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Baruch Baluku J, Musaazi J, Mulwana R, Bengo D, Sekaggya Wiltshire C, Andia-Biraro I. Sensitivity and specificity of the mean corpuscular volume and CD4/CD8 ratio in discriminating between rifampicin resistant and rifampicin sensitive tuberculosis. J Clin Tuberc Other Mycobact Dis 2020; 21:100205. [PMID: 33294630 PMCID: PMC7695869 DOI: 10.1016/j.jctube.2020.100205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background There is need for simple, cost effective and widely available point of care tests for low level health facilities in developing countries to screen for drug resistant tuberculosis (TB) after bacteriological confirmation of TB by smear microscopy. We evaluated the sensitivity and specificity of the mean corpuscular volume (MCV) and CD4/CD8 ratio in discriminating between rifampicin resistant (RR-TB) and rifampicin sensitive (RS-TB) tuberculosis. Methods We performed a secondary analysis of data from a cross sectional study that enrolled adult participants with bacteriologically confirmed pulmonary TB at a national tuberculosis treatment center in Uganda. Blood samples were tested for CD4 and CD8 cell counts, HIV serology and a full hemogram. Rifampicin sensitivity and the bacillary load grade were determined by Xpert MTB/RIF®. Fifty-five participants that had RR-TB (cases) were matched with 110 participants that had RS-TB (controls) for age, sex and HIV status in a ratio of 1:2 respectively. Sensitivity (Se), specificity (Sp), area under curve (AUC) analysis and determination of optimal cut-offs were performed using receiver operating characteristic curves. Results Cases differed from controls with respect to residence (p = 0.031), bacillary load grade (p < 0.010) and MCV (p = 0.021). The Se, Sp and AUC of the MCV (cut-off of > 74.6 femtolitres (fl)) were 88.9%, 34% and 0.607 (p = 0.021) respectively for RR-TB. Among HIV positive participants, the respective Se, Sp and AUC of the MCV for RR-TB (cut-off of > 72.5 fl) were 97.2%, 22.2% and 0.608 (p = 0.061). The respective Se, Sp and AUC of the CD4/CD8 ratio (cut-off of > 0.40) were 67.3%, 50.0% and 0.559 (p = 0.199) on the overall and 54.1%, 71.6% and 0.628 (p = 0.024) among the HIV positive participants for RR-TB. Conclusion The MCV had a high sensitivity but very low specificity for RR-TB. The CD4/CD8 ratio had a low sensitivity and specificity for RR-TB among HIV positive individuals. The utility of either test is low due to low diagnostic accuracy.
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Affiliation(s)
- Joseph Baruch Baluku
- Mulago National Referral Hospital, Pulmonology Division, PO Box 7051 Kampala, Uganda.,Makerere University Lung Institute, PO Box 7749 Kampala, Uganda.,Mildmay Uganda, P.O Box 24985 Kampala, Uganda
| | - Joseph Musaazi
- Makerere University College of Health Sciences, Infectious Disease Institute, PO Box 7072 Kampala, Uganda
| | - Rose Mulwana
- Mulago National Referral Hospital, Pulmonology Division, PO Box 7051 Kampala, Uganda
| | - Derrick Bengo
- Mulago Hospital, Department of Clinical Hematology, PO Box 7051 Kampala, Uganda
| | - Christine Sekaggya Wiltshire
- Makerere University College of Health Sciences, Infectious Disease Institute, PO Box 7072 Kampala, Uganda.,Makerere University College of Health Sciences, Department of Internal Medicine, PO Box 7072 Kampala, Uganda
| | - Irene Andia-Biraro
- Makerere University College of Health Sciences, Department of Internal Medicine, PO Box 7072 Kampala, Uganda.,Makerere University, Uganda Virus Research Institute Center of Excellence in Training Programme on Infections and Immunity (MUII-PLUS), PO Box 49 Entebbe, Uganda
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McNally TW, de Wildt G, Meza G, Wiskin CMD. Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals. BMC Health Serv Res 2019; 19:594. [PMID: 31438958 PMCID: PMC6704631 DOI: 10.1186/s12913-019-4429-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 08/13/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies. METHOD Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee. RESULTS Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered. CONCLUSIONS This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government.
