McCarthy Kerrigan, Fielding Katherine, Churchyard Gavin J, Grant Alison D
The Aurum Institute; Johannesburg, South Africa.
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
PLoS One. 2018 Jan 24;13(1):e0191608. doi: 10.1371/journal.pone.0191608. eCollection 2018.
The extent and circumstances under which empiric tuberculosis (TB) treatment (treatment without microbiological confirmation at treatment initiation) is administered in primary health care settings in South Africa are not well described.
We used data from a pragmatic evaluation of Xpert MTB/RIF in which persons undergoing TB investigations by PHC nurses were followed for six months. Following Xpert or smear-microscopy at enrolment, investigations for tuberculosis were undertaken at the discretion of health care workers. We identified persons whose TB treatment was initiated empirically (no microbiological confirmation at time of treatment initiation at a primary health care facility) and describe pathways to treatment initiation.
Of 4665 evaluable participants, 541 persons were initiated on treatment of whom 167 (31%) had negative sputum tests at enrolment. Amongst these 167, the median number of participant visits to health care providers prior to treatment initiation was 3 (interquartile range [IQR] 2-4). Chest radiography, sputum culture or hospital referral was done in 106/167 (63%). Reasons for TB treatment start were: 1) empiric (n = 82, 49%); 2) a positive laboratory test (n = 49, 29%); 3) referral and treatment start at a higher level of care (n = 28, 17%); and 4) indeterminable (n = 8, 5%). Empiric treatment accounted for 15% (82/541) of all TB treatment initiations and 1.7% (82/4665) of all persons undergoing TB investigations. Chest radiography findings compatible with TB (63/82 [77%]) were the basis for treatment initiation amongst the majority of empirically treated participants. Microbiological confirmation of TB was subsequently obtained for 11/82 (13%) empirically-treated participants. Median time to empiric treatment start was 3.9 weeks (IQR 1.4-11 weeks) after enrolment.
Uncommon prescription of empiric TB treatment with reliance on chest radiography in a nurse-managed programme underscores the need for highly sensitive TB diagnostics suitable for point-of-care, and strong health systems to support TB diagnosis in this setting.
在南非的初级卫生保健机构中，经验性结核病（TB）治疗（治疗开始时无微生物学确诊）的应用范围和情况尚未得到充分描述。
我们使用了对Xpert MTB/RIF进行务实评估的数据，其中对由初级卫生保健护士进行结核病调查的人员进行了为期六个月的跟踪。在入组时进行Xpert或涂片显微镜检查后，由医护人员自行决定是否进行结核病调查。我们确定了那些开始接受经验性结核病治疗的人员（在初级卫生保健机构治疗开始时无微生物学确诊），并描述了治疗开始的途径。
在4665名可评估的参与者中，有541人开始接受治疗，其中167人（31%）在入组时痰检呈阴性。在这167人中，治疗开始前参与者就诊于医护人员的中位数次数为3次（四分位间距[IQR]为2 - 4次）。106/167（63%）的人进行了胸部X光检查、痰培养或转诊至医院。结核病治疗开始的原因如下：1）经验性治疗（n = 82，49%）；2）实验室检查呈阳性（n = 49，29%）；3）转诊并在更高层级的医疗机构开始治疗（n = 28，17%）；4）无法确定（n = 8，5%）。经验性治疗占所有结核病治疗开始病例的15%（82/541），占所有接受结核病调查人员的1.7%（82/4665）。在大多数接受经验性治疗的参与者中，与结核病相符的胸部X光检查结果（63/82 [77%]）是治疗开始的依据。随后，11/82（13%）接受经验性治疗的参与者获得了结核病的微生物学确诊。入组后开始经验性治疗的中位时间为3.9周（IQR为1.4 - 11周）。
在护士管理的项目中，依赖胸部X光检查进行不常见的经验性结核病治疗处方，凸显了对适用于即时检测的高灵敏度结核病诊断方法的需求，以及在这种情况下支持结核病诊断的强大卫生系统的必要性。
