuals with suspected TB are sputum-scarce. The Alere Determine™ TB LAM Ag lateral flow strip test can be used to diagnose TB in HIV-infected patients with advanced immunosuppression. However, how urine LAM testing should be incorporated into testing algorithms and in the context of specific patient sub-groups remains unclear. Methods This study represents a post hoc sub-group analysis of data from a randomized multi-center parent study. The study population consisted of hospitalized HIV-infected patients with suspected TB who were unable to produce sputum and who underwent urine LAM testing. The diagnostic utility of urine LAM for TB in this group was compared to the performance of urine LAM in patients who did produce a sputum sample in the parent study. Results There were a total of 187 and 2341 patients in the sputum-scarce and sputum-producing cohorts, respectively. 80 of the sputum-scarce patients underwent testing with urine LAM. In comparison to those who did produce sputum, sputum-scarce patients had a younger age, a lower Karnofsky performance score, and a lower weight and BMI at admission. A greater proportion of sputum-scarce patients were urine LAM positive, compared to those who were able to produce sputum (31% vs. 21%, p = 0.04). A higher proportion of sputum-scarce patients died within 8 weeks of admission (32% vs. 24%, p = 0.013). We inferred that 19% of HIV-infected sputum-scarce patients suspected of TB were diagnosed with tuberculosis by urine LAM testing, with an estimated positive predictive value of 63% (95% CI 43–82%). Conclusions Urine LAM testing can effectively identify tuberculosis in HIV-infected patients who are at a higher risk of mortality yet are unable to generate a sputum sample for diagnostic testing. Our findings support the use of urine LAM testing in sputum-scarce hospitalized HIV-infected patients, and its incorporation into diagnostic algorithms for this patient population.
Collapse
Affiliation(s)
- Natasha F Sabur
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa.,Division of Respirology, Department of Medicine, St. Michael's Hospital and West Park Healthcare Centre, University of Toronto, Toronto, Canada
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa
| | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa. .,Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
17
|
Marcy O, Tejiokem M, Msellati P, Truong Huu K, Do Chau V, Tran Ngoc D, Nacro B, Ateba-Ndongo F, Tetang-Ndiang S, Ung V, Dim B, Neou L, Berteloot L, Borand L, Delacourt C, Blanche S. Mortality and its determinants in antiretroviral treatment-naive HIV-infected children with suspected tuberculosis: an observational cohort study. Lancet HIV 2017; 5:e87-e95. [PMID: 29174612 DOI: 10.1016/s2352-3018(17)30206-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/01/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tuberculosis is a major cause of morbidity and mortality in HIV-infected children, but is difficult to diagnose. We studied mortality and its determinants in antiretroviral treatment (ART)-naive HIV-infected children presenting with suspected tuberculosis. METHODS In this observational cohort study, HIV-infected children aged 13 years or younger with suspected tuberculosis were followed up for 6 months as part of the ANRS 12229 PAANTHER 01 cohort in eight hospitals in four countries (Burkina Faso, Cambodia, Cameroon, and Vietnam). Children started ART and antituberculosis treatment at the clinician's discretion and were retrospectively classified into one of three groups by tuberculosis documentation: confirmed by culture or Xpert MTB/RIF, unconfirmed, and unlikely. We assessed mortality and associated factors using Kaplan-Meier methods and Cox proportional hazard models. The ANRS 12229 PAANTHER 01 study is registered at ClinicalTrials.gov, number NCT01331811. FINDINGS 266 (61%) of 438 children enrolled in the study between April 27, 2011, and May 31, 2014, were ART-naive and included in the analysis (40 had confirmed tuberculosis, 119 unconfirmed tuberculosis, and 107 unlikely tuberculosis). 112·5 person-years of follow-up were available. 154 children (58%) started antituberculosis treatment and 212 (80%) started ART. 50 children (19%) died. Mortality by 6 months was higher in children with confirmed tuberculosis (14 deaths; 2 month survival probability 65·0% [95% CI 50·2-79·8]) compared with unconfirmed tuberculosis (19 deaths; 83·5% [76·8-90·3]) and unlikely tuberculosis (17 deaths; 83·5% [76·3-90·7]; log-rank p=0·0141) and was lower in children with confirmed or unconfirmed tuberculosis who started antituberculosis treatment (p<0·0001 for both). In a multivariate analysis, ART started during the first month of follow-up (hazard ratio 0·08; 95% CI 0·01-0·67), confirmed tuberculosis (6·33; 2·15-18·64), young age (5·90; 2·02-17·19), CD4 less than 10% (2·63; 1·25-5·53), miliary features (4·08; 1·56-10·66), and elevated serum transaminases (4·40; 1·82-10·65) were all independently associated with mortality. INTERPRETATION In our cohort, mortality was high in the first 6 months after suspicion of tuberculosis in ART-naive children. ART should be started early, particularly in children with factors associated with high mortality. Documented or empirical tuberculosis treatment decision should be accelerated to reduce mortality and allow early ART initiation. FUNDING ANRS and Fondation Total.
