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MacLean ELH, Zimmer AJ, den Boon S, Gupta-Wright A, Cirillo DM, Cobelens F, Gillespie SH, Nahid P, Phillips PP, Ruhwald M, Denkinger CM. Tuberculosis treatment monitoring tests during routine practice: study design guidance. Clin Microbiol Infect 2024; 30:481-488. [PMID: 38182047 DOI: 10.1016/j.cmi.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/10/2023] [Accepted: 12/25/2023] [Indexed: 01/07/2024]
Abstract
SCOPE The current tools for tuberculosis (TB) treatment monitoring, smear microscopy and culture, cannot accurately predict poor treatment outcomes. Research into new TB treatment monitoring tools (TMTs) is growing, but data are unreliable. In this article, we aim to provide guidance for studies investigating and evaluating TB TMT for use during routine clinical care. Here, a TB TMT would guide treatment during the course of therapy, rather than testing for a cure at the regimen's end. This article does not cover the use of TB TMTs as surrogate endpoints in the clinical trial context. METHODS Guidelines were initially informed by experiences during a systematic review of TB TMTs. Subsequently, a small content expert group was consulted for feedback on initial recommendations. After revision, feedback from substantive experts across sectors was sought. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS The proposed considerations and recommendations for studies evaluating TB TMTs for use during the treatment in routine clinical care fall into eight domains. We provide specific recommendations regarding study design and recruitment, outcome definitions, reference standards, participant follow-up, clinical setting, study population, treatment regimen reporting, and index tests and data presentation. Overall, TB TMTs should be evaluated in a manner similar to diagnostic tests, but TB TMT accuracy must be assessed at multiple timepoints throughout the treatment course, and TB TMTs should be evaluated in study populations who have already received a diagnosis of TB. Study design and outcome definitions must be aligned with the developmental phase of the TB TMT under evaluation. There is no reference standard for TB treatment response, so different reference standards and comparator tests have been proposed, the selection of which will vary depending on the developmental phase of the TMT under assessment. The use of comparator tests can assist in generating evidence. Clarity is required when reporting of timepoints, TMT read-outs, and analysis results. Implementing these recommendations will lead to higher quality TB TMT studies that will allow data to be meaningfully compared, thereby facilitating the development of novel tools to guide individual TB therapy and improve treatment outcomes.
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Affiliation(s)
- Emily Lai-Ho MacLean
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Alexandra J Zimmer
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Saskia den Boon
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | | | - Daniela M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers Location, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephen H Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, UK
| | - Payam Nahid
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Patrick P Phillips
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Claudia M Denkinger
- Division of Clinical Tropical Medicine, Center of Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; Center of Infection Research (DZIF), Partners Site Heidelberg, Heidelberg, Germany.
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Yerlikaya S, Broger T, Isaacs C, Bell D, Holtgrewe L, Gupta-Wright A, Nahid P, Cattamanchi A, Denkinger CM. Blazing the trail for innovative tuberculosis diagnostics. Infection 2024; 52:29-42. [PMID: 38032537 PMCID: PMC10811035 DOI: 10.1007/s15010-023-02135-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023]
Abstract
The COVID-19 pandemic brought diagnostics into the spotlight in an unprecedented way not only for case management but also for population health, surveillance, and monitoring. The industry saw notable levels of investment and accelerated research which sparked a wave of innovation. Simple non-invasive sampling methods such as nasal swabs have become widely used in settings ranging from tertiary hospitals to the community. Self-testing has also been adopted as standard practice using not only conventional lateral flow tests but novel and affordable point-of-care molecular diagnostics. The use of new technologies, including artificial intelligence-based diagnostics, have rapidly expanded in the clinical setting. The capacity for next-generation sequencing and acceptance of digital health has significantly increased. However, 4 years after the pandemic started, the market for SARS-CoV-2 tests is saturated, and developers may benefit from leveraging their innovations for other diseases; tuberculosis (TB) is a worthwhile portfolio expansion for diagnostics developers given the extremely high disease burden, supportive environment from not-for-profit initiatives and governments, and the urgent need to overcome the long-standing dearth of innovation in the TB diagnostics field. In exchange, the current challenges in TB detection may be resolved by adopting enhanced swab-based molecular methods, instrument-based, higher sensitivity antigen detection technologies, and/or artificial intelligence-based digital health technologies developed for COVID-19. The aim of this article is to review how such innovative approaches for COVID-19 diagnosis can be applied to TB to have a comparable impact.
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Affiliation(s)
- Seda Yerlikaya
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany.
| | - Tobias Broger
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | | | - David Bell
- Independent Consultant, Lake Jackson, TX, USA
| | - Lydia Holtgrewe
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Ankur Gupta-Wright
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Institute for Global Health, University College London, London, UK
| | - Payam Nahid
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - Claudia M Denkinger
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- German Centre for Infection Research, Partner Site Heidelberg University Hospital, Heidelberg, Germany
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Gupta-Wright A, Ha H, Abdulgadar S, Crowder R, Emmanuel J, Mukwatamundu J, Marcelo D, Phillips PPJ, Christopher DJ, Nhung NV, Theron G, Yu C, Nahid P, Cattamanchi A, Worodria W, Denkinger CM. Evaluation of the Xpert MTB Host Response assay for the triage of patients with presumed pulmonary tuberculosis: a prospective diagnostic accuracy study in Viet Nam, India, the Philippines, Uganda, and South Africa. Lancet Glob Health 2024; 12:e226-e234. [PMID: 38245113 PMCID: PMC11046618 DOI: 10.1016/s2214-109x(23)00541-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Non-sputum-based triage tests for tuberculosis are a priority for ending tuberculosis. We aimed to evaluate the diagnostic accuracy of the late-prototype Xpert MTB Host Response (Xpert HR) blood-based assay. METHODS We conducted a prospective diagnostic accuracy study among outpatients with presumed tuberculosis in outpatient clinics in Viet Nam, India, the Philippines, Uganda, and South Africa. Eligible participants were aged 18 years or older and reported cough lasting at least 2 weeks. We excluded those receiving tuberculosis treatment in the preceding 12 months and those who were unwilling to consent. Xpert HR was performed on capillary or venous blood. Reference standard testing included sputum Xpert MTB/RIF Ultra and mycobacterial culture. We performed receiver operating characteristic (ROC) analysis to identify the optimal cutoff value for the Xpert HR to achieve the target sensitivity of 90% or more while maximising specificity, then calculated diagnostic accuracy using this cutoff value. This study was prospectively registered with ClinicalTrials.gov, NCT04923958. FINDINGS Between July 13, 2021, and Aug 15, 2022, 2046 adults with at least 2 weeks of cough were identified, of whom 1499 adults (686 [45·8%] females and 813 [54·2%] males) had valid Xpert HR and reference standard results. 329 (21·9%) had microbiologically confirmed tuberculosis. Xpert HR had an area under the ROC curve of 0·89 (95% CI 0·86-0·91). The optimal cutoff value was less than or equal to -1·25, giving a sensitivity of 90·3% (95% CI 86·5-93·3; 297 of 329) and a specificity of 62·6% (95% CI 59·7-65·3; 732 of 1170). Sensitivity was similar across countries, by sex, and by subgroups, although specificity was lower in people living with HIV (45·1%, 95% CI 37·8-52·6) than in those not living with HIV (65·9%, 62·8-68·8; difference of 20·8%, 95% CI 13·0-28·6; p<0·0001). Xpert HR had high negative predictive value (95·8%, 95% CI 94·1-97·1), but positive predictive value was only 40·1% (95% CI 36·8-44·1). Using the Xpert HR as a triage test would have reduced confirmatory sputum testing by 57·3% (95% CI 54·2-60·4). INTERPRETATION Xpert HR did not meet WHO minimum specificity targets for a non-sputum-based triage test for pulmonary tuberculosis. Despite promise as a rule-out test that could reduce confirmatory sputum testing, further cost-effectiveness modelling and data on acceptability and usability are needed to inform policy recommendations. FUNDING National Institute of Allergy and Infectious Diseases of the US National Institutes of Health. TRANSLATIONS For the Vietnamese and Tagalog translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ankur Gupta-Wright
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany; Institute for Global Health, University College London, London, UK.
| | - Huy Ha
- Hanoi Lung Hospital, Hanoi, Viet Nam
| | - Shima Abdulgadar
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rebecca Crowder
- UCSF Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Jerusha Emmanuel
- Department of Pulmonary Medicine, Christian Medical College, Vellore, India
| | - Job Mukwatamundu
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kampala, Uganda
| | - Danaida Marcelo
- De La Salle Medical Health Sciences Institute, Dasmariñas City, Cavite, Philippines
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Charles Yu
- De La Salle Medical Health Sciences Institute, Dasmariñas City, Cavite, Philippines
| | - Payam Nahid
- UCSF Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- UCSF Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - William Worodria
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kampala, Uganda; Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
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Gupta-Wright A, den Boon S, MacLean EL, Cirillo D, Cobelens F, Gillespie SH, Kohli M, Ruhwald M, Savic R, Brigden G, Gidado M, Goletti D, Hanna D, Hasan R, Hewison C, Koura KG, Lienhardt C, Lungu P, McHugh TD, McKenna L, Scott C, Scriba T, Sekaggya-Wiltshire C, Kasaeva T, Zignol M, Denkinger CM, Falzon D. Target product profiles: tests for tuberculosis treatment monitoring and optimization. Bull World Health Organ 2023; 101:730-737. [PMID: 37961060 PMCID: PMC10630735 DOI: 10.2471/blt.23.290901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023] Open
Abstract
The World Health Organization has developed target product profiles containing minimum and optimum targets for key characteristics for tests for tuberculosis treatment monitoring and optimization. Tuberculosis treatment optimization refers to initiating or switching to an effective tuberculosis treatment regimen that results in a high likelihood of a good treatment outcome. The target product profiles also cover tests of cure conducted at the end of treatment. The development of the target product profiles was informed by a stakeholder survey, a cost-effectiveness analysis and a patient-care pathway analysis. Additional feedback from stakeholders was obtained by means of a Delphi-like process, a technical consultation and a call for public comment on a draft document. A scientific development group agreed on the final targets in a consensus meeting. For characteristics rated of highest importance, the document lists: (i) high diagnostic accuracy (sensitivity and specificity); (ii) time to result of optimally ≤ 2 hours and no more than 1 day; (iii) required sample type to be minimally invasive, easily obtainable, such as urine, breath, or capillary blood, or a respiratory sample that goes beyond sputum; (iv) ideally the test could be placed at a peripheral-level health facility without a laboratory; and (v) the test should be affordable to low- and middle-income countries, and allow wide and equitable access and scale-up. Use of these target product profiles should facilitate the development of new tuberculosis treatment monitoring and optimization tests that are accurate and accessible for all people being treated for tuberculosis.
