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Dat VQ, Geskus RB, Trinh DHK, Nadjm B, van Doorn HR, Thwaites CL. Reply to Kataoka. Clin Infect Dis 2022; 74:1884-1885. [PMID: 34618904 DOI: 10.1093/cid/ciab891] [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] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vu Quoc Dat
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Hanoi, Vietnam
- Department of Infectious Diseases, Hanoi Medical University, Ha Noi, Vietnam
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Hanoi, Vietnam
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdomand
| | - Dong Huu Khanh Trinh
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Hanoi, Vietnam
| | - Behzad Nadjm
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Hanoi, Vietnam
- Medical Research Council The Gambia, London School of Hygiene & Tropical Medicine, The Gambia
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Hanoi, Vietnam
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdomand
| | - Catherine Louise Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Hanoi, Vietnam
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdomand
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Dat VQ, Yen LM, Loan HT, Phu VD, Binh NT, Geskus RB, Trinh DHK, Mai NTH, Phu NH, Phu Huong Lan N, Thuy TP, Trung NV, Trung Cap N, Trinh DT, Hoa NT, Van NTT, Luan VTT, Nhu TTQ, Long HB, Ha NTT, Van NTT, Campbell J, Ahmadnia E, Kestelyn E, Wyncoll D, Thwaites GE, Van Hao N, Chien LT, Van Kinh N, Van Vinh Chau N, van Doorn HR, Thwaites CL, Nadjm B. Effectiveness of continuous endotracheal cuff pressure control for the prevention of ventilator associated respiratory infections: an open-label randomised, controlled trial. Clin Infect Dis 2021; 74:1795-1803. [PMID: 34420048 PMCID: PMC9155610 DOI: 10.1093/cid/ciab724] [Citation(s) in RCA: 13] [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] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Indexed: 12/30/2022] Open
Abstract
Background An endotracheal tube cuff pressure between 20 and 30 cmH2O is recommended to prevent ventilator-associated respiratory infection (VARI). We aimed to evaluate whether continuous cuff pressure control (CPC) was associated with reduced VARI incidence compared with intermittent CPC. Methods We conducted a multicenter open-label randomized controlled trial in intensive care unit (ICU) patients within 24 hours of intubation in Vietnam. Patients were randomly assigned 1:1 to receive either continuous CPC using an automated electronic device or intermittent CPC using a manually hand-held manometer. The primary endpoint was the occurrence of VARI, evaluated by an independent reviewer blinded to the CPC allocation. Results We randomized 600 patients; 597 received the intervention or control and were included in the intention to treat analysis. Compared with intermittent CPC, continuous CPC did not reduce the proportion of patients with at least one episode of VARI (74/296 [25%] vs 69/301 [23%]; odds ratio [OR] 1.13; 95% confidence interval [CI] .77–1.67]. There were no significant differences between continuous and intermittent CPC concerning the proportion of microbiologically confirmed VARI (OR 1.40; 95% CI .94–2.10), the proportion of intubated days without antimicrobials (relative proportion [RP] 0.99; 95% CI .87–1.12), rate of ICU discharge (cause-specific hazard ratio [HR] 0.95; 95% CI .78–1.16), cost of ICU stay (difference in transformed mean [DTM] 0.02; 95% CI −.05 to .08], cost of ICU antimicrobials (DTM 0.02; 95% CI −.25 to .28), cost of hospital stay (DTM 0.02; 95% CI −.04 to .08), and ICU mortality risk (OR 0.96; 95% CI .67–1.38). Conclusions Maintaining CPC through an automated electronic device did not reduce VARI incidence. Clinical Trial Registration NCT02966392.
