Can point-of-care urine LAM strip testing for tuberculosis add value to clinical decision making in hospitalised HIV-infected persons?
Can point-of-care urine LAM strip testing for tuberculosis add value to clinical decision making in hospitalised HIV-infected persons?
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DOI：
10.1371/journal.pone.0054875
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发表时间：
2013
期刊：
影响因子：
3.7
通讯作者：
Dheda K
中科院分区：
文献类型：
--
作者：
Peter JG;Theron G;Dheda K
尿脂阿拉伯糖甘露聚糖（LAM）试纸（确定®-TB）可快速诊断晚期免疫抑制hiv感染者的TB。然而，考虑到高负担环境中住院患者的经验性治疗率很高（约50%），尚不清楚LAM是否可以为临床决策增加任何价值，或者确定经验性治疗可能错过的不良结局患者亚群。281名hiv感染的住院结核病疑似患者接受了尿液LAM条检测，并被分类为明确（培养阳性）、可能和非结核病。通过LAM检测确定的结核病病例比例和发病率、早期经验性治疗（在检测结果可用之前开始）和一组临床预测指标进行了跨组比较。187/281例患者有明确结核（n = 116）或可能结核（n = 71）。作为确定和可能的结核病的常规检测，与早期经验性治疗相比，LAM识别出的结核病病例比例相似（85/187比93/187，p = 0.4），但比单独使用一组临床预测因子分类的比例更高（19/187;p<0.001）。187例确诊或可能患有结核病的lam阳性患者中有39例（21%）在早期经验性治疗中未被发现，其中25/39例（64%）在涂片镜检中也未被发现。因此，25/187（8%）的确诊或疑似结核病患者延迟开始结核病治疗，可通过LAM试纸检测出来。与早期经验性治疗的lam阴性患者相比，未接受早期经验性治疗的lam阳性患者CD4中位数计数较低（p = 0.008），疾病严重程度评分中位数较高（p = 0.001），尿素水平升高（p = 0.002）。LAM条检测优于基于临床标准的结核病诊断，但在日常实践中，与早期经验性治疗相比，确定的患者比例相似。然而，与经验治疗相比，LAM发现了一个不同的患者亚群，他们的免疫抑制更严重，疾病更严重。
The urine lipoarabinomannan (LAM) strip-test (Determine®-TB) can rapidly rule-in TB in HIV-infected persons with advanced immunosuppression. However, given high rates of empiric treatment amongst hospitalised patients in high-burden settings (∼50%) it is unclear whether LAM can add any value to clinical decision making, or identify a subset of patients with unfavourable outcomes that would otherwise have been missed by empiric treatment. 281 HIV-infected hospitalised patients with suspected TB received urine LAM strip testing, and were categorised as definite (culture-positive), probable-, or non-TB. Both the proportion and morbidity of TB cases identified by LAM testing, early empiric treatment (initiated prior to test result availability) and a set of clinical predictors were compared across groups. 187/281 patients had either definite- (n = 116) or probable-TB (n = 71). As a rule-in test for definite and probable-TB, LAM identified a similar proportion of TB cases compared to early empiric treatment (85/187 vs. 93/187, p = 0.4), but a greater proportion than classified by a set of clinical predictors alone (19/187; p<0.001). Thirty-nine of the 187 (21%) LAM-positive patients who had either definite- or probable-TB were missed by early empiric treatment, and of these 25/39 (64%) would also have been missed by smear microscopy. Thus, 25/187 (8%) of definite- or probable-TB patients with otherwise delayed initiation of TB treatment could be detected by the LAM strip test. LAM-positive patients missed by early empiric treatment had a lower median CD4 count (p = 0.008), a higher median illness severity score (p = 0.001) and increased urea levels (p = 0.002) compared to LAM-negative patients given early empiric treatment. LAM strip testing outperformed TB diagnosis based on clinical criteria but in day-to-day practice identified a similar proportion of patients compared to early empiric treatment. However, compared to empiric treatment, LAM identified a different subset of patients with more advanced immunosuppression and greater disease severity.
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DOI：
10.1097/qai.0b013e3181b98430
发表时间：
2009-10-01
影响因子：
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作者：
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DOI：
10.1183/09031936.00201711
发表时间：
2012-11
期刊：
The European respiratory journal
影响因子：
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