1
|
Divala TH, Corbett EL, Kandulu C, Moyo B, MacPherson P, Nliwasa M, French N, Sloan DJ, Chiume L, Ndaferankhande MJ, Chilanga S, Majiga ST, Odland JØ, Fielding KL. Trial-of-antibiotics to assist tuberculosis diagnosis in symptomatic adults in Malawi (ACT-TB study): a randomised controlled trial. Lancet Glob Health 2023; 11:e556-e565. [PMID: 36925176 PMCID: PMC10030459 DOI: 10.1016/s2214-109x(23)00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/01/2023] [Accepted: 01/18/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Clinical practice and diagnostic algorithms often assume that tuberculosis can be ruled out in mycobacteriology-negative individuals whose symptoms improve with a trial-of-antibiotics. We aimed to investigate diagnostic performance, clinical benefit, and antimicrobial resistance using a randomised controlled trial. METHODS In this three-arm, individually randomised, open-label, controlled trial, we enrolled Malawian adults (aged ≥18 years) attending primary care who reported being unwell for at least 14 days (including cough) with no immediate indication for hospitalisation at Limbe and Ndirande Health Centres in Blantyre. Participants were randomly allocated (1:1:1) to azithromycin (500 mg taken once per day for 3 days), amoxicillin (1 g taken three times per day for 5 days), or standard of care with no immediate antibiotics, stratified by study site. Sputum at enrolment and day 8 was tested for tuberculosis (microscopy, Xpert MTB/RIF, and culture). The primary efficacy outcome was day 8 specificity (percentage with symptom improvement among mycobacteriology-negative participants), and day 29 clinical outcome (death, hospitalisation, or missed tuberculosis diagnosis) among all randomised participants. This study is registered with ClinicalTrials.gov, NCT03545373. FINDINGS Between Feb 25, 2019, and March 14, 2020, 5825 adults were screened and 1583 (mean age 36 years; 236 [14·9%] HIV positive) were randomly assigned to standard of care (530 participants), azithromycin (527 participants), or amoxicillin (526 participants) groups. Overall, 6·3% (100 of 1583 participants) had positive baseline sputum mycobacteriology. 310 (79·1%) of 392 patients receiving standard of care reported symptom improvement at day 8, compared with 340 (88·7%) of 383 patients receiving azithromycin (adjusted difference 8·6%, 95% CI 3·9-13·3%; p<0·0004) and 346 (89·4%) of 387 receiving amoxicillin (adjusted difference 8·8%, 4·0-13·6%; p=0·0003). The proportion of participants with day 29 composite clinical outcomes was similar between groups (standard of care 1% [7 of 530 participants], azithromycin 1% [6 of 527 participants], amoxicillin 2% [12 of 526 participants]). INTERPRETATION Routine outpatient trial-of-antibiotics during tuberculosis investigations modestly improved diagnostic specificity for mycobacteriologically confirmed tuberculosis but had no appreciable effect on death, hospitalisation, and missed tuberculosis diagnosis. These results confirm the limited benefit of trial-of-antibiotics, presenting an opportunity for discontinuation of trial-of-antibiotics and improved antimicrobial stewardship during tuberculosis screening, without affecting clinical outcomes. FUNDING Northern Norway Regional Health Authority (Helse Nord RHF), Commonwealth Scholarship Commission in the UK, Wellcome Trust, UK Medical Research Council, and the UK Department for International Development.
Collapse
Affiliation(s)
- Titus H Divala
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Elizabeth L Corbett
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Chikondi Kandulu
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Brewster Moyo
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter MacPherson
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK; School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Marriott Nliwasa
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Neil French
- Institute of Infection Veterinary and Ecological Science, University of Liverpool, Liverpool, UK
| | - Derek J Sloan
- School of Medicine, University of St Andrews, Fife, Scotland, UK; Victoria Hospital, NHS Fife, Kirkcaldy, Scotland, UK
| | - Lingstone Chiume
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Sanderson Chilanga
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Sabina Tazirwa Majiga
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jon Øyvind Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Katherine L Fielding
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK
| |
Collapse
|
2
|
Nobrega D, Peirano G, Pitout JDD. Escherichia coli sequence type 73 bloodstream infections in a centralized Canadian region and their association with companion animals: an ecological study. Infection 2022; 50:1579-1585. [PMID: 35657530 DOI: 10.1007/s15010-022-01856-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/12/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Extraintestinal pathogenic E. coli (ExPEC) are important pathogens causing community-acquired infections in humans, including bloodstream infections (BSIs), and may also colonize and infect animals. Our aim was to investigate associations between incidence rates (IRs) of BSIs caused by ExPEC and number of dogs and cats in communities in Calgary. METHODS We used a well-characterized collection of blood isolates (n = 685) from Calgary, Alberta, Canada (2016). We used a combination of a seven-single-nucleotide-polymorphism quantitative PCR to type ExPEC into sequence types (STs). Calgary census data were used to estimate IRs per city community, as well as to investigate associations between number of companion animals per community, as obtained from licensing data, and IR of BSIs caused by each dominant ST. RESULTS From the 685 isolates available, ExPEC ST131 was most prevalent (21.3% of included isolates), followed by ST73 (13.7%), ST69 (8.2%), ST95 (6.7%), and ST1193 (5.3%), respectively. Incidence of BSIs caused by ExPECs among Calgary residents was 48.8 cases per 100,000 resident-years, whereas communities had on average of 1.7 companion animals per 10 residents. No association between the number of dogs and IR of BSIs caused by ExPECs was detected for any ST. Conversely, the incidence rate of BSIs caused by ST73 was 3.6 times higher (95%CI 1.3-9.99) for every increase of 1 cat per 10 habitants in communities. CONCLUSIONS Number of cats per habitant was positively associated with the incidence of BSIs caused by ExPEC ST73.
Collapse
Affiliation(s)
- Diego Nobrega
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, ON, N1G 2W1, Canada.
| | - Gisele Peirano
- Division of Microbiology, Alberta Precision Laboratories, Calgary, AB, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada
| | - Johann D D Pitout
- Division of Microbiology, Alberta Precision Laboratories, Calgary, AB, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada.,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| |
Collapse
|