Collapse
Affiliation(s)
- Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia; Bordeaux Population Health Centre U1219, Université de Bordeaux, Bordeaux, France.
| | - Mathurin Tejiokem
- Service d'Epidémiologie et de Santé Publique, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon
| | - Philippe Msellati
- UMI 233-U1175 TransVIHMI, Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France
| | - Khanh Truong Huu
- Infectious Disease Department, Pediatric Hospital Nhi Dong 1, Ho Chi Minh City, Vietnam
| | - Viet Do Chau
- Infectious Disease Department, Pediatric Hospital Nhi Dong 2, Ho Chi Minh City, Vietnam
| | - Duong Tran Ngoc
- Pediatric Department, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Boubacar Nacro
- Service de Pédiatrie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
| | | | | | - Vibol Ung
- Tuberculosis/HIV Department, National Pediatric Hospital, Phnom Penh, Cambodia; Planning and Research Department, University of Health Sciences, Phnom Penh, Cambodia
| | - Bunnet Dim
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Leakhena Neou
- Neonatal Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Laureline Berteloot
- Pediatric Radiology Department, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Laurence Borand
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Christophe Delacourt
- Service de Pneumologie et d'Allergologie Pédiatriques, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Stéphane Blanche
- Unité d'Immunologie Hématologie Rhumatologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | | |
Collapse
|
18
|
Cummings MJ, Goldberg E, Mwaka S, Kabajaasi O, Vittinghoff E, Katamba A, Cattamanchi A, Kenya-Mugisha N, Davis JL, Jacob ST. The sixth vital sign: HIV status assessment and severe illness triage in Uganda. Public Health Action 2017; 7:245-250. [PMID: 29584800 DOI: 10.5588/pha.17.0045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 08/27/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: Four in-patient health facilities in western Uganda. Objective: To determine the impact of an innovative multi-modal quality improvement program on human immunodeficiency virus (HIV) status assessment and the impact of HIV status on severe illness conditions and mortality. Design: This was a staggered, pre-post quasi-experimental study designed to assess a multi-modal intervention (collaborative improvement meetings, audit and feedback, clinical mentoring) for improving quality of care following formal training in the management of severe illness in low-income settings. Results: From August 2014 to May 2015, 5759 patients were hospitalized, of whom 2451 (42.6%) had their HIV status assessed; 395 (16.1%) were HIV-infected. HIV-infected patients were significantly more likely to meet criteria for shock (27.5% vs. 15.1%, risk ratio [RR] 1.8, 95% confidence interval [CI] 1.7-1.9, P < 0.001) and severe respiratory distress (6.7% vs. 4.3%, RR 1.5, 95%CI 1.2-2.0, P < 0.001), and were significantly more likely to die in hospital (12.0% vs. 2.9%, RR 4.1, 95%CI 3.2-5.4, P < 0.001). There was no evidence of improved HIV status assessment during the intervention period (36.5% vs. 44.8%, +8.3%, 95%CI -8.3 to 24.8, P = 0.33). Conclusions: Hospitalized HIV-infected patients in western Uganda are at high risk for severe illness and death. Novel quality improvement strategies are needed to enhance hospital-based HIV testing in high-burden settings.
