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Rapid microbiological screening for tuberculosis in HIV-positive patients on the first day of acute hospital admission by systematic testing of urine samples using Xpert MTB/RIF: a prospective cohort in South Africa.

Lawn SD, Kerkhoff AD, Burton R, Schutz C, van Wyk G, Vogt M, Pahlana P, Nicol MP, Meintjes G - BMC Med (2015)

Bottom Line: To evaluate a rapid screening strategy, we compared the diagnostic yield of Xpert testing sputum samples and urine samples obtained with assistance from a respiratory study nurse in the first 24 h of admission.The very high prevalence of active TB and its non-specific presentation strongly suggest the need for routine microbiological screening for TB in all HIV-positive medical admissions in high-burden settings.The incremental diagnostic yield from Xpert testing urine was very high and this strategy might be used to rapidly screen new admissions, especially if sputum is difficult to obtain.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. stephen.lawn@lshtm.ac.uk.

ABSTRACT

Background: Autopsy studies of HIV/AIDS-related hospital deaths in sub-Saharan Africa reveal frequent failure of pre-mortem diagnosis of tuberculosis (TB), which is found in 34-64 % of adult cadavers. We determined the overall prevalence and predictors of TB among consecutive unselected HIV-positive adults requiring acute hospital admission and the comparative diagnostic yield obtained by screening urine and sputum samples obtained on day 1 of admission with Xpert MTB/RIF (Xpert).

Methods: To determine overall TB prevalence accurately, comprehensive clinical sampling (sputum, urine, blood plus other relevant samples) was done and TB was defined by detection of Mycobacterium tuberculosis in any sample using Xpert and/or mycobacterial liquid culture. To evaluate a rapid screening strategy, we compared the diagnostic yield of Xpert testing sputum samples and urine samples obtained with assistance from a respiratory study nurse in the first 24 h of admission.

Results: Unselected HIV-positive acute adult new medical admissions (n = 427) who were not receiving TB treatment were enrolled irrespective of clinical presentation or symptom profile. From 2,391 cultures and Xpert tests done (mean, 5.6 tests/patient) on 1,745 samples (mean, 4.1 samples/patient), TB was diagnosed in 139 patients (median CD4 cell count, 80 cells/μL). TB prevalence was very high (32.6 %; 95 % CI, 28.1-37.2 %; 139/427). However, patient symptoms and risk factors were poorly predictive for TB. Overall, ≥1 non-respiratory sample(s) tested positive in 115/139 (83 %) of all TB cases, including positive blood cultures in 41/139 (29.5 %) of TB cases. In the first 24 h of admission, sputum (spot and/or induced samples) and urine were obtainable from 37.0 % and 99.5 % of patients, respectively (P <0.001). From these, the proportions of total TB cases (n = 139) that were diagnosed by Xpert testing sputum, urine or both sputum and urine combined within the first 24 h were 39/139 (28.1 %), 89/139 (64.0 %) and 108/139 (77.7 %) cases, respectively (P <0.001).

Conclusions: The very high prevalence of active TB and its non-specific presentation strongly suggest the need for routine microbiological screening for TB in all HIV-positive medical admissions in high-burden settings. The incremental diagnostic yield from Xpert testing urine was very high and this strategy might be used to rapidly screen new admissions, especially if sputum is difficult to obtain.

No MeSH data available.


Related in: MedlinePlus

Flow diagram showing the study population
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Fig1: Flow diagram showing the study population

Mentions: Between 6th June 2012 and 4th October 2013, the HIV status of 1,013 of 1,018 (99.5 %) unselected new admissions to the adult medical wards was ascertained (Fig. 1). Of the 609 patients who were HIV-positive, 585 (96.1 %) were enrolled in the study and investigated for TB. Those already receiving treatment for an existing diagnosis of TB at the time of admission (n = 158) were excluded, leaving 427 patients eligible for inclusion. These were typically young adults of whom a majority knew their positive HIV status before admission and more than one half had previously started ART (Table 2). Immunodeficiency was typically advanced and CD4 cell counts (median, 149 cells/μL) were lower among those who were ART-naive compared to those currently receiving ART (115 cells/μL versus 212 cells/μL; P <0.001). Two-thirds of all patients had moderate or severe anaemia. A history of previous TB was very common. No patients had received IPT. The vast majority of all patients had a positive WHO TB symptom screen regardless of TB status.Fig. 1


Rapid microbiological screening for tuberculosis in HIV-positive patients on the first day of acute hospital admission by systematic testing of urine samples using Xpert MTB/RIF: a prospective cohort in South Africa.