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Affiliation(s)
- Ankur Gupta-Wright
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | - Saskia den Boon
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Emily L MacLean
- Central Clinical School, University of Sydney, Sydney, Australia
| | | | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam, Kingdom of the Netherlands
| | - Stephen H Gillespie
- Division of Infection and Global Health, University of St Andrews, St Andrews, Scotland
| | | | | | - Rada Savic
- University of California San Francisco, San Francisco, California, United States of America (USA)
| | - Grania Brigden
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases L Spallanzani-IRCCS, Rome, Italy
| | - Debra Hanna
- Bill & Melinda Gates Foundation, Seattle, USA
| | | | | | - Kobto G Koura
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Christian Lienhardt
- French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - Patrick Lungu
- East, Central and Southern Africa Health Community, Arusha, United Republic of Tanzania
| | - Timothy D McHugh
- Centre for Clinical Microbiology, University College London, London, England
| | | | | | | | | | - Tereza Kasaeva
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Matteo Zignol
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Claudia M Denkinger
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | - Dennis Falzon
- Global Tuberculosis Programme, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
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Broger T, Koeppel L, Huerga H, Miller P, Gupta-Wright A, Blanc FX, Esmail A, Reeve BWP, Floridia M, Kerkhoff AD, Ciccacci F, Kasaro MP, Thit SS, Bastard M, Ferlazzo G, Yoon C, Van Hoving DJ, Sossen B, García JI, Cummings MJ, Wake RM, Hanson J, Cattamanchi A, Meintjes G, Maartens G, Wood R, Theron G, Dheda K, Olaru ID, Denkinger CM. Diagnostic yield of urine lipoarabinomannan and sputum tuberculosis tests in people living with HIV: a systematic review and meta-analysis of individual participant data. Lancet Glob Health 2023; 11:e903-e916. [PMID: 37202025 DOI: 10.1016/s2214-109x(23)00135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Sputum is the most widely used sample to diagnose active tuberculosis, but many people living with HIV are unable to produce sputum. Urine, in contrast, is readily available. We hypothesised that sample availability influences the diagnostic yield of various tuberculosis tests. METHODS In this systematic review and meta-analysis of individual participant data, we compared the diagnostic yield of point-of-care urine-based lipoarabinomannan tests with that of sputum-based nucleic acid amplification tests (NAATs) and sputum smear microscopy (SSM). We used microbiologically confirmed tuberculosis based on positive culture or NAAT from any body site as the denominator and accounted for sample provision. We searched PubMed, Web of Science, Embase, African Journals Online, and clinicaltrials.gov from database inception to Feb 24, 2022 for randomised controlled trials, cross-sectional studies, and cohort studies that assessed urine lipoarabinomannan point-of-care tests and sputum NAATs for active tuberculosis detection in participants irrespective of tuberculosis symptoms, HIV status, CD4 cell count, or study setting. We excluded studies in which recruitment was not consecutive, systematic, or random; provision of sputum or urine was an inclusion criterion; less than 30 participants were diagnosed with tuberculosis; early research assays without clearly defined cutoffs were tested; and humans were not studied. We extracted study-level data, and authors of eligible studies were invited to contribute deidentified individual participant data. The main outcomes were the tuberculosis diagnostic yields of urine lipoarabinomannan tests, sputum NAATs, and SSM. Diagnostic yields were predicted using Bayesian random-effects and mixed-effects meta-analyses. This study is registered with PROSPERO, CRD42021230337. FINDINGS We identified 844 records, from which 20 datasets and 10 202 participants (4561 [45%] male participants and 5641 [55%] female participants) were included in the meta-analysis. All studies assessed sputum Xpert (MTB/RIF or Ultra, Cepheid, Sunnyvale, CA, USA) and urine Alere Determine TB LAM (AlereLAM, Abbott, Chicago, IL, USA) in people living with HIV aged 15 years or older. Nearly all (9957 [98%] of 10 202) participants provided urine, and 82% (8360 of 10 202) provided sputum within 2 days. In studies that enrolled unselected inpatients irrespective of tuberculosis symptoms, only 54% (1084 of 1993) of participants provided sputum, whereas 99% (1966 of 1993) provided urine. Diagnostic yield was 41% (95% credible interval [CrI] 15-66) for AlereLAM, 61% (95% Crl 25-88) for Xpert, and 32% (95% Crl 10-55) for SSM. Heterogeneity existed across studies in the diagnostic yield, influenced by CD4 cell count, tuberculosis symptoms, and clinical setting. In predefined subgroup analyses, all tests had higher yields in symptomatic participants, and AlereLAM yield was higher in those with low CD4 counts and inpatients. AlereLAM and Xpert yields were similar among inpatients in studies enrolling unselected participants who were not assessed for tuberculosis symptoms (51% vs 47%). AlereLAM and Xpert together had a yield of 71% in unselected inpatients, supporting the implementation of combined testing strategies. INTERPRETATION AlereLAM, with its rapid turnaround time and simplicity, should be prioritised to inform tuberculosis therapy among inpatients who are HIV-positive, regardless of symptoms or CD4 cell count. The yield of sputum-based tuberculosis tests is undermined by people living with HIV who cannot produce sputum, whereas nearly all participants are able to provide urine. The strengths of this meta-analysis are its large size, the carefully harmonised denominator, and the use of Bayesian random-effects and mixed-effects models to predict yields; however, data were geographically restricted, clinically diagnosed tuberculosis was not considered in the denominator, and little information exists on strategies for obtaining sputum samples. FUNDING FIND, the Global Alliance for Diagnostics.
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Affiliation(s)
- Tobias Broger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Lisa Koeppel
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Poppy Miller
- New Zealand Institute for Plant and Food Research, Auckland, New Zealand
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - François-Xavier Blanc
- Service de Pneumologie, l'institut du thorax, Nantes Université, CHU Nantes, Nantes, France
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Byron W P Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Trauma Center, University of California San Francisco, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Fausto Ciccacci
- UniCamillus, International University of Health and Medical Science, Rome, Italy; Community of Sant'Egidio, DREAM programme, Rome, Italy
| | - Margaret P Kasaro
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; UNC Global Projects, LLC Zambia, Lusaka, Zambia
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | | | | | - Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Daniël J Van Hoving
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa; Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Bianca Sossen
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Juan Ignacio García
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA; Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rachel M Wake
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa; Institute for Infection and Immunity, St George's University of London, London, UK
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Adithya Cattamanchi
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Keertan Dheda
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK; Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Ioana Diana Olaru
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; German Center for Infection Research, partner site, Heidelberg University Hospital, Heidelberg, Germany.
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Huerga H, Gupta-Wright A, Muyindike W, Hewison C, Casenghi M, Bonnet M. Lots of considerations when evaluating the FujiLAM assay - Author's reply. Lancet Glob Health 2023; 11:e502. [PMID: 36925168 DOI: 10.1016/s2214-109x(23)00115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Helena Huerga
- Department of Field Epidemiology, Epicentre, Paris 75019, France.
| | | | - Winnie Muyindike
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | - Martina Casenghi
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Maryline Bonnet
- Université de Montpellier, TransVIHMI, INSERM, IRD, Montpellier, France
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Burke RM, Twabi HH, Johnston C, Nliwasa M, Gupta-Wright A, Fielding K, Ford N, MacPherson P, Corbett EL. Interventions to reduce deaths in people living with HIV admitted to hospital in low- and middle-income countries: A systematic review. PLOS Glob Public Health 2023; 3:e0001557. [PMID: 36963024 PMCID: PMC10022356 DOI: 10.1371/journal.pgph.0001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
People living with HIV (PLHIV) admitted to hospital have a high risk of death. We systematically appraised evidence for interventions to reduce mortality among hospitalised PLHIV in low- and middle-income countries (LMICs). Using a broad search strategy with terms for HIV, hospitals, and clinical trials, we searched for reports published between 1 Jan 2003 and 23 August 2021. Studies of interventions among adult HIV positive inpatients in LMICs were included if there was a comparator group and death was an outcome. We excluded studies restricted only to inpatients with a specific diagnosis (e.g. cryptococcal meningitis). Of 19,970 unique studies identified in search, ten were eligible for inclusion with 7,531 participants in total: nine randomised trials, and one before-after study. Three trials investigated systematic screening for tuberculosis; two showed survival benefit for urine TB screening vs. no urine screening, and one which compared Xpert MTB/RIF versus smear microscopy showed no difference in survival. One before-after study implemented 2007 WHO guidelines to improve management of smear negative tuberculosis in severely ill PLHIV, and showed survival benefit but with high risk of bias. Two trials evaluated complex interventions aimed at overcoming barriers to ART initiation in newly diagnosed PLHIV, one of which showed survival benefit and the other no difference. Two small trials evaluated early inpatient ART start, with no difference in survival. Two trials investigated protocol-driven fluid resuscitation for emergency-room attendees meeting case-definitions for sepsis, and showed increased mortality with use of a protocol for fluid administration. In conclusion, ten studies published since 2003 investigated interventions that aimed to reduce mortality in hospitalised adults with HIV, and weren't restricted to people with a defined disease diagnosis. Inpatient trials of diagnostics, therapeutics or a package of interventions to reduce mortality should be a research priority. Trial registration: PROSPERO Number: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019150341.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
| | - Hussein H. Twabi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Cheryl Johnston
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathan Ford
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Peter MacPherson
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elizabeth L. Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
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Huerga H, Bastard M, Lubega AV, Akinyi M, Antabak NT, Ohler L, Muyindike W, Taremwa IM, Stewart R, Bossard C, Nkosi N, Ndlovu Z, Hewison C, Stavia T, Okomo G, Ogoro JO, Ngozo J, Mbatha M, Aleny C, Wanjala S, Musoke M, Atwine D, Ascorra A, Ardizzoni E, Casenghi M, Ferlazzo G, Nakiyingi L, Gupta-Wright A, Bonnet M. Novel FujiLAM assay to detect tuberculosis in HIV-positive ambulatory patients in four African countries: a diagnostic accuracy study. Lancet Glob Health 2023; 11:e126-e135. [PMID: 36521944 PMCID: PMC9747168 DOI: 10.1016/s2214-109x(22)00463-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Development of rapid biomarker-based tests that can diagnose tuberculosis using non-sputum samples is a priority for tuberculosis control. We aimed to compare the diagnostic accuracy of the novel Fujifilm SILVAMP TB LAM (FujiLAM) assay with the WHO-recommended Alere Determine TB-LAM Ag test (AlereLAM) using urine samples from HIV-positive patients. METHODS We did a diagnostic accuracy study at five outpatient public health facilities in Uganda, Kenya, Mozambique, and South Africa. Eligible patients were ambulatory HIV-positive individuals (aged ≥15 years) with symptoms of tuberculosis irrespective of their CD4 T-cell count (group 1), and asymptomatic patients with advanced HIV disease (CD4 count <200 cells per μL, or HIV clinical stage 3 or 4; group 2). All participants underwent clinical examination, chest x-ray, and blood sampling, and were requested to provide a fresh urine sample, and two sputum samples. FujiLAM and AlereLAM urine assays, Xpert MTB/RIF Ultra assay on sputum or urine, sputum culture for Mycobacterium tuberculosis, and CD4 count were systematically carried out for all patients. Sensitivity and specificity of FujiLAM and AlereLAM were evaluated against microbiological and composite reference standards. FINDINGS Between Aug 24, 2020 and Sept 21, 2021, 1575 patients (823 [52·3%] women) were included in the study: 1031 patients in group 1 and 544 patients in group 2. Tuberculosis was microbiologically confirmed in 96 (9·4%) of 1022 patients in group 1 and 18 (3·3%) of 542 patients in group 2. Using the microbiological reference standard, FujiLAM sensitivity was 60% (95% CI 51-69) and AlereLAM sensitivity was 40% (31-49; p<0·001). Among patients with CD4 counts of less than 200 cells per μL, FujiLAM sensitivity was 69% (57-79) and AlereLAM sensitivity was 52% (40-64; p=0·0218). Among patients with CD4 counts of 200 cells per μL or higher, FujiLAM sensitivity was 47% (34-61) and AlereLAM sensitivity was 24% (14-38; p=0·0116). Using the microbiological reference standard, FujiLAM specificity was 87% (95% CI 85-89) and AlereLAM specificity was 86% (95 CI 84-88; p=0·941). FujiLAM sensitivity varied by lot number from 48% (34-62) to 76% (57-89) and specificity from 77% (72-81) to 98% (93-99). INTERPRETATION Next-generation, higher sensitivity urine-lipoarabinomannan assays are potentially promising tests that allow rapid tuberculosis diagnosis at the point of care for HIV-positive patients. However, the variability in accuracy between FujiLAM lot numbers needs to be addressed before clinical use. FUNDING ANRS and Médecins Sans Frontières.