Collapse
Affiliation(s)
- M J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - E Goldberg
- ImpactMatters, New York, New York, USA.,Walimu, Kampala, Uganda
| | | | | | - E Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - A Katamba
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - A Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | | | - J L Davis
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA.,Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - S T Jacob
- Walimu, Kampala, Uganda.,Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington, USA
| |
Collapse
|
19
|
Hermans SM, Babirye JA, Mbabazi O, Kakooza F, Colebunders R, Castelnuovo B, Sekaggya-Wiltshire C, Parkes-Ratanshi R, Manabe YC. Treatment decisions and mortality in HIV-positive presumptive smear-negative TB in the Xpert™ MTB/RIF era: a cohort study. BMC Infect Dis 2017; 17:433. [PMID: 28622763 PMCID: PMC5473987 DOI: 10.1186/s12879-017-2534-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/07/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The Xpert™ MTB/RIF (XP) has a higher sensitivity than sputum smear microscopy (70% versus 35%) for TB diagnosis and has been endorsed by the WHO for TB high burden countries to increase case finding among HIV co-infected presumptive TB patients. Its impact on the diagnosis of smear-negative TB in a routine care setting is unclear. We determined the change in diagnosis, treatment and mortality of smear-negative presumptive TB with routine use of Xpert MTB/RIF (XP). METHODS Prospective cohort study of HIV-positive smear-negative presumptive TB patients during a 12-month period after XP implementation in a well-staffed and trained integrated TB/HIV clinic in Kampala, Uganda. Prior to testing clinicians were asked to decide whether they would treat empirically prior to Xpert result; actual treatment was decided upon receipt of the XP result. We compared empirical and XP-informed treatment decisions and all-cause mortality in the first year. RESULTS Of 411 smear-negative presumptive TB patients, 175 (43%) received an XP; their baseline characteristics did not differ. XP positivity was similar in patients with a pre-XP empirical diagnosis and those without (9/29 [17%] versus 14/142 [10%], P = 0.23). Despite XP testing high levels of empirical treatment prevailed (18%), although XP results did change who ultimately was treated for TB. When adjusted for CD4 count, empirical treatment was not associated with higher mortality compared to no or microbiologically confirmed treatment. CONCLUSIONS XP usage was lower than expected. The lower sensitivity of XP in smear-negative HIV-positive patients led experienced clinicians to use XP as a "rule-in" rather than "rule-out" test, with the majority of patients still treated empirically.
Collapse
Affiliation(s)
- Sabine M Hermans
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda.
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
| | - Juliet A Babirye
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Olive Mbabazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Robert Colebunders
- Institute for Tropical Medicine, University of Antwerp, Antwerp, Belgium
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | | | - Rosalind Parkes-Ratanshi
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| |
Collapse
|
20
|
Monedero I, Bhavaraju R, Mendoza-Ticona A, Sánchez-Montalvá A. The paradigm shift to end tuberculosis. Are we ready to assume the changes? Expert Rev Respir Med 2017; 11:565-579. [PMID: 28562103 DOI: 10.1080/17476348.2017.1335599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is the number one infectious disease killer and exemplifies the most neglected of them. Drug-susceptible TB presents with high mortality especially in atypical forms, disproportionally affecting immunosuppressed and vulnerable populations. The drug-resistant TB (DR-TB) epidemic, a world crisis, is sustained and increased through person-to-person transmission in households and the community. TB diagnostics and treatment in recent years are highly evolving fields. New rapid molecular tests are changing the perspectives in diagnosis and resistance screening. Also, new drugs and shorter regimens for DR-TB are appearing. For the first time in recent history, a large number of randomized control trials are incoming. Areas covered: This article reviews most TB advances including new diagnostic tests, drugs, and regimens and outlines upcoming drug trials while disclosing the potential gaps the in development of patient-centered systems and current organizational challenges leading to a delay in the uptake of these innovations. Expert commentary: Innovations are occurring, but not many are implemented on a wide scale in developing countries. TB health systems and staff are not getting updated in parallel. More efforts and funds are needed not only to implement current novelties but also to research for future solutions to eliminate TB.