Lawn SD, Kerkhoff AD, Burton R, Schutz C, van Wyk G, Vogt M, Pahlana P, Nicol MP, Meintjes G - BMC Med (2015)

Flow diagram showing the study population
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4537538&req=5

Fig1: Flow diagram showing the study population
Mentions: Between 6th June 2012 and 4th October 2013, the HIV status of 1,013 of 1,018 (99.5 %) unselected new admissions to the adult medical wards was ascertained (Fig. 1). Of the 609 patients who were HIV-positive, 585 (96.1 %) were enrolled in the study and investigated for TB. Those already receiving treatment for an existing diagnosis of TB at the time of admission (n = 158) were excluded, leaving 427 patients eligible for inclusion. These were typically young adults of whom a majority knew their positive HIV status before admission and more than one half had previously started ART (Table 2). Immunodeficiency was typically advanced and CD4 cell counts (median, 149 cells/μL) were lower among those who were ART-naive compared to those currently receiving ART (115 cells/μL versus 212 cells/μL; P <0.001). Two-thirds of all patients had moderate or severe anaemia. A history of previous TB was very common. No patients had received IPT. The vast majority of all patients had a positive WHO TB symptom screen regardless of TB status.Fig. 1

Bottom Line: To evaluate a rapid screening strategy, we compared the diagnostic yield of Xpert testing sputum samples and urine samples obtained with assistance from a respiratory study nurse in the first 24 h of admission.The very high prevalence of active TB and its non-specific presentation strongly suggest the need for routine microbiological screening for TB in all HIV-positive medical admissions in high-burden settings.The incremental diagnostic yield from Xpert testing urine was very high and this strategy might be used to rapidly screen new admissions, especially if sputum is difficult to obtain.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. stephen.lawn@lshtm.ac.uk.

ABSTRACT

Background: Autopsy studies of HIV/AIDS-related hospital deaths in sub-Saharan Africa reveal frequent failure of pre-mortem diagnosis of tuberculosis (TB), which is found in 34-64 % of adult cadavers. We determined the overall prevalence and predictors of TB among consecutive unselected HIV-positive adults requiring acute hospital admission and the comparative diagnostic yield obtained by screening urine and sputum samples obtained on day 1 of admission with Xpert MTB/RIF (Xpert).

Methods: To determine overall TB prevalence accurately, comprehensive clinical sampling (sputum, urine, blood plus other relevant samples) was done and TB was defined by detection of Mycobacterium tuberculosis in any sample using Xpert and/or mycobacterial liquid culture. To evaluate a rapid screening strategy, we compared the diagnostic yield of Xpert testing sputum samples and urine samples obtained with assistance from a respiratory study nurse in the first 24 h of admission.

Results: Unselected HIV-positive acute adult new medical admissions (n = 427) who were not receiving TB treatment were enrolled irrespective of clinical presentation or symptom profile. From 2,391 cultures and Xpert tests done (mean, 5.6 tests/patient) on 1,745 samples (mean, 4.1 samples/patient), TB was diagnosed in 139 patients (median CD4 cell count, 80 cells/μL). TB prevalence was very high (32.6 %; 95 % CI, 28.1-37.2 %; 139/427). However, patient symptoms and risk factors were poorly predictive for TB. Overall, ≥1 non-respiratory sample(s) tested positive in 115/139 (83 %) of all TB cases, including positive blood cultures in 41/139 (29.5 %) of TB cases. In the first 24 h of admission, sputum (spot and/or induced samples) and urine were obtainable from 37.0 % and 99.5 % of patients, respectively (P <0.001). From these, the proportions of total TB cases (n = 139) that were diagnosed by Xpert testing sputum, urine or both sputum and urine combined within the first 24 h were 39/139 (28.1 %), 89/139 (64.0 %) and 108/139 (77.7 %) cases, respectively (P <0.001).

Conclusions: The very high prevalence of active TB and its non-specific presentation strongly suggest the need for routine microbiological screening for TB in all HIV-positive medical admissions in high-burden settings. The incremental diagnostic yield from Xpert testing urine was very high and this strategy might be used to rapidly screen new admissions, especially if sputum is difficult to obtain.

No MeSH data available.


Related in: MedlinePlus