Katagira Winceslaus, Walter Nicholas D, Den Boon Saskia, Kalema Nelson, Ayakaka Irene, Vittinghoff Eric, Worodria William, Cattamanchi Adithya, Huang Laurence, Davis John Lucian
*Makerere University-University of California San Francisco (MU-UCSF) Research Collaboration, Kampala, Uganda; †Pulmonary Section, Denver Veteran's Affairs Medical Center, Denver, CO; ‡Department of Biostatistics and Epidemiology, University of California San Francisco, San Francisco, CA; §Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; ‖Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA; ¶Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA; #Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT; and **Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, CT.
J Acquir Immune Defic Syndr. 2016 Jul 1;72(3):297-303. doi: 10.1097/QAI.0000000000000970.
In 2007, World Health Organization (WHO) issued emergency recommendations on empiric treatment of sputum acid-fast bacillus smear-negative patients with possible tuberculosis (TB) in HIV-prevalent areas, and called for operational research to evaluate their effectiveness. We sought to determine if early, empiric TB treatment of possible TB patients with abnormal chest radiography or severe illness as suggested by the 2007 WHO guidelines, is associated with improved survival.
We prospectively enrolled consecutive HIV-seropositive inpatients at Mulago Hospital in Kampala, Uganda, from 2007 to 2011 with cough for ≥2 weeks. We retrospectively examined the effect of empiric TB treatment before discharge on 8-week survival among those with and without a WHO-defined "danger sign," including fever >39°C, tachycardia >120 beats per minute, or tachypnea >30 breaths per minute. We modeled the interaction between empiric TB treatment and danger signs, and their combined effect on 8-week survival, and adjusted for relevant covariates.
Among 631 sputum smear-negative patients, 322 (51%) had danger signs. Cumulative 8-week survival of patients with danger signs was significantly higher with empiric TB treatment (80%) than without treatment (64%, P < 0.001). After adjusting for duration of cough and concurrent hypoxemia, patients with danger signs who received empiric TB treatment had a 44% reduction in 8-week mortality (risk ratio 0.56, 95% confidence interval: 0.34-0.91, P = 0.020).
Empiric TB treatment of HIV-seropositive, smear-negative, presumed pulmonary TB patients with 1 or more danger signs is associated with improved 8-week survival. Enhanced implementation of the 2007 WHO empiric treatment recommendations should be encouraged whenever and wherever rapid and highly sensitive diagnostic tests for TB are unavailable.
2007年，世界卫生组织（WHO）发布了关于在艾滋病高发地区对痰涂片抗酸杆菌阴性但可能患有结核病（TB）的患者进行经验性治疗的紧急建议，并呼吁开展运营研究以评估其有效性。我们试图确定，按照2007年WHO指南的建议，对胸部X光检查异常或患有严重疾病的可能患有结核病的患者进行早期经验性结核病治疗是否与生存率提高相关。
我们前瞻性纳入了2007年至2011年期间在乌干达坎帕拉穆拉戈医院连续住院的HIV血清学阳性患者，这些患者咳嗽≥2周。我们回顾性研究了出院前经验性结核病治疗对有无WHO定义的“危险信号”（包括体温>39°C、心率>120次/分钟或呼吸频率>30次/分钟）患者8周生存率的影响。我们对经验性结核病治疗与危险信号之间的相互作用及其对8周生存率的综合影响进行建模，并对相关协变量进行调整。
在631例痰涂片阴性患者中，322例（51%）有危险信号。有危险信号的患者接受经验性结核病治疗后的累积8周生存率（80%）显著高于未接受治疗的患者（64%，P<0.001）。在调整咳嗽持续时间和并发低氧血症后，接受经验性结核病治疗的有危险信号的患者8周死亡率降低了44%（风险比0.56，95%置信区间：0.34-0.91，P=0.020）。
对有1个或更多危险信号的HIV血清学阳性、涂片阴性、疑似肺结核患者进行经验性结核病治疗与8周生存率提高相关。无论何时何地，只要无法获得快速且高度灵敏的结核病诊断检测方法，就应鼓励加强实施2007年WHO的经验性治疗建议。