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Affiliation(s)
- Helena Huerga
- Department of Field Epidemiology, Epicentre, Paris, France.
| | | | | | - Milcah Akinyi
- Department of Medicine, Médecins Sans Frontières, Nairobi, Kenya
| | | | - Liesbet Ohler
- Department of Medicine, Médecins Sans Frontières, Eshowe, South Africa
| | - Winnie Muyindike
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | - Rosanna Stewart
- Department of Medicine, Médecins Sans Frontières, Eshowe, South Africa
| | - Claire Bossard
- Department of Field Epidemiology, Epicentre, Paris, France
| | - Nothando Nkosi
- Department of Medicine, Médecins Sans Frontières, Eshowe, South Africa
| | - Zibusiso Ndlovu
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - Turyahabwe Stavia
- National Tuberculosis and Leprosy Control Services, Ministry of Health, Kampala, Uganda
| | - Gordon Okomo
- Department of Health Services, Ministry of Health, Homa Bay, Kenya
| | - Jeremiah Okari Ogoro
- National Tuberculosis and Leprosy Control Services, Ministry of Health, Nairobi, Kenya
| | | | - Mduduzi Mbatha
- King Cetswayo District Office, Department of Health, Eshowe, South Africa
| | - Couto Aleny
- National STI, HIV/AIDS Control Program, Ministry of Health, Maputo, Mozambique
| | - Stephen Wanjala
- Department of Medicine, Médecins Sans Frontières, Nairobi, Kenya
| | - Mohammed Musoke
- Department of Medicine, Médecins Sans Frontières, Nairobi, Kenya
| | | | | | - Elisa Ardizzoni
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Martina Casenghi
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Gabriella Ferlazzo
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Lydia Nakiyingi
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Maryline Bonnet
- Université de Montpellier, TransVIHMI, INSERM, IRD, Montpellier, France
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9
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Gupta-Wright A. Tuberculosis diagnostics to reduce HIV-associated mortality. Clinical Infection in Practice 2022. [DOI: 10.1016/j.clinpr.2022.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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10
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Broger T, Denkinger CM, Rangaka MX, Gupta-Wright A, Fielding K, Wood R, Huerga H, Rücker SCM, Bjerrum S, Johansen IS, Thit SS, Kyi MM, Hanson J, Barr DA, Meintjes G, Maartens G. Diagnostic accuracy of WHO screening criteria to guide lateral-flow lipoarabinomannan testing among HIV-positive inpatients: A systematic review and individual participant data meta-analysis. J Infect 2022; 85:40-48. [PMID: 35588942 PMCID: PMC10152564 DOI: 10.1016/j.jinf.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND WHO recommends urine lateral-flow lipoarabinomannan (LF-LAM) testing with AlereLAM in HIV-positive inpatients only if screening criteria are met. We assessed the performance of WHO screening criteria and alternative screening tests/strategies to guide LF-LAM testing and compared diagnostic accuracy of the WHO AlereLAM algorithm (WHO screening criteria followed by AlereLAM if screen positive) with AlereLAM and FujiLAM (a novel LF-LAM test) testing in all HIV-positive inpatients. METHODS We searched MEDLINE, Embase, and Cochrane Library from Jan 1, 2011 to March 1, 2020 for studies among adult/adolescent HIV-positive inpatients regardless of tuberculosis signs and symptoms. The reference standards were (1) AlereLAM or FujiLAM for screening tests/strategies and (2) culture or Xpert for AlereLAM/FujiLAM. We determined proportion of inpatients eligible for AlereLAM using WHO screening criteria; assessed accuracy of WHO criteria and alternative screening tests/strategies to guide LF-LAM testing; compared accuracy of WHO AlereLAM algorithm with AlereLAM/FujiLAM testing in all; and determined diagnostic yield of AlereLAM, FujiLAM, and Xpert MTB/RIF (Xpert). We estimated pooled proportions with a random-effects model, assessed diagnostic accuracy using random-effects bivariate models, and assessed diagnostic yield descriptively. FINDINGS We obtained data from all 5 identified studies (n = 3,504). The pooled proportion of inpatients eligible for AlereLAM using WHO criteria was 93% (95%CI 91, 95). Among screening tests/strategies to guide LF-LAM testing, WHO criteria, C-reactive protein (≥5 mg/L), and CD4 count (<200 cells/μL) had high sensitivities but low specificities; cough (≥2 weeks), hemoglobin (<8 g/dL), body mass index (<18.5 kg/m2), lymphadenopathy, and WHO-defined danger signs had higher specificities but suboptimal sensitivities. AlereLAM in all had the same sensitivity (62%) and specificity (88%) as WHO AlereLAM algorithm. Sensitivity of FujiLAM and AlereLAM was 69% and 48%, while specificity was 88% and 96%, respectively. In 2 studies that collected sputum and non-sputum samples for Xpert and/or culture, diagnostic yield of sputum Xpert was 40-41%, AlereLAM was 39-76%, and urine Xpert was 35-62%. In one study, FujiLAM diagnosed 80% of tuberculosis cases (vs 39% for AlereLAM), and sputum Xpert combined with AlereLAM, urine Xpert, or FujiLAM diagnosed 61%, 81%, and 92% of all cases, respectively. INTERPRETATION WHO criteria and alternative screening tests/strategies have limited utility in guiding LF-LAM testing, suggesting that AlereLAM testing in all HIV-positive medical inpatients be implemented. Routine FujiLAM may improve tuberculosis diagnosis. FUNDING None.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global TB Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Tobias Broger
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; FIND, Geneva, Switzerland
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; German Center of Infection Research, Heidelberg, Germany; FIND, Geneva, Switzerland
| | - Molebogeng X Rangaka
- Institute for Global Health, University College London, London, UK; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | | | - Stephanie Bjerrum
- Department of Clinical Research, Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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11
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Nel J, Gupta-Wright A. Urine tuberculosis diagnostics in patients with advanced HIV. AIDS 2022; 36:897-898. [PMID: 35506266 DOI: 10.1097/qad.0000000000003178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jeremy Nel
- University of the Witwatersrand, Johannesburg, South Africa
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London UK
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12
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Rangaka MX, Kredo T, Baddeley A, Miller C, Gupta-Wright A, Fielding K, Wood R, Huerga H, Rücker SCM, Heidebrecht C, Wilson D, Bjerrum S, Johansen IS, Thit SS, Kyi MM, Hanson J, Barr DA, Meintjes G, Maartens G. Tuberculosis screening among HIV-positive inpatients: a systematic review and individual participant data meta-analysis. Lancet HIV 2022; 9:e233-e241. [PMID: 35338834 PMCID: PMC8964502 DOI: 10.1016/s2352-3018(22)00002-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since 2011, WHO has recommended that HIV-positive inpatients be routinely screened for tuberculosis with the WHO four-symptom screen (W4SS) and, if screened positive, receive a molecular WHO-recommended rapid diagnostic test (eg, Xpert MTB/RIF [Xpert] assay). To inform updated WHO tuberculosis screening guidelines, we conducted a systematic review and individual participant data meta-analysis to assess the performance of W4SS and alternative screening tests to guide Xpert testing and compare the diagnostic accuracy of the WHO Xpert algorithm (ie, W4SS followed by Xpert) with Xpert for all HIV-positive inpatients. METHODS We searched MEDLINE, Embase, and Cochrane Library from Jan 1, 2011, to March 1, 2020, for studies of adult and adolescent HIV-positive inpatients enrolled regardless of tuberculosis signs and symptoms. The separate reference standards were culture and Xpert. Xpert was selected since it is most likely to be the confirmatory test used in practice. We assessed the proportion of inpatients eligible for Xpert testing using the WHO algorithm; assessed the accuracy of W4SS and alternative screening tests or strategies to guide diagnostic testing; and compared the accuracy of the WHO Xpert algorithm (W4SS followed by Xpert) with Xpert for all. We obtained pooled proportion estimates with a random-effects model, assessed diagnostic accuracy by fitting random-effects bivariate models, and assessed diagnostic yield descriptively. This systematic review has been registered on PROSPERO (CRD42020155895). FINDINGS Of 6162 potentially eligible publications, six were eligible and we obtained data for all of the six publications (n=3660 participants). The pooled proportion of inpatients eligible for an Xpert was 90% (95% CI 89-91; n=3658). Among screening tests to guide diagnostic testing, W4SS and C-reactive protein (≥5 mg/L) had highest sensitivities (≥96%) but low specificities (≤12%); cough (≥2 weeks), haemoglobin concentration (<8 g/dL), body-mass index (<18·5 kg/m2), and lymphadenopathy had higher specificities (61-90%) but suboptimal sensitivities (12-57%). The WHO Xpert algorithm (W4SS followed by Xpert) had a sensitivity of 76% (95% CI 67-84) and specificity of 93% (88-96; n=637). Xpert for all had similar accuracy to the WHO Xpert algorithm: sensitivity was 78% (95% CI 69-85) and specificity was 93% (87-96; n=639). In two cohorts that had sputum and non-sputum samples collected for culture or Xpert, diagnostic yield of sputum Xpert was 41-70% and 61-64% for urine Xpert. INTERPRETATION The W4SS and other potential screening tests to guide Xpert testing have suboptimal accuracy in HIV-positive inpatients. On the basis of these findings, WHO now strongly recommends molecular rapid diagnostic testing in all medical HIV-positive inpatients in settings where tuberculosis prevalence is higher than 10%. FUNDING World Health Organization.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global TB Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Molebogeng X Rangaka
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Institute for Global Health, University College London, London, UK
| | - Tamara Kredo
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | | | | | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Robin Wood
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | | | | | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stephanie Bjerrum
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Swe Swe Thit
- Department of Medicine, University of Medicine, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine, Yangon, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Burke RM, Nyirenda S, Twabi HH, Nliwasa M, Joekes E, Walker N, Nyirenda R, Gupta-Wright A, Fielding K, MacPherson P, Corbett EL. Design and protocol for a cluster randomised trial of enhanced diagnostics for tuberculosis screening among people living with HIV in hospital in Malawi (CASTLE study). PLoS One 2022; 17:e0261877. [PMID: 35007306 PMCID: PMC8746787 DOI: 10.1371/journal.pone.0261877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND People living with HIV (PLHIV) have a high risk of death if hospitalised in low-income countries. Tuberculosis has long been the leading cause of admission and death, in part due to suboptimal diagnostics. Two promising new diagnostic tools are digital chest Xray with computer-aided diagnosis (DCXR-CAD) and urine testing with Fujifilm SILVAMP LAM (FujiLAM). Neither test has been rigorously evaluated among inpatients. Test characteristics may be complementary, with FujiLAM especially sensitive for disseminated tuberculosis and DCXR-CAD especially sensitive for pulmonary tuberculosis, making combined interventions of interest. DESIGN AND METHODS An exploratory unblinded, single site, two-arm cluster randomised controlled trial, with day of admission as the unit of randomisation. A third, smaller, integrated cohort arm (4:4:1 random allocation) contributes to understanding case-mix, but not trial outcomes. Participants are adults living with HIV not currently on TB treatment. The intervention (DCXR-CAD plus urine FujiLAM plus usual care) is compared to usual care alone. The primary outcome is proportion of participants started on tuberculosis treatment by day 56, with secondary outcomes of mortality (time to event) measured to to 56 days from enrolment, proportions with undiagnosed tuberculosis at death or hospital discharge and comparing proportions with enrolment-day tuberculosis treatment initiation. DISCUSSION Both DCXR-CAD and FujiLAM have potential clinical utility and may have complementary diagnostic performance. To our knowledge, this is the first randomised trial to evaluate these tests among hospitalised PLHIV.
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Affiliation(s)
- Rachael M. Burke
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Saulos Nyirenda
- Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Hussein H. Twabi
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Marriott Nliwasa
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Naomi Walker
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rose Nyirenda
- Department of HIV AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | - Ankur Gupta-Wright
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Institute for Global Health, University College London, London, England
| | - Katherine Fielding
- Faculty of Epidemiology and Population Health, Infectious Disease Epidemiology Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter MacPherson
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
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14
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Burke RM, Henrion MYR, Mallewa J, Masamba L, Kalua T, Khundi M, Gupta-Wright A, Rylance J, Gordon SB, Masesa C, Corbett EL, Mwandumba HC, Macpherson P. Incidence of HIV-positive admission and inpatient mortality in Malawi (2012-2019). AIDS 2021; 35:2191-2199. [PMID: 34172671 PMCID: PMC7611991 DOI: 10.1097/qad.0000000000003006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate trends in population incidence of HIV-positive hospital admission and risk of in-hospital death among adults living with HIV between 2012 and 2019 in Blantyre, Malawi. DESIGN Population cohort study using an existing electronic health information system ('SPINE') at Queen Elizabeth Central Hospital and Blantyre census data. METHODS We used multiple imputation and negative binomial regression to estimate population age-specific and sex-specific admission rates over time. We used a log-binomial model to investigate trends in risk of in-hospital death. RESULTS Of 32 814 adult medical admissions during Q4 2012--Q3 2019, HIV status was recorded for 75.6%. HIV-positive admissions decreased substantially between 2012 and 2019. After imputation for missing data, HIV-positive admissions were highest in Q3 2013 (173 per 100 000 adult Blantyre residents) and lowest in Q3 2019 (53 per 100 000 residents). An estimated 10 818 fewer than expected people with HIV (PWH) [95% confidence interval (CI) 10 068-11 568] were admitted during 2012-2019 compared with the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2264 fewer HIV-positive admissions, 95% CI 2002-2526). In-hospital mortality for PWH was 23.5%, with no significant change over time in any age-sex group, and no association with antiretroviral therapy (ART) use at admission. CONCLUSION Rates of admission for adult PWH decreased substantially, likely because of large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PWH.
