Cargando…
Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis
BACKGROUND: Empirical treatment of tuberculosis (TB) may be necessary in patients with negative or no Xpert MTB/RIF results. In a context with access to Xpert, we assessed mortality in the 6 months after the initial TB consultation among HIV-positive and HIV-negative patients who received empirical...
Autores principales: | , , , , , , , |
---|---|
Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BioMed Central
2019
|
Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369550/ https://www.ncbi.nlm.nih.gov/pubmed/30744603 http://dx.doi.org/10.1186/s12879-019-3775-z |
_version_ | 1783394211585851392 |
---|---|
author | Huerga, Helena Ferlazzo, Gabriella Wanjala, Stephen Bastard, Mathieu Bevilacqua, Paolo Ardizzoni, Elisa Sitienei, Joseph Bonnet, Maryline |
author_facet | Huerga, Helena Ferlazzo, Gabriella Wanjala, Stephen Bastard, Mathieu Bevilacqua, Paolo Ardizzoni, Elisa Sitienei, Joseph Bonnet, Maryline |
author_sort | Huerga, Helena |
collection | PubMed |
description | BACKGROUND: Empirical treatment of tuberculosis (TB) may be necessary in patients with negative or no Xpert MTB/RIF results. In a context with access to Xpert, we assessed mortality in the 6 months after the initial TB consultation among HIV-positive and HIV-negative patients who received empirical TB treatment or TB treatment based on bacteriological confirmation and we compared it with the mortality among those who did not receive TB treatment. METHODS: This prospective cohort study included consecutively adult patients with signs and symptoms of TB attending an outpatient TB clinic in Western Kenya. At the first consultation, patients received a clinical exam and chest X-ray. Sputum was collected for microscopy, Xpert and Mycobacterium tuberculosis complex (MTB) culture. Patients not started on TB treatment were reassessed after 5 days. All patients bacteriologically confirmed (positive Xpert or culture) received TB treatment. Empirical treatment was defined as a decision to start TB treatment without bacteriological confirmation. Patients were reassessed after 6 months. RESULTS: Of 606 patients included, 344/606 (56.8%) were women. Median age was 35 years [Interquartile Range (IQR):27–47] and 398/594 (67.0%) were HIV-positive. In total, 196/606 (32.3%) patients were Xpert- or culture-positive and 331/606 (54.6%) started TB treatment. Overall, 100/398 (25.1%) HIV-positive and 31/196 (15.8%) HIV-negative patients received empirical treatment. Mortality in the 6 months following the first consultation was 1.6 and 0.8/100 patient-months among HIV-positive and HIV-negative patients respectively. In the multivariate analyses, TB treatment - whether empirical or based on bacteriological confirmation- was not associated with increased mortality among HIV-positive patients (aHR:2.51, 95%CI:0.79–7.90 and aHR:1.25, 95%CI:0.37–4.21 respectively). However, HIV-negative patients who received empirical treatment had a higher risk of mortality (aHR:4.85, 95%CI:1.08–21.67) compared to those not started on treatment. HIV-negative patients treated for TB based on bacteriological confirmation did not have a different risk of mortality (aHR:0.77, 95%CI:0.08–7.41). CONCLUSIONS: Our findings suggest that in a context with access to Xpert, clinicians should continue using empirical TB treatment in HIV-positive patients with signs and symptoms of TB and negative Xpert results. However, differential diagnoses other than TB should be actively sought before initiating empirical TB treatment, particularly in HIV-negative patients. |
format | Online Article Text |
id | pubmed-6369550 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2019 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-63695502019-02-21 Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis Huerga, Helena Ferlazzo, Gabriella Wanjala, Stephen Bastard, Mathieu Bevilacqua, Paolo Ardizzoni, Elisa Sitienei, Joseph Bonnet, Maryline BMC Infect Dis Research Article BACKGROUND: Empirical treatment of tuberculosis (TB) may be necessary in patients with negative or no Xpert MTB/RIF results. In a context with access to Xpert, we assessed mortality in the 6 months after the initial TB consultation among HIV-positive and HIV-negative patients who received empirical TB treatment or TB treatment based on bacteriological confirmation and we compared it with the mortality among those who did not receive TB treatment. METHODS: This prospective cohort study included consecutively adult patients with signs and symptoms of TB attending an outpatient TB clinic in Western Kenya. At the first consultation, patients received a clinical exam and chest X-ray. Sputum was collected for microscopy, Xpert and Mycobacterium tuberculosis complex (MTB) culture. Patients not started on TB treatment were reassessed after 5 days. All patients bacteriologically confirmed (positive Xpert or culture) received TB treatment. Empirical treatment was defined as a decision to start TB treatment without bacteriological confirmation. Patients were reassessed after 6 months. RESULTS: Of 606 patients included, 344/606 (56.8%) were women. Median age was 35 years [Interquartile Range (IQR):27–47] and 398/594 (67.0%) were HIV-positive. In total, 196/606 (32.3%) patients were Xpert- or culture-positive and 331/606 (54.6%) started TB treatment. Overall, 100/398 (25.1%) HIV-positive and 31/196 (15.8%) HIV-negative patients received empirical treatment. Mortality in the 6 months following the first consultation was 1.6 and 0.8/100 patient-months among HIV-positive and HIV-negative patients respectively. In the multivariate analyses, TB treatment - whether empirical or based on bacteriological confirmation- was not associated with increased mortality among HIV-positive patients (aHR:2.51, 95%CI:0.79–7.90 and aHR:1.25, 95%CI:0.37–4.21 respectively). However, HIV-negative patients who received empirical treatment had a higher risk of mortality (aHR:4.85, 95%CI:1.08–21.67) compared to those not started on treatment. HIV-negative patients treated for TB based on bacteriological confirmation did not have a different risk of mortality (aHR:0.77, 95%CI:0.08–7.41). CONCLUSIONS: Our findings suggest that in a context with access to Xpert, clinicians should continue using empirical TB treatment in HIV-positive patients with signs and symptoms of TB and negative Xpert results. However, differential diagnoses other than TB should be actively sought before initiating empirical TB treatment, particularly in HIV-negative patients. BioMed Central 2019-02-11 /pmc/articles/PMC6369550/ /pubmed/30744603 http://dx.doi.org/10.1186/s12879-019-3775-z Text en © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Research Article Huerga, Helena Ferlazzo, Gabriella Wanjala, Stephen Bastard, Mathieu Bevilacqua, Paolo Ardizzoni, Elisa Sitienei, Joseph Bonnet, Maryline Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis |
title | Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis |
title_full | Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis |
title_fullStr | Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis |
title_full_unstemmed | Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis |
title_short | Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis |
title_sort | mortality in the first six months among hiv-positive and hiv-negative patients empirically treated for tuberculosis |
topic | Research Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369550/ https://www.ncbi.nlm.nih.gov/pubmed/30744603 http://dx.doi.org/10.1186/s12879-019-3775-z |
work_keys_str_mv | AT huergahelena mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT ferlazzogabriella mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT wanjalastephen mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT bastardmathieu mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT bevilacquapaolo mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT ardizzonielisa mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT sitieneijoseph mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis AT bonnetmaryline mortalityinthefirstsixmonthsamonghivpositiveandhivnegativepatientsempiricallytreatedfortuberculosis |