Urine lipoarabinomannan (LAM) and antimicrobial usage in seriously-ill HIV-infected patients with sputum smear-negative pulmonary tuberculosis.

Autor:	Mthiyane T; Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa., Peter J; Division of Allergology, Department of Medicine, University of Cape Town, Cape Town, South Africa., Allen J; Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa.; Queensland Audit of Surgical Mortality, East Brisbane, Queensland, Australia., Connolly C; Biostatistics Department, South African Medical Research Council, Durban, South Africa., Davids M; Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa., Rustomjee R; Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa.; Division of AIDS/NIAID/NIH/DHHS, Therapeutics Research Program, Tuberculosis Clinical Research Branch, Rockville, MD, USA., Holtz TH; Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA., Malinga L; Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa., Dheda K; Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.; Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
Jazyk:	angličtina
Zdroj:	Journal of thoracic disease [J Thorac Dis] 2019 Aug; Vol. 11 (8), pp. 3505-3514.
DOI:	10.21037/jtd.2019.07.69
Abstrakt:	Background: Based on current WHO guidelines, hospitalized tuberculosis (TB) and HIV co-infected patients with CD4 count <100 cells/mm 3 who are urine lipoarabinomannan (LAM) positive should be initiated on TB treatment. This recommendation is conditional, and data are limited in sputum smear-negative patients from TB endemic countries where the LAM test is largely inaccessible. Other potential benefits of LAM, including reduction in antibiotic usage have, hitherto, not been explored. Methods: We consecutively enrolled newly-admitted seriously-ill HIV-infected patients (n=187) with suspected TB from three hospitals in KwaZulu-Natal, South Africa. All patients were empirically treated for TB as per the WHO 2007 smear-negative TB algorithm (patients untreated for TB were not recruited). Bio-banked urine, donated prior to anti-TB treatment, was tested for TB-infection using a commercially available LAM-ELISA test. TB sputum and blood cultures were performed. Results: Data from 156 patients containing CD4 count, urine-LAM, sputum and blood culture results were analysed. Mean age was 37 years, median CD4-count was 75 cells/mm 3 [interquartile range (IQR), 34-169 cells/mm 3 ], 54/156 (34.6%) were sputum culture-positive, 12/54 (22.2%) blood-culture positive, and 53/156 (34.0%) LAM-positive. Thus, LAM sensitivity was 55.6% (30/54). The study design did not allow for calculation of specificity. Urine-LAM positivity was associated with low CD4 count (P=0.002). Ninety-point-six percent (48/53) of LAM-positive patients received antibiotics [15/48 (31.3%), 23/48 (47.9%) and 10/48 (20.8%) received one, two or three different antibiotics respectively], while the duration of antibiotic therapy was more than 5 days in 26 of 46 (56.5%) patients. Conclusions: Urine LAM testing in sputum smear-negative severely-ill hospitalized patients with TB-HIV co-infection and advanced immunosuppression, offered an immediate rule-in diagnosis in one-third of empirically treated patients. Moreover, LAM, by providing a rapid alternative diagnosis, could potentially reduce antibiotic overusage in such patients thereby reducing health-care costs and facilitating antibiotic stewardship. Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.
Databáze:	MEDLINE
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