Clinical Predictors and Accuracy of Empiric Tuberculosis Treatment among Sputum Smear-Negative HIV-Infected Adult TB Suspects in Uganda
Clinical Predictors and Accuracy of Empiric Tuberculosis Treatment among Sputum Smear-Negative HIV-Infected Adult TB Suspects in Uganda
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DOI：
10.1371/journal.pone.0074023
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发表时间：
2013-09-06
期刊：
影响因子：
3.7
通讯作者：
Manabe, Yukari C.
中科院分区：
文献类型：
--
作者：
Nakiyingi, Lydia;Bwanika, John Mark;Manabe, Yukari C.
简介：现有的痰涂片阴性结核病（TB）诊断算法复杂、耗时，而且往往难以实施。在资源有限的国家开始结核病治疗的决定通常主要基于临床预测因素。我们试图以痰培养作为参考标准，确定 HIV 感染的痰涂片阴性结核病嫌疑人开始经验性结核病治疗的临床预测因素和准确性。地点：乌干达坎帕拉的 HIV-TB 综合城市门诊诊所。方法：使用痰涂片显微镜筛查 HIV 感染的结核病嫌疑人，并进行分枝杆菌痰液体和固体培养。涂片结果提供给临床医生，临床医生可以对痰涂片阴性患者开始经验性结核病治疗做出临床决定。对痰涂片呈阴性的患者的临床记录进行审查，以收集有关社会人口统计学、结核病症状学、胸部 X 光检查结果、CD4 细胞计数和结核病治疗开始的数据。 结果：在 253 名涂阴结核疑似患者中，56% (142/253) 为女性，中位年龄 38 IQR (31-44) 岁，中位 CD4 细胞计数为 291 IQR (150-482) 细胞/毫米 (3)。在根据经验开始接受结核病治疗的 85 名（33.6%）涂阴患者中，35.3%（n = 30）痰培养呈阳性，而 168 名未经治疗的患者中只有 18 名（10.7%）出现痰培养阳性（p < 0.001）。胸部 X 光检查异常 [aOR 10.18，95% CI (3.14-33.00)，p < 0.001] 和晚期 HIV 临床分期 [aOR 3.92，95% CI (1.20-12.85)，p = 0.024] 与开始经验性结核病治疗显着相关。涂片镜检阴性后开始经验性结核病治疗诊断 HIV 感染者结核病的敏感性和特异性分别为 62.5% 和 73.7%。 结论：在资源有限的环境中，临床晚期 HIV 和异常胸部 X 线检查可显着预测临床决定对涂片阴性 HIV 感染者进行经验性开始结核病治疗。经验性结核病治疗的开始与结核病培养的相关性较差。在资源有限的环境中，需要经济、准确和快速的护理点诊断，以更准确地确定哪些感染艾滋病毒的结核病疑似患有涂阴结核病。
Introduction: The existing diagnostic algorithms for sputum smear-negative tuberculosis (TB) are complicated, time-consuming, and often difficult to implement. The decision to initiate TB treatment in resource-limited countries is often largely based on clinical predictors. We sought to determine the clinical predictors and accuracy of empiric TB treatment initiation in HIV-infected sputum smear-negative TB suspects using sputum culture as a reference standard.Setting: Out-patient HIV-TB integrated urban clinic in Kampala, Uganda.Methods: HIV-infected TB suspects were screened using sputum smear microscopy, and mycobacterial sputum liquid and solid cultures were performed. Smear results were made available to the clinician who made a clinical decision on empiric TB treatment initiation for sputum smear-negative patients. Clinic records were reviewed for patients whose sputum smears were negative to collect data on socio-demographics, TB symptomatology, chest X-ray findings, CD4 cell counts and TB treatment initiation.Results: Of 253 smear-negative TB suspects, 56% (142/253) were females, median age 38 IQR (31-44) years, with a median CD4 cell count of 291 IQR (150-482) cells/mm(3). Of the 85 (33.6%) smear-negative patients empirically initiated on TB treatment, 35.3% (n = 30) were sputum culture positive compared to only 18 (10.7%) of the 168 untreated patients (p < 0.001). Abnormal chest X-ray [aOR 10.18, 95% CI (3.14-33.00), p < 0.001] and advanced HIV clinical stage [aOR 3.92, 95% CI (1.20-12.85), p = 0.024] were significantly associated with empiric TB treatment initiation. The sensitivity and specificity of empiric TB treatment initiation in the diagnosis of TB in HIV-infected patients after negative smear microscopy was 62.5% and 73.7% respectively.Conclusion: In resource-limited settings, clinically advanced HIV and abnormal chest X-ray significantly predict a clinical decision to empirically initiate TB treatment in smear-negative HIV-infected patients. Empiric TB treatment initiation correlates poorly with TB cultures. Affordable, accurate and rapid point-of-care diagnostics are needed in resource-limited settings to more accurately determine which HIV-infected TB suspects have smear-negative TB.