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Affiliation(s)
- Rachael M Burke
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
| | - Marc Y R Henrion
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Jane Mallewa
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Leo Masamba
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - McEwan Khundi
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Ankur Gupta-Wright
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
| | - Jamie Rylance
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Stephen B Gordon
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Clemens Masesa
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Elizabeth L Corbett
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
| | - Henry C Mwandumba
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Peter Macpherson
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
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15
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Houston H, Deas G, Naik S, Shah K, Patel S, Greca Dottori M, Tay M, Filson SA, Biggin-Lamming J, Ross J, Vaughan N, Vaid N, Gopal Rao G, Amin AK, Gupta-Wright A, John L. Utility of the FebriDx point-of-care assay in supporting a triage algorithm for medical admissions with possible COVID-19: an observational cohort study. BMJ Open 2021; 11:e049179. [PMID: 34373308 PMCID: PMC8354759 DOI: 10.1136/bmjopen-2021-049179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To evaluate a triage algorithm used to identify and isolate patients with suspected COVID-19 among medical patients needing admission to hospital using simple clinical criteria and the FebriDx assay. DESIGN Retrospective observational cohort. SETTING Large acute National Health Service hospital in London, UK. PARTICIPANTS All medical admissions from the emergency department between 10 August 2020 and 4 November 2020 with a valid SARS-CoV-2 RT-PCR result. INTERVENTIONS Medical admissions were triaged as likely, possible or unlikely COVID-19 based on clinical criteria. Patients triaged as possible COVID-19 underwent FebriDx lateral flow assay on capillary blood, and those positive for myxovirus resistance protein A (a host response protein) were managed as likely COVID-19. PRIMARY OUTCOME MEASURES Diagnostic accuracy (sensitivity, specificity and predictive values) of the algorithm and the FebriDx assay using SARS-CoV-2 RT-PCR from nasopharyngeal swabs as the reference standard. RESULTS 4.0% (136) of 3443 medical admissions had RT-PCR confirmed COVID-19. Prevalence of COVID-19 was 46% (80/175) in those triaged as likely, 4.1% (50/1225) in possible and 0.3% (6/2033) in unlikely COVID-19. Using a SARS-CoV-2 RT-PCR reference standard, clinical triage had sensitivity of 96% (95% CI 91% to 98%) and specificity of 61.5% (95% CI 59.8% to 63.1%), while the triage algorithm including FebriDx had sensitivity of 93% (95% CI 87% to 96%) and specificity of 86.4% (95% CI 85.2% to 87.5%). While 2033 patients were deemed not to require isolation using clinical criteria alone, the addition of FebriDx to clinical triage allowed a further 826 patients to be released from isolation, reducing the need for isolation rooms by 9.5 per day, 95% CI 8.9 to 10.2. Ten patients missed by the algorithm had mild or asymptomatic COVID-19. CONCLUSIONS A triage algorithm including the FebriDx assay had good sensitivity and was useful to 'rule-out' COVID-19 among medical admissions to hospital.
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Affiliation(s)
- Hamish Houston
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Gavin Deas
- Department of Acute Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Shivam Naik
- School of Medicine, Imperial College London, London, UK
| | - Kamal Shah
- School of Medicine, Imperial College London, London, UK
| | - Shiras Patel
- School of Medicine, Imperial College London, London, UK
| | | | - Michael Tay
- School of Medicine, Imperial College London, London, UK
| | - Sarah Ann Filson
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - James Biggin-Lamming
- Transformation Programme Director, London North West University Healthcare NHS Trust, London, UK
| | - John Ross
- Emergency Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Natalie Vaughan
- Department of Pathology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Nidhi Vaid
- Department of Acute Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Guduru Gopal Rao
- Department of Microbiology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
- Department of Medicine, Imperial College London, London, UK
| | - Amit K Amin
- Department of Microbiology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurence John
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
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16
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Fink DL, Goldman NR, Cai J, El-Shakankery KH, Sismey GE, Gupta-Wright A, Tai CX. Ratio of Oxygen Saturation Index to Guide Management of COVID-19 Pneumonia. Ann Am Thorac Soc 2021; 18:1426-1428. [PMID: 33636094 PMCID: PMC8513664 DOI: 10.1513/annalsats.202008-934rl] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Douglas L. Fink
- Whipps Cross University HospitalLondon, United Kingdom
- London School of Hygiene and Tropical MedicineLondon, United Kingdom
| | | | - James Cai
- Whipps Cross University HospitalLondon, United Kingdom
| | | | | | - Ankur Gupta-Wright
- London School of Hygiene and Tropical MedicineLondon, United Kingdom
- University College LondonLondon, United Kingdom
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17
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Gupta-Wright A, Barnabas RV, Ingold H, Duneton P, Abubakar I. HIV self-testing: lessons learnt and priorities for adaptation in a shifting landscape. BMJ Glob Health 2021; 6:bmjgh-2020-004418. [PMID: 34275867 PMCID: PMC8287622 DOI: 10.1136/bmjgh-2020-004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK .,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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18
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Bresges C, Wilson D, Fielding K, Corbett EL, Del-Greco F, Grint D, Peters J, Gupta-Wright A. Early Empirical Tuberculosis Treatment in HIV-Positive Patients Admitted to Hospital in South Africa: An Observational Cohort Study. Open Forum Infect Dis 2021; 8:ofab162. [PMID: 34327252 PMCID: PMC8314941 DOI: 10.1093/ofid/ofab162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Empirical tuberculosis (TB) treatment in human immunodeficiency virus (HIV)-positive inpatients is common and may undermine the impact of new diagnostics. We sought to describe empirical TB treatment and compare characteristics and outcomes with patients treated for TB after screening. METHODS This was a retrospective observational cohort study of HIV-positive inpatients treated empirically for TB prior to TB screening. Data on clinical characteristics, investigations, and outcomes were collected from medical records. Comparison cohorts with microbiologically confirmed or empirical TB treatment after TB screening with Xpert MTB/RIF and urine lipoarabinomannan assays were taken from South African Screening for Tuberculosis to Reduce AIDS-Related Mortality in Hospitalized Patients in Africa (STAMP) trial site. In-hospital mortality was compared using a competing-risks analysis adjusted for age, sex, and CD4 cell count. RESULTS Between January 2016 and September 2017, 100 patients excluded from STAMP were treated for TB empirically prior to TB screening. After enrollment in STAMP and TB screening, 240 of 1177 (20.4%) patients received TB treatment, of whom 123 had positive TB tests and 117 were treated empirically. Characteristics were similar among early empirically treated patients and those treated after TB screening. 50% of early empirical TB treatment was based on radiological investigations, 22% on cerebrospinal or pleural fluid testing, and 28% on clinical features alone. Only 11 of 100 empirically treated patients had subsequent microbiological confirmation. In-hospital mortality was lower in patients with microbiologically confirmed TB compared to those treated empirically (adjusted subdistribution hazard ratio, 0.5 [95% confidence interval, .3-.9). CONCLUSIONS Empirical TB treatment remains common in severely ill HIV-positive inpatients. These patients may benefit from TB screening using existing rapid diagnostics, both to improve confirmation of TB disease and reduce overtreatment for TB.
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Affiliation(s)
- Carolin Bresges
- Global Health and Infection Department, Brighton and Sussex Medical School, Brighton, United Kingdom.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizabeth L Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Fabrizia Del-Greco
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel Grint
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jurgens Peters
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Institute for Global Health, University College London, London, United Kingdom
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19
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Gupta-Wright A, Macleod CK, Barrett J, Filson SA, Corrah T, Parris V, Sandhu G, Harris M, Tennant R, Vaid N, Takata J, Duraisingham S, Gandy N, Chana H, Whittington A, McGregor A, Papineni P. False-negative RT-PCR for COVID-19 and a diagnostic risk score: a retrospective cohort study among patients admitted to hospital. BMJ Open 2021; 11:e047110. [PMID: 33563629 PMCID: PMC7874904 DOI: 10.1136/bmjopen-2020-047110] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To describe the characteristics and outcomes of patients with a clinical diagnosis of COVID-19 and false-negative SARS-CoV-2 reverse transcription-PCR (RT-PCR), and develop and internally validate a diagnostic risk score to predict risk of COVID-19 (including RT-PCR-negative COVID-19) among medical admissions. DESIGN Retrospective cohort study. SETTING Two hospitals within an acute NHS Trust in London, UK. PARTICIPANTS All patients admitted to medical wards between 2 March and 3 May 2020. OUTCOMES Main outcomes were diagnosis of COVID-19, SARS-CoV-2 RT-PCR results, sensitivity of SARS-CoV-2 RT-PCR and mortality during hospital admission. For the diagnostic risk score, we report discrimination, calibration and diagnostic accuracy of the model and simplified risk score and internal validation. RESULTS 4008 patients were admitted between 2 March and 3 May 2020. 1792 patients (44.8%) were diagnosed with COVID-19, of whom 1391 were SARS-CoV-2 RT-PCR positive and 283 had only negative RT-PCRs. Compared with a clinical reference standard, sensitivity of RT-PCR in hospital patients was 83.1% (95% CI 81.2%-84.8%). Broadly, patients with false-negative RT-PCR COVID-19 and those confirmed by positive PCR had similar demographic and clinical characteristics but lower risk of intensive care unit admission and lower in-hospital mortality (adjusted OR 0.41, 95% CI 0.27-0.61). A simple diagnostic risk score comprising of age, sex, ethnicity, cough, fever or shortness of breath, National Early Warning Score 2, C reactive protein and chest radiograph appearance had moderate discrimination (area under the receiver-operator curve 0.83, 95% CI 0.82 to 0.85), good calibration and was internally validated. CONCLUSION RT-PCR-negative COVID-19 is common and is associated with lower mortality despite similar presentation. Diagnostic risk scores could potentially help triage patients requiring admission but need external validation.
