Chaka Wendy, Berger Christopher, Huo Stella, Robertson Valerie, Tachiona Chipo, Magwenzi Marcelyn, Magombei Trish, Mpamhanga Chengetai, Katzenstein David, Metcalfe John
University of Zimbabwe College of Health Sciences, Department of Medical Microbiology, Box A178 Avondale, Harare, Zimbabwe.
Zuckerberg San Francisco General Hospital, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, USA.
Int J Infect Dis. 2020 Jul;96:276-283. doi: 10.1016/j.ijid.2020.04.004. Epub 2020 Apr 11.
To define sepsis syndromes in high-HIV burden settings in the antiretroviral therapy (ART) era.
We characterized a prospective cohort of adults presenting to a tertiary emergency department in Harare, Zimbabwe with suspected community-acquired sepsis using blood and urine cultures, urine tuberculosis lipoarabinomannan (TB LAM), and serum cryptococcal antigen (CrAg) testing. The primary outcome was 30-day all-cause mortality.
Of 142 patients enrolled 68% (n=96/142, 95% confidence interval (CI) [60-75%]) were HIV-positive, 41% (n=39/96, 95% CI [31-50%]) of whom were ART-naïve. Among HIV-positive patients, both opportunistic pathogens (TB LAM-positivity, 36%, 95% CI [24-48%]; CrAg-positivity, 15%, 95% CI [7-23%]) and severe non-AIDS infections (S. pneumoniae urine antigen-positivity 12%, 95% CI [4-20%]; bacteraemia 17% (n=16/96, 95% CI [9-24%]), of which 56% (n=9/16, 95% CI [30-80%]) were gram-negative organisms) were common. Klebsiella pneumoniae recovered from blood and urine was uniformly resistant to ceftriaxone, as were most Escherichia coli isolates. Acknowledging the power limitations of our study, we conclude that relative to HIV-negative patients, HIV-positive patients had modestly higher 30-day mortality (adjusted hazard ratio (HR) 1.88, 95% CI [0.78-4.55]; p=0.16, and 3.59, 95% CI [1.27-10.16], p=0.02) among those with and without viral suppression, respectively.
Rapid point-of-care assays provide substantial clinically actionable information in the setting of suspected sepsis, even in areas with high ART coverage. Antimicrobial resistance to first-line antibiotics in high burden settings is a growing threat.
在抗逆转录病毒治疗（ART）时代，明确高HIV负担地区的脓毒症综合征。
我们对津巴布韦哈拉雷一家三级急诊科疑似社区获得性脓毒症的成年前瞻性队列进行了特征分析，采用血培养、尿培养、尿结核脂阿拉伯甘露聚糖（TB LAM）检测及血清隐球菌抗原（CrAg）检测。主要结局为30天全因死亡率。
在纳入的142例患者中，68%（n = 96/142，95%置信区间（CI）[60 - 75%]）为HIV阳性，其中41%（n = 39/96，95% CI [31 - 50%]）未接受过ART治疗。在HIV阳性患者中，机会性病原体（TB LAM阳性率36%，95% CI [24 - 48%]；CrAg阳性率15%，95% CI [7 - 23%]）和严重非艾滋病感染（肺炎链球菌尿抗原阳性率12%，95% CI [4 - 20%]；菌血症17%（n = 16/96，95% CI [9 - 24%]），其中56%（n = 9/16，95% CI [30 - 80%]）为革兰氏阴性菌）均很常见。从血液和尿液中分离出的肺炎克雷伯菌对头孢曲松均耐药，大多数大肠埃希菌分离株也是如此。鉴于我们研究的统计学效力有限，我们得出结论，相对于HIV阴性患者，HIV阳性患者在病毒抑制和未抑制的情况下，30天死亡率分别适度升高（调整后风险比（HR）分别为1.88，95% CI [0.78 - 4.55]；p = 0.16，以及3.59，95% CI [1.27 - 10.16]，p = 0.02）。
即时检验在疑似脓毒症情况下可提供大量具有临床可操作性的信息，即使在ART覆盖率高的地区也是如此。高负担地区对一线抗生素的耐药性构成日益严重的威胁。
