Byashalira Kenneth, Mbelele Peter, Semvua Hadija, Chilongola Jaffu, Semvua Seleman, Liyoyo Alphonce, Mmbaga Blandina, Mfinanga Sayoki, Moore Christopher, Heysell Scott, Mpagama Stellah
Kilimanjaro Christian Medical University College; Kibong'oto Infectious Diseases Hospital, Tanzania.
Kibong'oto Infectious Diseases Hospital, Tanzania.
Int J Mycobacteriol. 2019 Oct-Dec;8(4):313-319. doi: 10.4103/ijmy.ijmy_135_19.
Despite effort to diagnose tuberculosis (TB) in the Human Immunodeficiency Virus (HIV) infected population, 45% of adults with HIV that had a previously unknown reason for death, demonstrated TB was the cause by autopsy examination. We aimed to assess the clinical outcomes of implementation a new algorithm for diagnosis and treatment of tuberculosis (TB) related sepsis among PLHIV presenting with life-threatening illness.
This study is a prospective cohort conducted in three-referral hospitals in Kilimanjaro, recruited 97 PLHIV from February through June 2018. Patients provided urine and sputum samples for testing lateral flow - lipoarabinomannan (LF-LAM) and Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF) assays, respectively. Anti-TB was prescribed to patients with positive LF-LAM or Xpert MTB/RIF or received broad-spectrum antibiotics but deteriorated.
Of 97 patients, 84 (87%) provided urine and sputa, and 13 (13%) provided only urine. The mean age (95% confidence interval) was 40 (38-43) years and 52 (54%) were female. In 84 patients, LF-LAM increased TB detection from 26 (31%) by Xpert MTB/RIF to 41 (55%) by both tests. Of 97 patients, 69 (71%) prescribed anti-TB, 67% (46/69) and 33% (23/69) had definitive and probable TB respectively. Sixteen (16.5%) patients died, of which one died before treatment, 73% (11/15) died within 7 days of admission. The 30-day survival was similar in both treatment groups (log rank = 0.1574). Mortality was significantly higher among hospitalized patients compared to outpatients (P ≤ 0.027).
Implementation of new algorithm increased TB case detection in patients that could have been missed by Xpert MTB/RIF assay. Survival of PLHIV with confirmed or probable TB was comparable to those of PLHIV that were treated with broad-spectrum antibiotics alone. Further work should focus on the optimal timing and content of the immediate antimicrobial regimen for sepsis among PLHIV in TB-endemic settings.
尽管努力在感染人类免疫缺陷病毒（HIV）的人群中诊断结核病（TB），但在45%既往死因不明的成年HIV感染者中，尸检显示TB是死因。我们旨在评估对出现危及生命疾病的HIV感染者实施一种新的结核病（TB）相关脓毒症诊断和治疗算法的临床结果。
本研究是在乞力马扎罗的三家转诊医院进行的一项前瞻性队列研究，于2018年2月至6月招募了97名HIV感染者。患者分别提供尿液和痰液样本，用于检测侧向流动-脂阿拉伯甘露聚糖（LF-LAM）和Xpert结核分枝杆菌（MTB）/利福平（RIF）检测。对LF-LAM或Xpert MTB/RIF检测呈阳性或接受广谱抗生素治疗但病情恶化的患者开具抗结核药物。
97名患者中，84名（87%）提供了尿液和痰液，13名（13%）仅提供了尿液。平均年龄（95%置信区间）为40（38 - 43）岁，52名（54%）为女性。在84名患者中，LF-LAM将TB检测率从Xpert MTB/RIF检测的26例（31%）提高到两种检测联合的41例（55%）。97名患者中，69名（71%）开具了抗结核药物，其中67%（46/69）确诊为TB，33%（23/69）可能为TB。16名（16.5%）患者死亡，其中1名在治疗前死亡，73%（11/15）在入院后7天内死亡。两个治疗组的30天生存率相似（对数秩检验 = 0.1574）。住院患者的死亡率显著高于门诊患者（P≤0.027）。
新算法的实施增加了Xpert MTB/RIF检测可能漏诊的患者中的TB病例检出率。确诊或可能患有TB的HIV感染者的生存率与仅接受广谱抗生素治疗的HIV感染者相当。进一步的工作应集中在TB流行地区HIV感染者脓毒症即时抗菌治疗方案的最佳时机和内容上。