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Affiliation(s)
- Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Diseases, Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Colin Kenneth Macleod
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Jessica Barrett
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Sarah Ann Filson
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Tumena Corrah
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Victoria Parris
- Department of Infectious Diseases, Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Gurjinder Sandhu
- Department of Infectious Diseases, Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Miriam Harris
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Rachel Tennant
- Department of Acute Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Nidhi Vaid
- Department of Acute Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Junko Takata
- Department of Elderly Care, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Sai Duraisingham
- Department of Elderly Care, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Nemi Gandy
- Department of Radiology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Harmeet Chana
- Department of Radiology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Ashley Whittington
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Alastair McGregor
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Padmasayee Papineni
- Department of Infectious Diseases, Ealing Hospital, London North West University Healthcare NHS Trust, London, UK
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20
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Houston H, Gupta-Wright A, Toke-Bjolgerud E, Biggin-Lamming J, John L. Diagnostic accuracy and utility of SARS-CoV-2 antigen lateral flow assays in medical admissions with possible COVID-19. J Hosp Infect 2021; 110:203-205. [PMID: 33539935 PMCID: PMC7848576 DOI: 10.1016/j.jhin.2021.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 11/17/2022]
Affiliation(s)
- H Houston
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - A Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK; Ealing Hospital, London North West University Healthcare NHS Trust, London, UK.
| | - E Toke-Bjolgerud
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - J Biggin-Lamming
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - L John
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
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21
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Gupta-Wright A. Improving TB diagnosis in people living with HIV. Public Health Action 2020; 10:131. [PMID: 33437675 PMCID: PMC7790489 DOI: 10.5588/pha.20.0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- A Gupta-Wright
- Institute for Global Health, University College London, London, UK
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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22
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Gupta-Wright A, Fielding K, Wilson D, van Oosterhout JJ, Grint D, Mwandumba HC, Alufandika-Moyo M, Peters JA, Chiume L, Lawn SD, Corbett EL. Tuberculosis in Hospitalized Patients With Human Immunodeficiency Virus: Clinical Characteristics, Mortality, and Implications From the Rapid Urine-based Screening for Tuberculosis to Reduce AIDS Related Mortality in Hospitalized Patients in Africa. Clin Infect Dis 2020; 71:2618-2626. [PMID: 31781758 PMCID: PMC7744971 DOI: 10.1093/cid/ciz1133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/15/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is the major killer of people living with human immunodeficiency virus (HIV) globally, with suboptimal diagnostics and management contributing to high case-fatality rates. METHODS A prospective cohort of patients with confirmed TB (Xpert MTB/RIF and/or Determine TB-LAM Ag positive) identified through screening HIV-positive inpatients with sputum and urine diagnostics in Malawi and South Africa (Rapid urine-based Screening for Tuberculosis to reduce AIDS Related Mortality in hospitalized Patients in Africa [STAMP] trial). Urine was tested prospectively (intervention) or retrospectively (standard of care arm). We defined baseline clinical phenotypes using hierarchical cluster analysis, and also used Cox regression analysis to identify associations with early mortality (≤56 days). RESULTS Of 322 patients with TB confirmed between October 2015 and September 2018, 78.0% had ≥1 positive urine test. Antiretroviral therapy (ART) coverage was 80.2% among those not newly diagnosed, but with median CD4 count 75 cells/µL and high HIV viral loads. Early mortality was 30.7% (99/322), despite near-universal prompt TB treatment. Older age, male sex, ART before admission, poor nutritional status, lower hemoglobin, and positive urine tests (TB-LAM and/or Xpert MTB/RIF) were associated with increased mortality in multivariate analyses. Cluster analysis (on baseline variables) defined 4 patient subgroups with early mortality ranging from 9.8% to 52.5%. Although unadjusted mortality was 9.3% lower in South Africa than Malawi, in adjusted models mortality was similar in both countries (hazard ratio, 0.9; P = .729). CONCLUSIONS Mortality following prompt inpatient diagnosis of HIV-associated TB remained unacceptably high, even in South Africa. Intensified management strategies are urgently needed, for which prognostic indicators could potentially guide both development and subsequent use.
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Affiliation(s)
- Ankur Gupta-Wright
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Katherine Fielding
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of the Witwatersrand, Johannesburg, South Africa
| | - Douglas Wilson
- Department of Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Daniel Grint
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Jurgens A Peters
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen D Lawn
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth L Corbett
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
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23
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Reddy KP, Denkinger CM, Broger T, McCann NC, Gupta-Wright A, Kerkhoff AD, Pei PP, Shebl FM, Fielding KL, Nicol MP, Horsburgh CR, Meintjes G, Freedberg KA, Wood R, Walensky RP. Cost-effectiveness of a novel lipoarabinomannan test for tuberculosis in patients with HIV. Clin Infect Dis 2020; 73:e2077-e2085. [PMID: 33200169 PMCID: PMC8492225 DOI: 10.1093/cid/ciaa1698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/13/2020] [Indexed: 02/03/2023] Open
Abstract
Background A novel urine lipoarabinomannan assay (FujiLAM) has higher sensitivity and higher cost than the first-generation AlereLAM assay. We evaluated the cost-effectiveness of FujiLAM for tuberculosis testing among hospitalized people with human immunodeficiency virus (HIV), irrespective of symptoms. Methods We used a microsimulation model to project clinical and economic outcomes of 3 testing strategies: (1) sputum Xpert MTB/RIF (Xpert), (2) sputum Xpert plus urine AlereLAM (Xpert+AlereLAM), (3) sputum Xpert plus urine FujiLAM (Xpert+FujiLAM). The modeled cohort matched that of a 2-country clinical trial. We applied diagnostic yields from a retrospective study (yields for Xpert/Xpert+AlereLAM/Xpert+FujiLAM among those with CD4 <200 cells/µL: 33%/62%/70%; among those with CD4 ≥200 cells/µL: 33%/35%/47%). Costs of Xpert/AlereLAM/FujiLAM were US$15/3/6 (South Africa) and $25/3/6 (Malawi). Xpert+FujiLAM was considered cost-effective if its incremental cost-effectiveness ratio (US$/year-of-life saved) was <$940 (South Africa) and <$750 (Malawi). We varied key parameters in sensitivity analysis and performed a budget impact analysis of implementing FujiLAM countrywide. Results Compared with Xpert+AlereLAM, Xpert+FujiLAM increased life expectancy by 0.2 years for those tested in South Africa and Malawi. Xpert+FujiLAM was cost-effective in both countries. Xpert+FujiLAM for all patients remained cost-effective compared with sequential testing and CD4-stratified testing strategies. FujiLAM use added 3.5% (South Africa) and 4.7% (Malawi) to 5-year healthcare costs of tested patients, primarily reflecting ongoing HIV treatment costs among survivors. Conclusions FujiLAM with Xpert for tuberculosis testing in hospitalized people with HIV is likely to increase life expectancy and be cost-effective at the currently anticipated price in South Africa and Malawi. Additional studies should evaluate FujiLAM in clinical practice settings.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Nicole C McCann
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Ankur Gupta-Wright
- Division of Infection and Immunity, University College London, London, United Kingdom.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Pamela P Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark P Nicol
- Infection and Immunity, University of Western Australia, Perth, Australia
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Graeme Meintjes
- Department of Medicine, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Gupta-Wright A, Fielding K, van Oosterhout JJ, Alufandika M, Grint DJ, Chimbayo E, Heaney J, Byott M, Nastouli E, Mwandumba HC, Corbett EL, Gupta RK. Virological failure, HIV-1 drug resistance, and early mortality in adults admitted to hospital in Malawi: an observational cohort study. Lancet HIV 2020; 7:e620-e628. [PMID: 32890497 PMCID: PMC7487765 DOI: 10.1016/s2352-3018(20)30172-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/03/2020] [Accepted: 06/12/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) scale-up in sub-Saharan Africa combined with weak routine virological monitoring has driven increasing HIV drug resistance. We investigated ART failure, drug resistance, and early mortality among patients with HIV admitted to hospital in Malawi. METHODS This observational cohort study was nested within the rapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalised patients in Africa (STAMP) trial, which recruited unselected (ie, irrespective of clinical presentation) adult (aged ≥18 years) patients with HIV-1 at admission to medical wards. Patients were included in our observational cohort study if they were enrolled at the Malawi site (Zomba Central Hospital) and were taking ART for at least 6 months at admission. Patients who met inclusion criteria had frozen plasma samples tested for HIV-1 viral load. Those with HIV-1 RNA of at least 1000 copies per mL had drug resistance testing by ultra-deep sequencing, with drug resistance defined as intermediate or high-level resistance using the Stanford HIVDR program. Mortality risk was calculated 56 days from enrolment. Patients were censored at death, at 56 days, or at last contact if lost to follow-up. The modelling strategy addressed the causal association between HIV multidrug resistance and mortality, excluding factors on the causal pathway (most notably, CD4 cell count, clinical signs of advanced HIV, and poor functional and nutritional status). FINDINGS Of 1316 patients with HIV enrolled in the STAMP trial at the Malawi site between Oct 26, 2015, and Sept 19, 2017, 786 had taken ART for at least 6 months. 252 (32%) of 786 patients had virological failure (viral load ≥1000 copies per mL). Mean age was 41·5 years (SD 11·4) and 528 (67%) of 786 were women. Of 237 patients with HIV drug resistance results available, 195 (82%) had resistance to lamivudine, 128 (54%) to tenofovir, and 219 (92%) to efavirenz. Resistance to at least two drugs was common (196, 83%), and this was associated with increased mortality (adjusted hazard ratio 1·7, 95% CI 1·2-2·4; p=0·0042). INTERPRETATION Interventions are urgently needed and should target ART clinic, hospital, and post-hospital care, including differentiated care focusing on patients with advanced HIV, rapid viral load testing, and routine access to drug resistance testing. Prompt diagnosis and switching to alternative ART could reduce early mortality among inpatients with HIV. FUNDING Joint Global Health Trials Scheme of the Medical Research Council, UK Department for International Development, and Wellcome Trust.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Infection and Immunity, University College London, London UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | - Daniel J Grint
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Chimbayo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Judith Heaney
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew Byott
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Eleni Nastouli
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth L Corbett
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Ravindra K Gupta
- Department of Medicine, University of Cambridge, Cambridge, UK; Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
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Divala TH, Fielding KL, Kandulu C, Nliwasa M, Sloan DJ, Gupta-Wright A, Corbett EL. Utility of broad-spectrum antibiotics for diagnosing pulmonary tuberculosis in adults: a systematic review and meta-analysis. Lancet Infect Dis 2020; 20:1089-1098. [PMID: 32437700 PMCID: PMC7456780 DOI: 10.1016/s1473-3099(20)30143-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 01/15/2020] [Accepted: 02/18/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Suboptimal diagnostics for pulmonary tuberculosis drive the use of the so-called trial of antibiotics, a course of broad-spectrum antibiotics without activity against Mycobacterium tuberculosis that is given to patients who are mycobacteriology negative but symptomatic, with the aim of distinguishing pulmonary tuberculosis from bacterial lower respiratory tract infection. The underlying assumption-that patients with lower respiratory tract infection will improve, whereas those with pulmonary tuberculosis will not-has an unclear evidence base for such a widely used intervention (at least 26·5 million courses are prescribed per year). We aimed to collate available evidence on the diagnostic performance of the trial of antibiotics. METHODS In this systematic review and meta-analysis we searched the MEDLINE, Embase, and Global Health databases for studies published up to March 15, 2019, that investigated the sensitivity and specificity of the trial of antibiotics against mycobacteriology tests in adults (≥15 years) with tuberculosis symptoms. We used the QUADAS-2 tool to assess the risk of bias. We estimated pooled values for sensitivity and specificity of trial of antibiotics (as the index text) versus mycobacteriology tests (as the reference standard) using random-effects bivariate modelling, and we used the I2 statistic to assess heterogeneity between studies contributing to these estimates. This study is registered with PROSPERO, number CRD42017083915. FINDINGS Of the 9410 articles identified by our search, eight studies were eligible for inclusion. The studies were from seven countries in Africa, South America, and Asia, and involved 2786 participants. Six studies used mycobacterial culture as the reference standard, and six used penicillins for the trial of antibiotics. The treatment duration, number of antimicrobial courses, and definition of what constituted response to treatment varied substantially between studies. The pooled sensitivity (67%, 95% CI 42-85) and specificity (73%, 58-85) of the trial of antibiotics versus mycobacteriology tests were below internationally defined minimum performance profiles for tuberculosis diagnostics and had substantial heterogeneity (I2 was 96% for sensitivity and 99% for specificity). Each included study failed on one or more domain of the QUADAS-2 tool. INTERPRETATION Current policy and practice regarding the trial of antibiotics appear inappropriate, given the weak evidence base, poor diagnostic performance, potential contribution to the global antimicrobial resistance crisis, and adverse individual and public health consequences from the misclassification of tuberculosis status. Antibiotic strategies during tuberculosis investigations should instead optimise clinical outcomes, ideally guided by clinical trials in both inpatient and outpatient groups. FUNDING Helse Nord RHF, Wellcome Trust, and the UK Commonwealth Scholarship Commission.
