A Clinical Prediction Score Including Trial of Antibiotics and C-Reactive Protein to Improve the Diagnosis of Tuberculosis in Ambulatory People With HIV
A Clinical Prediction Score Including Trial of Antibiotics and C-Reactive Protein to Improve the Diagnosis of Tuberculosis in Ambulatory People With HIV
复制标题
DOI：
10.1093/ofid/ofz543
复制
发表时间：
2020-02-01
影响因子：
4.2
通讯作者：
Maartens, Gary
中科院分区：
文献类型：
--
作者：
Boyles, Tom H.;Nduna, Matilda;Maartens, Gary
背景资料。根据专家意见，2007年在世界卫生组织(WHO)的建议中删除了将“抗生素试验”作为细菌性肺炎的经验性疗法作为I-IIV(PWII)患者结核病诊断工具的做法。目前的指南仅在2Xpert MTB/RIF测试(如果可用)、胸部X光和临床评估表明不太可能出现结核病后才建议使用抗生素。尽管如此，“抗生素试验”在低资源环境下的算法中仍然很常见，但其价值尚不确定。C-反应蛋白(CRP)被认为是结核病的一种“排除”试验，它可能是一种客观的抗菌药物反应的标志物。我们对WHO症状筛查阳性的成人PWH进行了被动病例发现队列研究。所有参与者在第一次就诊时都按照当地的规程接受了抗生素治疗，并进行了复查以确定临床反应。在两次访问中都测量了看护点的CRP。所有患者均用Xpert MTB/RIF Ultra(Ultra)进行痰检测，参考标准为2种痰分支杆菌培养。我们探索了基于1次或2次就诊的结核病多变量预测模型。207名患者中有75名(36%)确诊为肺结核。2天后对抗生素的临床反应是疾病的良好预测指标。基于两次就诊的MPM，没有CRP，具有可接受的区分度(c-统计量，0.75)和校准(拟合度P=0.07)。抗生素后加用C反应蛋白对模型有一定改善作用(c-统计量，0.78)。初诊时的C反应蛋白不是结核病的独立预测因子。在寻求治疗结核病症状的成人PWH中，对抗生素缺乏反应是疾病的强烈预测因素，很可能有用，特别是在获得Ultra的机会有限的情况下。C反应蛋白在抗生素后测量时会增加价值，但在第一次就诊时价值有限。
Background. The use of a "trial of antibiotics" as empiric therapy for bacterial pneumonia as a diagnostic tool for tuberculosis in people with I IIV (PWII) was removed from World health Organization (WHO) recommendations in 2007, based on expert opinion. Current guidelines recommend antibiotics only after 2 Xpert MTB/RIF tests (if available), chest x-ray, and clinical assessment have suggested that tuberculosis is unlikely. Despite this, a "trial of antibiotics" remains common in algorithms in low-resource settings, but its value is uncertain. C-reactive protein (CRP), which has been proposed as a "rule-out" test for tuberculosis, may be an objective marker of response to antibiotics.Methods. We performed a passive case-finding cohort study of adult PWH with a positive WHO symptom screen. All participants received antibiotics at first visit according to the local protocol and were reviewed to ascertain clinical response. Point-of-care CRP was measured at both visits. All patients had sputum tested with Xpert MTB/RIF Ultra (Ultra), and the reference standard was based on 2 sputum mycobacterial cultures. We explored multivariable prediction models (MPM) for tuberculosis based on 1 or 2 visits.Results. Seventy-five of 207 patients (36%) had confirmed tuberculosis. Clinical response to antibiotics after 2 days was a good predictor of disease. An MPM based on 2 visits, without CRP, had acceptable discrimination (c-statistic, 0.75) and calibration (goodness-of-fit P = .07). Addition of CRP after antibiotics improved the model moderately (c-statistic, 0.78). CRP at first visit was not an independent predictor of tuberculosis.Conclusions. In adult PWH seeking care for symptoms suggestive of tuberculosis, lack of response to antibiotics is a strong predictor of disease and is likely to be useful, particularly when access to Ultra is limited. CRP adds value when measured after antibiotics but is of limited value at first visit.