Collapse
Affiliation(s)
- Ignacio Monedero
- a TB-HIV Department. International Union against Tuberculosis and Lung Disease (The Union) , Paris , France
| | - Rajita Bhavaraju
- b Global Tuberculosis Institute, Rutgers, The State University of New Jersey , Newark , NJ , USA
| | - Alberto Mendoza-Ticona
- a TB-HIV Department. International Union against Tuberculosis and Lung Disease (The Union) , Paris , France.,c Clinical Research Department , Asociación Civil IMPACTA , Lima , Peru
| | - Adrián Sánchez-Montalvá
- d Infectious diseases department, Tropical Medicine Unit, PROCIS (International Health Program of the Catalan Health Institute) , Vall d'Hebron University Hospital,Universistat Autònoma de Barcelona , Barcelona , Spain
| |
Collapse
|
21
|
Nicol MP. How should tuberculosis molecular diagnostics be adapted for use in seriously ill HIV patients? Expert Rev Mol Diagn 2016; 16:1237-1239. [PMID: 27820959 DOI: 10.1080/14737159.2016.1257386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mark P Nicol
- a Division of Medical Microbiology, Department of Pathology and Institute for Infectious Diseases and Molecular Medicine , University of Cape Town and National Health Laboratory Service , Cape Town , South Africa
| |
Collapse
|
22
|
Manabe YC, Worodria W, van Leth F, Mayanja-Kizza H, Traore AN, Ferro J, Pakker N, Frank M, Grobusch MP, Colebunders R, Cobelens F. Prevention of Early Mortality by Presumptive Tuberculosis Therapy Study: An Open Label, Randomized Controlled Trial. Am J Trop Med Hyg 2016; 95:1265-1271. [PMID: 27928077 DOI: 10.4269/ajtmh.16-0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 08/25/2016] [Indexed: 01/09/2023] Open
Abstract
Early mortality after initiation of antiretroviral therapy (ART) occurs in 9-39% of patients in sub-Saharan Africa. A significant proportion of deaths are attributable to tuberculosis (TB). Low baseline CD4 T-cell count and low body mass index (BMI) are strongly associated with early mortality. We hypothesized that initiation of ART concurrent with presumptive anti-TB chemotherapy in high-risk patients would reduce mortality within the first 6 months by treating unrecognized TB. From October 2011 to December 2012, ART-naive, smear-negative participants with a CD4 T-cell count < 50 cells/μL and BMI < 18 kg/m2 were randomly assigned to undergo either empiric four-drug anti-TB treatment followed 2 weeks later by efavirenz-based ART (N = 23) (ART + TB) or ART only (N = 20). This open-label, 1:1 randomized, controlled trial took place in Uganda, Mozambique, and Gabon and was stopped prematurely by the sponsor for slow recruitment. Overall, the 43 participants had a median CD4 of 22 (interquartile range [IQR]: 9-35) cells/μL and a median BMI of 17.5 (IQR: 16.6-18.0) kg/m2 The mortality was 14% (95% confidence interval [CI]: 5.3-27.9); two (10.0%) participants (ART-only group), and four (17.4%; ART + TB group). The associated hazard ratio (HR) for all-cause mortality was 1.6 (95% CI: 0.30-8.90). Despite limited enrollment, the study did not suggest that empiric TB treatment in severely immunosuppressed patients with low BMI decreased mortality and, had an HR in the opposite direction than expected. Notably, two participants in the ART + TB group died with autopsy-confirmed drug-induced hepatotoxicity. Improved TB diagnostics sensitive in immunosuppressed patients presenting late to care are urgently needed for more targeted interventions.
Collapse
Affiliation(s)
- Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda. .,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William Worodria
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Frank van Leth
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Harriet Mayanja-Kizza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Afsatou Ndama Traore
- Centre de Récherches Medicales en Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon.,Department of Microbiology, University of Venda, Thohoyandou, South Africa
| | - Josefo Ferro
- Catholic University of Mozambique, Beira, Mozambique
| | - Nadine Pakker
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Matthias Frank
- Centre de Récherches Medicales en Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Martin P Grobusch
- Centre de Récherches Medicales en Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert Colebunders
- Institute of Tropical Medicine, Antwerp, Belgium.,Global Health Institute, University of Antwerp, Belgium
| | - Frank Cobelens
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.,KNCV Tuberculosis Foundation, The Hague, The Netherlands
| |
Collapse
|