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Affiliation(s)
- Titus H Divala
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Chikondi Kandulu
- Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marriott Nliwasa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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Gupta-Wright A, Kerkhoff AD, Meintjes G, Corbett EL. Urinary Lipoarabinomannan Detection and Disseminated Nontuberculous Mycobacterial Disease. Clin Infect Dis 2019; 66:158. [PMID: 29020175 DOI: 10.1093/cid/cix735] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene & Tropical Medicine, United Kingdom.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
| | | | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town Faculty of Health Sciences, South Africa
| | - Elizabeth L Corbett
- Clinical Research Department, London School of Hygiene & Tropical Medicine, United Kingdom.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
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Abstract
Implementation science uses methods to promote the scaling up and use of evidence-based practices by health systems to improve quality and outcomes. Its use is vital to maximise the efficiency of limited resources for health care in tropical settings. HIV and tuberculosis (TB) are two of the major causes of morbidity and mortality in sub-Saharan Africa, and globally. Although effective treatments are widely available, lack of diagnosis remains a large barrier to accessing treatment, particularly in resource-limited settings. We explore HIV and TB diagnostics that can be used at point-of-care in any settings, and outline some important principles and applications of implementation science to aid their application and use. Despite robust evidence of diagnostic accuracy and efficacy in improving patient-centred outcomes, such interventions cannot be fully utilised without addressing operational barriers and knowledge gaps.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infection, St Thomas' Hospital, London, UK
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine Johns Hopkins School of Medicine, Baltimore, USA
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Reddy KP, Gupta-Wright A, Fielding KL, Costantini S, Zheng A, Corbett EL, Yu L, van Oosterhout JJ, Resch SC, Wilson DP, Horsburgh CR, Wood R, Alufandika-Moyo M, Peters JA, Freedberg KA, Lawn SD, Walensky RP. Cost-effectiveness of urine-based tuberculosis screening in hospitalised patients with HIV in Africa: a microsimulation modelling study. Lancet Glob Health 2019; 7:e200-e208. [PMID: 30683239 PMCID: PMC6370043 DOI: 10.1016/s2214-109x(18)30436-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/23/2018] [Accepted: 09/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Testing urine improves the number of tuberculosis diagnoses made among patients in hospital with HIV. In conjunction with the two-country randomised Rapid Urine-based Screening for Tuberculosis to Reduce AIDS-related Mortality in Hospitalised Patients in Africa (STAMP) trial, we used a microsimulation model to estimate the effects on clinical outcomes and the cost-effectiveness of adding urine-based tuberculosis screening to sputum screening for hospitalised patients with HIV. METHODS We compared two tuberculosis screening strategies used irrespective of symptoms among hospitalised patients with HIV in Malawi and South Africa: a GeneXpert assay (Cepheid, Sunnyvale, CA, USA) for Mycobacterium tuberculosis and rifampicin resistance (Xpert) in sputum samples (standard of care) versus sputum Xpert combined with a lateral flow assay for M tuberculosis lipoarabinomannan in urine (Determine TB-LAM Ag test, Abbott, Waltham, MA, USA [formerly Alere]; TB-LAM) and concentrated urine Xpert (intervention). A cohort of simulated patients was modelled using selected characteristics of participants, tuberculosis diagnostic yields, and use of hospital resources in the STAMP trial. We calibrated 2-month model outputs to the STAMP trial results and projected clinical and economic outcomes at 2 years, 5 years, and over a lifetime. We judged the intervention to be cost-effective if the incremental cost-effectiveness ratio (ICER) was less than US$750/year of life saved (YLS) in Malawi and $940/YLS in South Africa. A modified intervention of adding only TB-LAM to the standard of care was also evaluated. We did a budget impact analysis of countrywide implementation of the intervention. FINDINGS The intervention increased life expectancy by 0·5-1·2 years and was cost-effective, with an ICER of $450/YLS in Malawi and $840/YLS in South Africa. The ICERs decreased over time. At lifetime horizon, the intervention remained cost-effective under nearly all modelled assumptions. The modified intervention was at least as cost-effective as the intervention (ICERs $420/YLS in Malawi and $810/YLS in South Africa). Over 5 years, the intervention would save around 51 000 years of life in Malawi and around 171 000 years of life in South Africa. Health-care expenditure for screened individuals was estimated to increase by $37 million (10·8%) and $261 million (2·8%), respectively. INTERPRETATION Urine-based tuberculosis screening of all hospitalised patients with HIV could increase life expectancy and be cost-effective in resource-limited settings. Urine TB-LAM is especially attractive because of high incremental diagnostic yield and low additional cost compared with sputum Xpert, making a compelling case for expanding its use to all hospitalised patients with HIV in areas with high HIV burden and endemic tuberculosis. FUNDING UK Medical Research Council, UK Department for International Development, Wellcome Trust, US National Institutes of Health, Royal College of Physicians, Massachusetts General Hospital.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Costantini
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Amy Zheng
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Liyang Yu
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi; Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen C Resch
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Douglas P Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Medicine, Boston, MA, USA; Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | | | - Jurgens A Peters
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Boston University School of Medicine, Boston, MA, USA
| | - Stephen D Lawn
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Divala TH, Fielding KL, Nliwasa M, Sloan DJ, Gupta-Wright A, Corbett EL. Sensitivity and specificity of using trial-of-antibiotics versus sputum mycobacteriology for diagnosis of tuberculosis: protocol for a systematic literature review. Syst Rev 2018; 7:141. [PMID: 30219089 PMCID: PMC6138901 DOI: 10.1186/s13643-018-0806-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 09/02/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Suboptimal diagnostics for pulmonary tuberculosis (PTB) drives use of 'trial-of-antibiotics (non-tuberculosis)' in an attempt to distinguish PTB patients from those with bacterial lower respiratory tract infection (LRTI). The underlying assumption-that patients with LRTI will report 'response' to broad-spectrum antibiotics, while those with PTB will not-has minimal evidence base for such a widely used intervention. Numerous potential causes of misclassification include bacterial super-infection of active PTB, placebo effect, and antimicrobial resistance (AMR). The main aim of this systematic review is to collate available evidence on the performance of trial-of-antibiotics as a diagnostic test and to explore the timing, interpretation, and decision-making process. METHODS We will search MEDLINE, Embase, and Global Health using the Ovid platform for published studies that recruited adults being investigated for PTB, performed trial-of-antibiotics accompanied by mycobacteriological investigations, and reported both diagnostic test outcomes at the individual level. Following article selection, two authors will independently review titles and abstracts against eligibility criteria then perform full-text screening and extraction into a spreadsheet. We will conduct a risk of bias assessment at the level of the study using QUADAS-2 (University of Bristol) tool that assesses diagnostic evaluation work in four domains: (1) patient selection, (2) the index test, (3) the reference standard, and (4) patient flow and timing of tests. We will perform a narrative synthesis and, where possible, meta-analyses addressing our primary outcome. Our protocol adheres to the standards recommended by the PRISMA-P. DISCUSSION Pooling all available evidence on the accuracy, approach, and interpretation of results of trial-of-antibiotics in the context of PTB diagnosis will meet an urgent need, considering the widespread utilisation and potential for antimicrobial resistance. We therefore believe that our findings will have impact on policy and that they will inform the design of future detailed investigations into this important diagnostic approach. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017083915.
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Affiliation(s)
- Titus H. Divala
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
- Helse Nord Tuberculosis Initiative, Department of Microbiology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Katherine L. Fielding
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
| | - Marriott Nliwasa
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
- Helse Nord Tuberculosis Initiative, Department of Microbiology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Derek J. Sloan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Ankur Gupta-Wright
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
- Malawi, Liverpool Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Elizabeth L. Corbett
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
- Helse Nord Tuberculosis Initiative, Department of Microbiology, University of Malawi College of Medicine, Blantyre, Malawi
- Malawi, Liverpool Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
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30
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Gupta-Wright A, Corbett EL, van Oosterhout JJ, Wilson D, Grint D, Alufandika-Moyo M, Peters JA, Chiume L, Flach C, Lawn SD, Fielding K. Rapid urine-based screening for tuberculosis in HIV-positive patients admitted to hospital in Africa (STAMP): a pragmatic, multicentre, parallel-group, double-blind, randomised controlled trial. Lancet 2018; 392:292-301. [PMID: 30032978 PMCID: PMC6078909 DOI: 10.1016/s0140-6736(18)31267-4] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Current diagnostics for HIV-associated tuberculosis are suboptimal, with missed diagnoses contributing to high hospital mortality and approximately 374 000 annual HIV-positive deaths globally. Urine-based assays have a good diagnostic yield; therefore, we aimed to assess whether urine-based screening in HIV-positive inpatients for tuberculosis improved outcomes. METHODS We did a pragmatic, multicentre, double-blind, randomised controlled trial in two hospitals in Malawi and South Africa. We included HIV-positive medical inpatients aged 18 years or more who were not taking tuberculosis treatment. We randomly assigned patients (1:1), using a computer-generated list of random block size stratified by site, to either the standard-of-care or the intervention screening group, irrespective of symptoms or clinical presentation. Attending clinicians made decisions about care; and patients, clinicians, and the study team were masked to the group allocation. In both groups, sputum was tested using the Xpert MTB/RIF assay (Xpert; Cepheid, Sunnyvale, CA, USA). In the standard-of-care group, urine samples were not tested for tuberculosis. In the intervention group, urine was tested with the Alere Determine TB-LAM Ag (TB-LAM; Alere, Waltham, MA, USA), and Xpert assays. The primary outcome was all-cause 56-day mortality. Subgroup analyses for the primary outcome were prespecified based on baseline CD4 count, haemoglobin, clinical suspicion for tuberculosis; and by study site and calendar time. We used an intention-to-treat principle for our analyses. This trial is registered with the ISRCTN registry, number ISRCTN71603869. FINDINGS Between Oct 26, 2015, and Sept 19, 2017, we screened 4788 HIV-positive adults, of which 2600 (54%) were randomly assigned to the study groups (n=1300 for each group). 13 patients were excluded after randomisation from analysis in each group, leaving 2574 in the final intention-to-treat analysis (n=1287 in each group). At admission, 1861 patients were taking antiretroviral therapy and median CD4 count was 227 cells per μL (IQR 79-436). Mortality at 56 days was reported for 272 (21%) of 1287 patients in the standard-of-care group and 235 (18%) of 1287 in the intervention group (adjusted risk reduction [aRD] -2·8%, 95% CI -5·8 to 0·3; p=0·074). In three of the 12 prespecified, but underpowered subgroups, mortality was lower in the intervention group than in the standard-of-care group for CD4 counts less than 100 cells per μL (aRD -7·1%, 95% CI -13·7 to -0·4; p=0.036), severe anaemia (-9·0%, -16·6 to -1·3; p=0·021), and patients with clinically suspected tuberculosis (-5·7%, -10·9 to -0·5; p=0·033); with no difference by site or calendar period. Adverse events were similar in both groups. INTERPRETATION Urine-based tuberculosis screening did not reduce overall mortality in all HIV-positive inpatients, but might benefit some high-risk subgroups. Implementation could contribute towards global targets to reduce tuberculosis mortality. FUNDING Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, and the Wellcome Trust.
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Affiliation(s)
- Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi.
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi
| | - Douglas Wilson
- Department of Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Daniel Grint
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Jurgens A Peters
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi
| | - Clare Flach
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Stephen D Lawn
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
On 24th March, the world commemorates the day in 1882 when Dr Robert Koch announced his discovery of Mycobacterium tuberculosis (MTB). Over 130 years later, tuberculosis (TB) continues to affect individuals, communities, and entire health systems and economies. Koch unsuccessfully tried to 'cure' TB, and despite major advances in other areas of medicine, control of TB remains elusive- in 2016 TB was the leading infectious cause of death. The STOP TB partnership and World Health Organization (WHO) have announced their theme for World TB Day 2018 "Wanted: Leaders for a TB-Free World. You can make history. End TB." This theme recognizes that TB is much larger than any one person, institute or discipline of research, and provides an opportunity for us to reflect on the major challenges and consider how we, as a scientific community, can work together and take the lead to address the global crisis of drug-resistant TB (DR-TB).
