Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries: a multicohort study
Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries: a multicohort study
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DOI：
10.1002/jia2.25392
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发表时间：
2019-09-01
影响因子：
6
通讯作者：
de Waal, Renee
中科院分区：
文献类型：
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作者：
Zurcher, Kathrin;Ballif, Marie;de Waal, Renee
肺外结核（EPTB）很难从细菌学上确诊，需要特殊的诊断能力。在资源不足的环境中，诊断尤其具有挑战性。我们研究了在低收入和中等收入国家（LMIC）抗逆转录病毒治疗（ART）项目中hiv阳性成人中EPTB与肺结核（PTB）的诊断方式和临床结果。方法收集2012年至2014年撒哈拉以南非洲、亚太和加勒比、中南美洲地区参与国际艾滋病流行病学数据库评估（IeDEA）联盟的22个抗逆转录病毒治疗项目的艾滋病毒阳性结核病患者（年龄16岁）的数据。我们将结核病分为PTB或EPTB （EPTB包括混合PTB/EPTB）。我们使用多变量逻辑回归来评估与临床结果的关联。结果与讨论我们分析了2695例hiv阳性结核患者。中位年龄为36岁（四分位数范围（IQR） 30至43），1102名女性（41%），TB治疗开始时的中位CD4计数为114细胞/ μ L （IQR 40至248）。总的来说，1930人患有肺结核（72%），765人患有EPTB（28%）。EPTB患者中，最常见的受累部位是淋巴结（24%）、胸膜（15%）、腹部（11%）和脑膜（6%）。大多数肺结核（1930例中有1123例，占58%）和EPTB（765例中有582例，占76%）患者是根据临床标准诊断的。1557例PTB患者中有897例（52%）和438例EPTB患者中有183例（42%）获得细菌学证实（使用阳性涂片镜检、培养、Xpert MTB/RIF或其他核酸扩增试验结果）。与PTB相比，EPTB与更高的死亡率无关（调整奇数比（aOR） 1.0, 95% CI 0.8至1.3），但结核性脑膜炎与之相关（aOR 1.9, 95% CI 1.0至3.1）。与检测结果阴性的结核病患者相比，细菌学确认与肺结核患者（aOR为0.7,95% CI为0.6至0.8）和肺结核患者（aOR为0.3,95% CI为0.1至0.8）的死亡率降低相关。结论中低收入国家抗逆转录病毒治疗项目中EPTB和PTB的诊断主要基于临床标准。提高结核病诊断检测的可得性和使用率将改善EPTB和PTB的诊断和临床结果。
Introduction Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC). Methods We collected data from HIV-positive TB patients (>= 16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. Results and Discussion We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/mu L (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result. Conclusions Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.