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Affiliation(s)
- Vu Quoc Dat
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Department of Infectious Diseases, Hanoi Medical University, Ha Noi, Vietnam
| | - Lam Minh Yen
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam
| | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Vu Dinh Phu
- National Hospital of Tropical Diseases, Hanoi, Vietnam
| | | | - Ronald B Geskus
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Dong Huu Khanh Trinh
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam
| | | | | | | | - Nguyen Vu Trung
- National Hospital of Tropical Diseases, Hanoi, Vietnam.,Trung Vuong Hospital, Ho Chi Minh City, Vietnam
| | | | | | | | | | - Vy Thi Thu Luan
- Department of Microbiology, Hanoi Medical University, Ha Noi, Vietnam
| | | | - Hoang Bao Long
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam
| | - Nguyen Thi Thanh Ha
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam
| | - Ninh Thi Thanh Van
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam
| | - James Campbell
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Ehsan Ahmadnia
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, United Kingdom
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Duncan Wyncoll
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Le Thanh Chien
- Department of Microbiology, Hanoi Medical University, Ha Noi, Vietnam
| | | | | | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Behzad Nadjm
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.,Medical Research Council The Gambia at The London School of Hygiene & Tropical Medicine, The Gambia
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Donovan J, Thu DDA, Phu NH, Dung VTM, Quang TP, Nghia HDT, Oanh PKN, Nhu TB, Chau NVV, Ha VTN, Hang VTT, Trinh DHK, Geskus RB, Tan LV, Thuong NTT, Thwaites GE. Xpert MTB/RIF Ultra versus Xpert MTB/RIF for the diagnosis of tuberculous meningitis: a prospective, randomised, diagnostic accuracy study. Lancet Infect Dis 2020; 20:299-307. [PMID: 31924551 PMCID: PMC7045088 DOI: 10.1016/s1473-3099(19)30649-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [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: 05/14/2019] [Revised: 09/24/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Xpert MTB/RIF Ultra (Xpert Ultra) might have higher sensitivity than its predecessor, Xpert MTB/RIF (Xpert), but its role in tuberculous meningitis diagnosis is uncertain. We aimed to compare Xpert Ultra with Xpert for the diagnosis of tuberculous meningitis in HIV-uninfected and HIV-infected adults. METHODS In this prospective, randomised, diagnostic accuracy study, adults (≥16 years) with suspected tuberculous meningitis from a single centre in Vietnam were randomly assigned to cerebrospinal fluid testing by either Xpert Ultra or Xpert at baseline and, if treated for tuberculous meningitis, after 3-4 weeks of treatment. Test performance (sensitivity, specificity, and positive and negative predictive values) was calculated for Xpert Ultra and Xpert and compared against clinical and mycobacterial culture reference standards. Analyses were done for all patients and by HIV status. FINDINGS Between Oct 16, 2017, and Feb 10, 2019, 205 patients were randomly assigned to Xpert Ultra (n=103) or Xpert (n=102). The sensitivities of Xpert Ultra and Xpert for tuberculous meningitis diagnosis against a reference standard of definite, probable, and possible tuberculous meningitis were 47·2% (95% CI 34·4-60·3; 25 of 53 patients) for Xpert Ultra and 39·6% (27·6-53·1; 21 of 53) for Xpert (p=0·56); specificities were 100·0% (95% CI 92·0-100·0; 44 of 44) and 100·0% (92·6-100·0; 48 of 48), respectively. In HIV-negative patients, the sensitivity of Xpert Ultra was 38·9% (24·8-55·1; 14 of 36) versus 22·9% (12·1-39·0; eight of 35) by Xpert (p=0·23). In HIV co-infected patients, the sensitivities were 64·3% (38·8-83·7; nine of 14) for Xpert Ultra and 76·9% (49·7-91·8; ten of 13) for Xpert (p=0·77). Negative predictive values were 61·1% (49·6-71·5) for Xpert Ultra and 60·0% (49·0-70·0) for Xpert. Against a reference standard of mycobacterial culture, sensitivities were 90·9% (72·2-97·5; 20 of 22 patients) for Xpert Ultra and 81·8% (61·5-92·7; 18 of 22) for Xpert (p=0·66); specificities were 93·9% (85·4-97·6; 62 of 66) and 96·9% (89·5-91·2; 63 of 65), respectively. Six (22%) of 27 patients had a positive test by Xpert Ultra after 4 weeks of treatment versus two (9%) of 22 patients by Xpert. INTERPRETATION Xpert Ultra was not statistically superior to Xpert for the diagnosis of tuberculous meningitis in HIV-uninfected and HIV-infected adults. A negative Xpert Ultra or Xpert test does not rule out tuberculous meningitis. New diagnostic strategies are urgently required. FUNDING Wellcome Trust and the Foundation for Innovative New Diagnostics.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Do Dang Anh Thu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Viet Anh Ward, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Vu Thi Mong Dung
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Tran Phu Quang
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Viet Anh Ward, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Kieu Nguyet Oanh
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Viet Anh Ward, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Bao Nhu
- Viet Anh Ward, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Van Vinh Chau
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Viet Anh Ward, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Vu Thi Ngoc Ha
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Vu Thi Ty Hang
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Dong Huu Khanh Trinh
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Le Van Tan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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