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Affiliation(s)
| | | | - Molebogeng X Rangaka
- Institute for Global Health , University College London, London, UK.,School of Public Health , University of Cape Town, Cape Town, South Africa
| | - Helen A Fletcher
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
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Gupta-Wright A, Tembo D, Jambo KC, Chimbayo E, Mvaya L, Caldwell S, Russell DG, Mwandumba HC. Functional Analysis of Phagocyte Activity in Whole Blood from HIV/Tuberculosis-Infected Individuals Using a Novel Flow Cytometry-Based Assay. Front Immunol 2017; 8:1222. [PMID: 29033941 PMCID: PMC5624998 DOI: 10.3389/fimmu.2017.01222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/15/2017] [Indexed: 12/02/2022] Open
Abstract
The accurate assessment of immune competence through ex vivo analysis is paramount to our understanding of those immune mechanisms that lead to protection or susceptibility against a broad range of human pathogens. We have developed a flow cytometry-based, whole blood phagocyte functional assay that utilizes the inflammatory inducer zymosan, coupled to OxyBURST-SE, a fluorescent reporter of phagosomal oxidase activity. The assay measures both phagocytic uptake and the superoxide burst in the phagocyte populations in whole blood. We utilized this assay to demonstrate impaired superoxide burst activity in the phagocytes of hospitalized HIV-positive patients with laboratory-confirmed tuberculosis. These data validate the use of the assay to assess the immune competence of patients in a clinical setting. The method is highly reproducible with minimal intraindividual variation and opens opportunities for the rapid assessment of cellular immune competence in peripheral blood in a disease setting.
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Affiliation(s)
- Ankur Gupta-Wright
- College of Medicine, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dumizulu Tembo
- Department of Microbiology and Immunology, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Kondwani C Jambo
- College of Medicine, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth Chimbayo
- College of Medicine, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Leonard Mvaya
- College of Medicine, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Shannon Caldwell
- Department of Microbiology and Immunology, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - David G Russell
- Department of Microbiology and Immunology, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Henry C Mwandumba
- College of Medicine, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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33
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Lawn SD, Kerkhoff AD, Burton R, Schutz C, Boulle A, Vogt M, Gupta-Wright A, Nicol MP, Meintjes G. Diagnostic accuracy, incremental yield and prognostic value of Determine TB-LAM for routine diagnostic testing for tuberculosis in HIV-infected patients requiring acute hospital admission in South Africa: a prospective cohort. BMC Med 2017; 15:67. [PMID: 28320384 PMCID: PMC5359871 DOI: 10.1186/s12916-017-0822-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/17/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND We previously reported that one-third of HIV-positive adults requiring medical admission to a South African district hospital had laboratory-confirmed tuberculosis (TB) and that almost two-thirds of cases could be rapidly diagnosed using Xpert MTB/RIF-testing of concentrated urine samples obtained on the first day of admission. Implementation of urine-based, routine, point-of-care TB screening is an attractive intervention that might be facilitated by use of a simple, low-cost diagnostic tool, such as the Determine TB-LAM lateral-flow rapid test for HIV-associated TB. METHODS Sputum, urine and blood samples were systematically obtained from unselected HIV-positive adults within 24 hours of admission to a South African township hospital. Additional clinical samples were obtained during hospitalization as clinically indicated. TB was defined by the detection of Mycobacterium tuberculosis in any sample using Xpert MTB/RIF or liquid culture. The diagnostic yield, accuracy and prognostic value of urine-lipoarabinomannan (LAM) testing were determined, but urine-LAM results did not inform treatment decisions. RESULTS Consecutive HIV-positive adult acute medical admissions not already receiving TB treatment (n = 427) were enrolled regardless of clinical presentation or symptoms. TB was diagnosed in 139 patients (TB prevalence 32.6%; median CD4 count 80 cells/μL). In the first 24 hours of admission, sputum (spot and/or induced) samples were obtained from 37.0% of patients and urine samples from 99.5% of patients (P < 0.001). The diagnostic yields from these specimens were 19.4% (n = 27/139) for sputum-microscopy, 26.6% (n = 37/139) for sputum-Xpert, 38.1% (n = 53/139) for urine-LAM and 52.5% (n = 73/139) for sputum-Xpert/urine-LAM combined (P < 0.01). Corresponding yields among patients with CD4 counts <100 cells/μL were 18.9%, 24.3%, 55.4% and 63.5%, respectively (P < 0.01). The diagnostic yield of urine-LAM was unrelated to respiratory symptoms, and LAM assay specificity (using a grade-2 cut-off) was 98.9% (274/277; 95% confidence interval [CI] 96.9-99.8). Among TB cases, positive urine-LAM status was strongly associated with mortality at 90 days (adjusted hazard ratio 4.20; 95% CI 1.50-11.75). CONCLUSIONS Routine testing for TB in newly admitted HIV-positive adults using Determine TB-LAM to test urine provides major incremental diagnostic yield with very high specificity when used in combination with sputum testing and has important utility among those without respiratory TB symptoms and/or unable to produce sputum. The assay also rapidly identifies individuals with a poor prognosis.
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Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Rosie Burton
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,GF Jooste Hospital, Manenberg, Cape Town, South Africa.,Khayelitsha District Hospital, Cape Town, South Africa
| | - Charlotte Schutz
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,GF Jooste Hospital, Manenberg, Cape Town, South Africa.,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Monica Vogt
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark P Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,GF Jooste Hospital, Manenberg, Cape Town, South Africa. .,Khayelitsha District Hospital, Cape Town, South Africa. .,Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Lawn SD, Gupta-Wright A. Detection of lipoarabinomannan (LAM) in urine is indicative of disseminated TB with renal involvement in patients living with HIV and advanced immunodeficiency: evidence and implications. Trans R Soc Trop Med Hyg 2016; 110:180-5. [PMID: 26884498 PMCID: PMC4755427 DOI: 10.1093/trstmh/trw008] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
TB is the leading cause of HIV/AIDS-related deaths globally. New diagnostic tools are urgently needed to avert deaths from undiagnosed HIV-associated TB. Although simple assays that detect lipoarabinomannan (LAM) in urine have been commercially available for years, their specific role and utility were initially misunderstood, such that they have been slower to emerge from the diagnostics pipeline than otherwise might have been expected. In this article, we review and explain how urine-LAM assays should be understood as diagnostics for disseminated TB in HIV-positive patients with advanced immunodeficiency, in whom haematogenous TB dissemination to the kidneys serves as the primary mechanism by which LAM enters the urine. These insights are critical for the appropriate design of studies to evaluate these assays and to understand how they might be most usefully implemented. This understanding also supports the 2015 WHO recommendations on the restricted use of these assays in sick HIV-positive patients with advanced immunodeficiency.
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Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi
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Gupta-Wright A, Fielding KL, van Oosterhout JJ, Wilson DK, Corbett EL, Flach C, Reddy KP, Walensky RP, Peters JA, Alufandika-Moyo M, Lawn SD. Erratum to: Rapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalized patients in Africa (the STAMP trial): study protocol for a randomised controlled trial. BMC Infect Dis 2016; 16:604. [PMID: 27782816 PMCID: PMC5080728 DOI: 10.1186/s12879-016-1949-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/20/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK. .,Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,University of the Witwatersrand, Johannesburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Douglas K Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Elizabeth L Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi
| | - Clare Flach
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Krishna P Reddy
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Rochelle P Walensky
- Divisions of General Medicine and Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.,The Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Jurgens A Peters
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Stephen D Lawn
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.,The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Gupta-Wright A, Fielding KL, van Oosterhout JJ, Wilson DK, Corbett EL, Flach C, Reddy KP, Walensky RP, Peters JA, Alufandika-Moyo M, Lawn SD. Rapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalized patients in Africa (the STAMP trial): study protocol for a randomised controlled trial. BMC Infect Dis 2016; 16:501. [PMID: 27659507 PMCID: PMC5034586 DOI: 10.1186/s12879-016-1837-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/16/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND HIV-associated tuberculosis (TB) co-infection remains an enormous burden to international public health. Post-mortem studies have highlighted the high proportion of HIV-positive adults admitted to hospital with TB. Determine TB-LAM and Xpert MTB/RIF assays can substantially increase diagnostic yield of TB within one day of hospital admission. However, it remains unclear if this approach can impact clinical outcomes. The STAMP trial aims to test the hypothesis that the implementation a urine-based screening strategy for TB can reduce all cause-mortality among HIV-positive patients admitted to hospital when compared to current, sputum-based screening. METHODS The trial is a pragmatic, individually randomised, multi-country (Malawi and South Africa) clinical trial with two study arms (1:1 recruitment). Unselected HIV-positive patients admitted to medical wards, irrespective of presentation, meeting the inclusion criteria and giving consent will be randomized to screening for TB using either: (i) 'standard of care'- testing of sputum using the Xpert MTB/RIF assay (Xpert) or (ii) 'intervention'- testing of sputum using Xpert and testing of urine using (a) Determine TB-LAM lateral-flow assay and (b) Xpert following concentration of urine by centrifugation. Patients will be excluded if they have received TB treatment in the previous 12 months, if they have received isoniazid preventive therapy in the last 6 months, if they are aged <18 years or they live outside the pre-specified geographical area. Results will be provided to the responsible medical team as soon as available to inform decisions regarding TB treatment. Both the study and routine medical team will be masked to study arm allocation. 1300 patients will be enrolled per arm (equal numbers at the two trial sites). The primary endpoint is all-cause mortality at 56 days. An economic analysis will be conducted to project long-term outcomes for shorter-term trial data, including cost-effectiveness. DISCUSSION This pragmatic trial assesses an intervention to reduce the high mortality caused by HIV-associated TB, which could feasibly be scaled up in high-burden settings if shown to be efficacious and cost-effective. We discuss the challenges of designing a trial to assess the impact on mortality of laboratory-based TB screening interventions given frequent initiation of empirical treatment and a failure of several previous clinical trials to demonstrate an impact on clinical outcomes. We also elaborate on the practical and ethical issues of 'testing a test' in general. TRIAL REGISTRATION ISRCTN Registry ( ISRCTN71603869 ) prospectively registered 08 May 2015; the South African National Controlled Trials Registry (DOH-27-1015-5185) prospectively registered October 2015.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- University of the Witwatersrand, Johannesburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Douglas K Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Elizabeth L Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi
| | - Clare Flach
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Krishna P Reddy
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Rochelle P Walensky
- Divisions of General Medicine and Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- The Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Jurgens A Peters
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Stephen D Lawn
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Auld AF, Fielding KL, Gupta-Wright A, Lawn SD. Xpert MTB/RIF - why the lack of morbidity and mortality impact in intervention trials? Trans R Soc Trop Med Hyg 2016; 110:432-44. [PMID: 27638038 DOI: 10.1093/trstmh/trw056] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/10/2016] [Indexed: 11/13/2022] Open
Abstract
Compared with smear microscopy, the Xpert MTB/RIF assay (Xpert), with superior accuracy and capacity to diagnose rifampicin resistance, has advanced TB diagnostic capability. However, recent trials of Xpert impact have not demonstrated reductions in patient morbidity and mortality. We conducted a narrative review of Xpert impact trials to summarize which patient-relevant outcomes Xpert has improved and explore reasons for no observed morbidity or mortality reductions. We searched PubMed, Google Scholar, Cochrane Library and Embase and identified eight trials meeting inclusion criteria: three individually randomized, three cluster-randomized, and two pre-post trials. In six trials Xpert increased diagnostic yield of bacteriologically-confirmed TB from sputa and in four trials Xpert shortened time to TB treatment. However, all-cause mortality was similar between arms in all six trials reporting this outcome, and the only trial to assess Xpert impact on morbidity reported no impact. Trial characteristics that might explain lack of observed impact on morbidity and mortality include: higher rates of empiric TB treatment in microscopy compared with Xpert arms, enrollment of study populations not comprised exclusively of populations most likely to benefit from Xpert, and health system weaknesses. So far as equipoise exists, future trials that address past limitations are needed to inform Xpert use in resource-limited settings.