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Affiliation(s)
- Thomas W McNally
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Gilles de Wildt
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Graciela Meza
- Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Connie M D Wiskin
- Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
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Boyd R, Ford N, Padgen P, Cox H. Time to treatment for rifampicin-resistant tuberculosis: systematic review and meta-analysis. Int J Tuberc Lung Dis 2017; 21:1173-1180. [PMID: 29037299 PMCID: PMC5644740 DOI: 10.5588/ijtld.17.0230] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/25/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To reduce transmission and improve patient outcomes, rapid diagnosis and treatment of rifampicin-resistant tuberculosis (RR-TB) is required. OBJECTIVE To conduct a systematic review and meta-analysis assessing time to treatment for RR-TB and variability using diagnostic testing methods and treatment delivery approach. DESIGN Studies from 2000 to 2015 reporting time to second-line treatment initiation were selected from PubMed and published conference abstracts. RESULTS From 53 studies, 83 cohorts (13 034 patients) were included. Overall weighted mean time to treatment from specimen collection was 81 days (95%CI 70-91), and was shorter with ambulatory (57 days, 95%CI 40-74) than hospital-based treatment (86 days, 95%CI 71-102). Time to treatment was shorter with genotypic susceptibility testing (38 days, 95%CI 27-49) than phenotypic testing (108 days, 95%CI 98-117). The mean percentage of diagnosed patients initiating treatment was 76% (95%CI 70-83, range 25-100). CONCLUSION Time to second-line anti-tuberculosis treatment initiation is extremely variable across studies, and often unnecessarily long. Reduced delays are associated with genotypic testing and ambulatory treatment settings. Routine monitoring of the proportion of diagnosed patients initiating treatment and time to treatment are necessary to identify areas for intervention.
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Affiliation(s)
- R Boyd
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - N Ford
- Centre for Infectious Disease Research, University of Cape Town, Cape Town, South Africa
| | - P Padgen
- College of Global Public Health, New York University, New York, New York, USA
| | - H Cox
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Harris RC, Grandjean L, Martin LJ, Miller AJP, Nkang JEN, Allen V, Khan MS, Fielding K, Moore DAJ. The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review. BMC Infect Dis 2016; 16:193. [PMID: 27142682 PMCID: PMC4855810 DOI: 10.1186/s12879-016-1524-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 04/22/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Globally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance. METHODS Eight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded. RESULTS The initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review. CONCLUSIONS Whilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.
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Affiliation(s)
- Rebecca C Harris
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Louis Grandjean
- Department of Infection, Immunology and Rheumatology, University College London, Institute of Child Health, Guilford Street, London, WC1E 6BT, UK
| | - Laura J Martin
- Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
| | - Alexander J P Miller
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joseph-Egre N Nkang
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Victoria Allen
- Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Mishal S Khan
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, 119077, Singapore
| | - Katherine Fielding
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - David A J Moore
- TB Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Predominant Mycobacterium tuberculosis Families and High Rates of Recent Transmission among New Cases Are Not Associated with Primary Multidrug Resistance in Lima, Peru. J Clin Microbiol 2015; 53:1854-63. [PMID: 25809979 DOI: 10.1128/jcm.03585-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/20/2015] [Indexed: 11/20/2022] Open
Abstract
Sputum samples from new tuberculosis (TB) cases were collected over 2 years as part of a prospective study in the northeastern part of Lima, Peru. To measure the contribution of recent transmission to the high rates of multidrug resistance (MDR) in this area, Mycobacterium tuberculosis complex (MTBc) isolates were tested for drug susceptibility to first-line drugs and were genotyped by spoligotyping and 15-locus mycobacterial interspersed repetitive-unit (MIRU-15)-variable-number tandem repeat (VNTR) analysis. MDR was found in 6.8% of 844 isolates, of which 593 (70.3%) were identified as belonging to a known MTBc lineage, whereas 198 isolates (23.5%) could not be assigned to these lineages and 12 (1.4%) represented mixed infections. Lineage 4 accounted for 54.9% (n = 463) of the isolates, most of which belonged to the Haarlem family (n = 279). MIRU-15 analysis grouped 551/791 isolates (69.7%) in 102 clusters, with sizes ranging from 2 to 46 strains. The overall high clustering rate suggests a high level of recent transmission in this population, especially among younger patients (odds ratio [OR], 1.6; P = 0.01). Haarlem strains were more prone to cluster, compared to the other families taken together (OR, 2.0; P < 0.0001), while Beijing (OR, 0.6; P = 0.006) and LAM (OR, 0.7; P = 0.07) strains clustered less. Whereas streptomycin-resistant strains were more commonly found in clusters (OR, 1.8; P = 0.03), clustering rates did not differ between MDR and non-MDR strains (OR, 1.8; P = 0.1). Furthermore, only 16/51 MDR strains clustered with other MDR strains, suggesting that patients with primary MDR infections acquired the infections mostly from index cases outside the study population, such as retreated cases.
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