Laboratory-Reflex Cryptococcal Antigen Screening Is Associated With a Survival Benefit in Tanzania.
Laboratory-Reflex Cryptococcal Antigen Screening Is Associated With a Survival Benefit in Tanzania.
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DOI：
10.1097/qai.0000000000001899
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发表时间：
2019-02-01
期刊：
影响因子：
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通讯作者：
Letang E
中科院分区：
文献类型：
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作者：
Faini D;Kalinjuma AV;Katende A;Mbwaji G;Mnzava D;Nyuri A;Glass TR;Furrer H;Hatz C;Boulware DR;Letang E
建议对晚期艾滋病毒/艾滋病患者进行隐球菌抗原（CrAg）筛查，以预防死亡。仅在门诊患者中实施CrAg筛查可能会低估真正的CrAg患病率并降低其潜在影响。我们之前在未接受氟康唑治疗的CrAg阳性患者中的12个月生存率/保留率为0%。在坦桑尼亚伊法卡拉，向所有未接受过抗逆转录病毒治疗的门诊患者和住院患者提供了艾滋病毒检测，随后进行了实验室反射性CrAg筛查，以确定CD 4 <150个细胞/μL。对CrAg阳性患者进行腰椎穿刺，并根据是否存在脑膜炎使用抗真菌药物。我们使用多变量考克斯回归模型评估了对生存率和继续护理的影响。我们筛选了560个人的CrAg。中位CD 4计数为61个细胞/μL（IQR 26-103）。CD 4 ≤150和≤100 cells/μL的个体中CrAg患病率分别为6.1%（34/560）和7.5%。住院患者的CrAg患病率是门诊患者的2.3倍（12% vs. 5.3%，p=0.02）。我们对94%（32/34）的患者进行了腰椎穿刺，31%（10/34）的患者患有隐球菌脑膜炎。治疗CrAg阳性无脑膜炎和CrAg阴性个体之间的死亡率无显著差异（分别为7.3 vs 5.4例死亡/100人-年，p=0.25）。6个月死亡/失访的独立预测因子为低CD 4、隐球菌性脑膜炎（调整后风险比= 2.76，95%CI 1.31-5.82）和未开始ART治疗（调整后风险比= 3.12，95%CI 2.16-4.50）。在门诊患者和住院患者中实施实验室反射性CrAg筛查可快速检测隐球菌病并提高生存率。这些结果提供了一个可行的，有效的和可扩展的CrAg筛查和治疗策略整合到非洲农村的常规护理模式。
Cryptococcal antigen (CrAg) screening in persons with advanced HIV/AIDS is recommended to prevent death. Implementing CrAg screening only in outpatients may underestimate the true CrAg prevalence and decrease its potential impact. Our previous 12-month survival/retention in CrAg-positive persons not treated with fluconazole was 0%. HIV testing was offered to all ART-naive outpatients and hospitalized patients in Ifakara, Tanzania, followed by laboratory-reflex CrAg screening for CD4<150 cells/μL. CrAg-positive individuals were offered lumbar punctures, and antifungals were tailored to the presence/absence of meningitis. We assessed the impact on survival and retention-in-care using multivariate Cox regression models. We screened 560 individuals for CrAg. The median CD4 count was 61 cells/μL (IQR 26–103). CrAg prevalence was 6.1% (34/560) among individuals with CD4 ≤150 and 7.5% among ≤100 cells/μL. CrAg prevalence was 2.3-fold higher among hospitalized participants than in outpatients (12% vs. 5.3%, p=0.02). We performed lumbar punctures in 94% (32/34), and 31% (10/34) had cryptococcal meningitis. Mortality did not differ significantly between treated CrAg-positive without meningitis and CrAg-negative individuals (7.3 vs 5.4 deaths per 100 persons-year, respectively, p=0.25). Independent predictors of 6-month death/lost to follow-up were low CD4, cryptococcal meningitis (adjusted hazard ratio = 2.76, 95% CI 1.31–5.82)), and no ART initiation (adjusted hazard ratio = 3.12, 95%CI 2.16–4.50). Implementing laboratory-reflex CrAg screening among outpatients and hospitalized-individuals resulted in a rapid detection of cryptococcosis and a survival benefit. These results provide a model of a feasible, effective and scalable CrAg screening and treatment strategy integrated into routine care in rural Africa.