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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...

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Autores principales: Huerga, Helena, Ferlazzo, Gabriella, Wanjala, Stephen, Bastard, Mathieu, Bevilacqua, Paolo, Ardizzoni, Elisa, Sitienei, Joseph, Bonnet, Maryline
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
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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.
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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
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