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, 30333, USA
| | - Katherine L Fielding
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK
| | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Gupta-Wright A, Peters JA, Flach C, Lawn SD. Detection of lipoarabinomannan (LAM) in urine is an independent predictor of mortality risk in patients receiving treatment for HIV-associated tuberculosis in sub-Saharan Africa: a systematic review and meta-analysis. BMC Med 2016; 14:53. [PMID: 27007773 PMCID: PMC4804532 DOI: 10.1186/s12916-016-0603-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/17/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Simple immune capture assays that detect mycobacterial lipoarabinomannan (LAM) antigen in urine are promising new tools for the diagnosis of HIV-associated tuberculosis (HIV-TB). In addition, however, recent prospective cohort studies of patients with HIV-TB have demonstrated associations between LAM in the urine and increased mortality risk during TB treatment, indicating an additional utility of urinary LAM as a prognostic marker. We conducted a systematic review and meta-analysis to summarise the evidence concerning the strength of this relationship in adults with HIV-TB in sub-Saharan Africa, thereby quantifying the assay's prognostic value. METHODS We searched MEDLINE and Embase databases using comprehensive search terms for 'HIV', 'TB', 'LAM' and 'sub-Saharan Africa'. Identified studies were reviewed and selected according to predefined criteria. RESULTS We identified 10 studies eligible for inclusion in this systematic review, reporting on a total of 1172 HIV-TB cases. Of these, 512 patients (44 %) tested positive for urinary LAM. After a variable duration of follow-up of between 2 and 6 months, overall case fatality rates among HIV-TB cases varied between 7 % and 53 %. Pooled summary estimates generated by random-effects meta-analysis showed a two-fold increased risk of mortality for urinary LAM-positive HIV-TB cases compared to urinary LAM-negative HIV-TB cases (relative risk 2.3, 95 % confidence interval 1.6-3.1). Some heterogeneity was explained by study setting and patient population in sub-group analyses. Five studies also reported multivariable analyses of risk factors for mortality, and pooled summary estimates demonstrated over two-fold increased mortality risk (odds ratio 2.5, 95 % confidence interval 1.4-4.5) among urinary LAM-positive HIV-TB cases, even after adjustment for other risk factors for mortality, including CD4 cell count. CONCLUSIONS We have demonstrated that detectable LAM in urine is associated with increased risk of mortality during TB treatment, and that this relationship remains after adjusting for other risk factors for mortality. This may simply be due to a positive test for urinary LAM serving as a marker of higher mycobacterial load and greater disease dissemination and severity. Alternatively, LAM antigen may directly compromise host immune responses through its known immunomodulatory effects. Detectable LAM in the urine is an independent risk factor for mortality among patients receiving treatment for HIV-TB. Further research is warranted to elucidate the underlying mechanisms and to determine whether this vulnerable patient population may benefit from adjunctive interventions.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Jurgens A Peters
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Flach
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Hunt L, Gupta-Wright A, Simms V, Tamba F, Knott V, Tamba K, Heisenberg-Mansaray S, Tamba E, Sheriff A, Conteh S, Smith T, Tobin S, Brooks T, Houlihan C, Cummings R, Fletcher T. Clinical presentation, biochemical, and haematological parameters and their association with outcome in patients with Ebola virus disease: an observational cohort study. Lancet Infect Dis 2015; 15:1292-9. [PMID: 26271406 DOI: 10.1016/s1473-3099(15)00144-9] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/07/2015] [Accepted: 06/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical management of Ebola virus disease remains challenging. Routine laboratory analytics are often unavailable in the outbreak setting, and few data exist for the associated haematological and biochemical abnormalities. We aimed to assess laboratory and clinical data from patients with Ebola virus disease to better inform clinical management algorithms, improve understanding of key variables associated with outcome, and provide insight into the pathophysiology of Ebola virus disease. METHODS We recruited all patients, alive on arrival, with confirmed Ebola virus disease who were admitted to the Kerry Town Ebola treatment centre in Sierra Leone. At admission, all patients had clinical presentation recorded and blood taken for Ebola confirmation using reverse-transcriptase-PCR (RT-PCR) and for haematological and biochemical analysis. We studied the association between these and clinical outcome. The primary outcome was discharge from the Ebola treatment centre. FINDINGS 150 patients were admitted to the treatment centre between Dec 8, 2014, and Jan 9, 2015. The mean age of patients was 26 years (SD 14·7). Case fatality rate was 37% (55/150). Most patients presented with stage 2 (gastrointestinal involvement, 72/118 [61%]) and stage 3 (severe or complicated, 12/118 [10%]) disease. Acute kidney injury was common (52/104 [50%]), as were abnormal serum potassium (32/97 [33%]), severe hepatitis (54/92 [59%]), and raised C-reactive protein (21/100 [21%]). Haematological abnormalities were common, including raised haematocrit (15/100 [15%]), thrombocytopenia (47/104 [45%]), and granulocytosis (44/104 [42%]). Severe acute kidney injury, low RT-PCR cycle threshold (<20 cycles), and severe hepatitis were independently associated with mortality. INTERPRETATION Ebola virus disease is associated with a high prevalence of haematological and biochemical abnormalities, even in mild disease and in the absence of gastrointestinal symptoms. Clinical care that targets hypovolaemia, electrolyte disturbance, and acute kidney injury is likely to reduce historically high case fatality rates. FUNDING None.
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Affiliation(s)
- Luke Hunt
- Save the Children International, London, UK.
| | - Ankur Gupta-Wright
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Fayia Tamba
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Kongoneh Tamba
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Emmanuel Tamba
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | | | - Tom Smith
- Save the Children International, London, UK
| | - Shelagh Tobin
- Defence Medical Services, Whittington Barracks, Lichfield, UK
| | - Tim Brooks
- Public Health England, Porton Down, Salisbury, UK
| | - Catherine Houlihan
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Tom Fletcher
- Defence Medical Services, Whittington Barracks, Lichfield, UK; Liverpool School of Tropical Medicine, Liverpool, Merseyside, UK
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Martyn E, Marks M, Edwards S, Bandula S, Gupta-Wright A, Morris-Jones S, Moore DA. Fever and weight loss in a patient with HIV. Lancet 2015; 386:e8. [PMID: 26333981 DOI: 10.1016/s0140-6736(15)61545-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker LG, Lawn SD. The predictive value of current haemoglobin levels for incident tuberculosis and/or mortality during long-term antiretroviral therapy in South Africa: a cohort study. BMC Med 2015; 13:70. [PMID: 25889688 PMCID: PMC4411796 DOI: 10.1186/s12916-015-0320-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low haemoglobin concentrations may be predictive of incident tuberculosis (TB) and death in HIV-infected patients receiving antiretroviral therapy (ART), but data are limited and inconsistent. We examined these relationships retrospectively in a long-term South African ART cohort with multiple time-updated haemoglobin measurements. METHODS Prospectively collected clinical data on patients receiving ART for up to 8 years in a community-based cohort were analysed. Time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded, and TB diagnoses and deaths from all causes were ascertained. Anaemia severity was classified using World Health Organization criteria. TB incidence and mortality rates were calculated and Poisson regression models were used to identify independent predictors of incident TB and mortality, respectively. RESULTS During a median follow-up of 5.0 years (IQR, 2.5-5.8) of 1,521 patients, 476 cases of incident TB and 192 deaths occurred during 6,459 person-years (PYs) of follow-up. TB incidence rates were strongly associated with time-updated anaemia severity; those without anaemia had a rate of 4.4 (95%CI, 3.8-5.1) cases/100 PYs compared to 10.0 (95%CI, 8.3-12.1), 26.6 (95%CI, 22.5-31.7) and 87.8 (95%CI, 57.0-138.2) cases/100 PYs in those with mild, moderate and severe anaemia, respectively. Similarly, mortality rates in those with no anaemia or mild, moderate and severe time-updated anaemia were 1.1 (95%CI, 0.8-1.5), 3.5 (95%CI, 2.7-4.8), 11.8 (95%CI, 9.5-14.8) and 28.2 (95%CI, 16.5-51.5) cases/100 PYs, respectively. Moderate and severe anaemia (time-updated) during ART were the strongest independent predictors for incident TB (adjusted IRR = 3.8 [95%CI, 3.0-4.8] and 8.2 [95%CI, 5.3-12.7], respectively) and for mortality (adjusted IRR = 6.0 [95%CI, 3.9-9.2] and adjusted IRR = 8.0 [95%CI, 3.9-16.4], respectively). CONCLUSIONS Increasing severity of anaemia was associated with exceptionally high rates of both incident TB and mortality during long-term ART. Patients receiving ART who have moderate or severe anaemia should be prioritized for TB screening using microbiological assays and may require adjunctive clinical interventions.
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Affiliation(s)
- Andrew D Kerkhoff
- George Washington University School of Medicine and Health Sciences, 2300 Eye St, NW, Washington, DC, 20037, USA. .,Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands. .,The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Frank G Cobelens
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands. .,KNCV Tuberculosis Foundation, The Hague, the Netherlands.
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Sharon Irvine
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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Kerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker LG, Lawn SD. Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa. BMC Infect Dis 2014; 14:3860. [PMID: 25528467 PMCID: PMC4300078 DOI: 10.1186/s12879-014-0702-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/11/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Anaemia is frequently associated with both HIV-infection and HIV-related tuberculosis (TB) in antiretroviral therapy (ART)-naïve patients in sub-Saharan Africa and is strongly associated with poor prognosis. However, the effect of ART on the resolution of anaemia in patient cohorts with a high prevalence and incidence of tuberculosis is incompletely defined and the impact of TB episodes on haemoglobin recovery has not previously been reported. We therefore examined these issues using data from a well-characterised cohort of patients initiating ART in South Africa. METHODS Prospectively collected clinical and haematological data were retrospectively analysed from patients receiving ART in a South African township ART service. TB diagnoses and time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded. Anaemia severity was classified according to WHO criteria. Multivariable logistic regression analysis was used to determine factors independently associated with anaemia after 12 months of ART. RESULTS Of 1,140 patients with baseline haemoglobin levels, 814 were alive in care and had repeat values available after 12 months of ART. The majority of patients were female (73%), the median CD4 count was 104 cells/uL and 30.5% had a TB diagnosis in the first year of ART. At baseline, anaemia (any severity) was present in 574 (70.5%) patients and was moderate/severe in 346 (42.5%). After 12 months of ART, 218 (26.8%) patients had anaemia of any severity and just 67 (8.2%) patients had moderate/severe anaemia. Independent predictors of anaemia after 12 months of ART included greater severity of anaemia at baseline, time-updated erythrocyte microcytosis and receipt of an AZT-containing regimen. In contrast, prevalent and/or incident TB, gender and baseline and time-updated CD4 cell count and viral load measurements were not independent predictors. CONCLUSIONS Although anaemia was very common among ART-naive patients, the anaemia resolved during the first year of ART in a large majority of patients regardless of TB status without routine use of additional interventions. However, approximately one-quarter of patients remained anaemic after one year of ART and may require additional investigations and/or interventions.
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Affiliation(s)
- Andrew D Kerkhoff
- George Washington University School of Medicine and Health Sciences, 2300 I St, NW, 20037, Washington, DC, USA.
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands.
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Frank G Cobelens
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands.
- KNCV Tuberculosis Foundation, The Hague, the Netherlands.
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Abstract
The number of people travelling to malaria-endemic countries continues to increase, and malaria remains the commonest cause of serious imported infection in non-endemic areas. Severe malaria, mostly caused by Plasmodium falciparum, often requires intensive care unit (ICU) admission and can be complicated by cerebral malaria, respiratory distress, acute kidney injury, bleeding complications, and co-infection. The mortality from imported malaria remains significant. This article reviews the manifestations, complications and principles of management of severe malaria as relevant to critical care clinicians, incorporating recent studies of anti-malarial and adjunctive treatment. Effective management of severe malaria includes prompt diagnosis and early institution of effective anti-malarial therapy, recognition of complications, and appropriate supportive management in an ICU. All cases should be discussed with a specialist unit and transfer of the patient considered.
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Affiliation(s)
- M Marks
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - A Gupta-Wright
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - J F Doherty
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK
| | - M Singer
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
| | - D Walker
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
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