Effect of Antiretroviral Therapy on the Diagnostic Accuracy of Symptom Screening for Intensified Tuberculosis Case Finding in a South African HIV Clinic
Effect of Antiretroviral Therapy on the Diagnostic Accuracy of Symptom Screening for Intensified Tuberculosis Case Finding in a South African HIV Clinic
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DOI：
10.1093/cid/cis775
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发表时间：
2012-12-15
影响因子：
11.8
通讯作者：
Maartens, Gary
中科院分区：
文献类型：
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作者：
Rangaka, Molebogeng X.;Wilkinson, Robert J.;Maartens, Gary
背景目前用于加强结核病病例发现或在感染人类免疫缺陷病毒（HIV）的患者中进行异烟肼预防性治疗（IPT）之前的症状筛查算法来自抗逆转录病毒初治队列。有必要验证筛选算法在抗逆转录病毒治疗（ART）的患者。我们对症状筛查的诊断准确性进行了横断面评估，包括世界卫生组织（WHO）的算法，以排除ART前HIV感染者和IPT前接受ART筛查的HIV感染者的结核病。共有1429名参与者（54%接受ART）进行了症状筛查和痰培养结果。在126名患者中诊断出培养阳性结核病（8.8%，95%置信区间[CI]，7.4%-10.4%）。与ART前组相比，ART中的WHO症状筛查的敏感性较低（23.8% vs 47.6%），但特异性较高（94.4% vs 79.8%）。在多变量分析中，ART的效果与CD 4（+）计数无关。在接受抗逆转录病毒治疗前和接受抗逆转录病毒治疗组中，WHO筛查阴性后结核病的检测后概率分别为8.9%（95% CI，7.4%-10.8%）和4.4%（95% CI，3.7%-5.2%）。在WHO筛查中增加体重指数显著提高了两个ART组的区分能力，增加CD 4计数和ART持续时间进一步提高了区分能力。世卫组织症状筛查的敏感性较差，特别是在定期进行结核病筛查的诊所中接受抗逆转录病毒治疗的患者中。因此，尽管有很高的阴性预测值，但仍有相当比例的结核病患者无意中接受了异烟肼单药治疗。在建立更灵敏的排除结核病的方法之前，在可行的情况下，在IPT之前进行痰培养是谨慎的。
Background. Current symptom screening algorithms for intensified tuberculosis case finding or prior to isoniazid preventive therapy (IPT) in patients infected with human immunodeficiency virus (HIV) were derived from antiretroviral-naive cohorts. There is a need to validate screening algorithms in patients on antiretroviral therapy (ART).Methods. We performed cross-sectional evaluation of the diagnostic accuracy of symptom screening, including the World Health Organization (WHO) algorithm, to rule out tuberculosis in HIV-infected individuals pre-ART and on ART undergoing screening prior to IPT.Results. A total of 1429 participants, 54% on ART, had symptom screening and a sputum culture result available. Culture-positive tuberculosis was diagnosed in 126 patients (8.8%, 95% confidence interval [CI], 7.4%-10.4%). The WHO symptom screen in the on-ART compared with the pre-ART group had a lower sensitivity (23.8% vs 47.6%), but higher specificity (94.4% vs 79.8%). The effect of ART was independent of CD4(+) count in multivariable analyses. The posttest probability of tuberculosis following a negative WHO screen was 8.9% (95% CI, 7.4%-10.8%) and 4.4% (95% CI, 3.7%-5.2%) for the pre-ART and on-ART groups, respectively. Addition of body mass index to the WHO screen significantly improved discriminatory ability in both ART groups, which was further improved by adding CD4 count and ART duration.Conclusions. The WHO symptom screen has poor sensitivity, especially among patients on ART, in a clinic where regular tuberculosis screening is practiced. Consequently, a significant proportion of individuals with tuberculosis would inadvertently be placed on isoniazid monotherapy despite high negative predictive values. Until more sensitive methods of ruling out tuberculosis are established, it would be prudent to do a sputum culture prior to IPT where this is feasible.