Abstract
BackgroundWhen manifested as Mycobacterium tuberculosis (MTB) bacteremia, disseminated MTB infection clinically mimics other serious blood stream infections often hindering early diagnosis and initiation of potentially life-saving anti-tuberculosis therapy. In a cohort of hospitalized HIV-infected Ugandan patients with severe sepsis, we report the frequency, management and outcomes of patients with MTB bacteremia and propose a risk score based on clinical predictors of MTB bacteremia.MethodsWe prospectively enrolled adult patients with severe sepsis at two Ugandan hospitals and obtained blood cultures for MTB identification. Multivariable logistic regression modeling was used to determine predictors of MTB bacteremia and to inform the stratification of patients into MTB bacteremia risk categories based on relevant patient characteristics.ResultsAmong 368 HIV-infected patients with a syndrome of severe sepsis, eighty-six (23%) had MTB bacteremia. Patients with MTB bacteremia had a significantly lower median CD4 count (17 vs 64 lymphocytes/mm3, p<0.001) and a higher 30-day mortality (53% vs 32%, p = 0.001) than patients without MTB bacteremia. A minority of patients with MTB bacteremia underwent standard MTB diagnostic testing (24%) or received empiric anti-tuberculosis therapy (15%). Independent factors associated with MTB bacteremia included male sex, increased heart rate, low CD4 count, absence of highly active anti-retroviral therapy, chief complaint of fever, low serum sodium and low hemoglobin. A risk score derived from a model containing these independent predictors had good predictive accuracy [area under the curve = 0.85, 95% CI 0.80–0.89].ConclusionsNearly 1 in 4 adult HIV-infected patients hospitalized with severe sepsis in 2 Ugandan hospitals had MTB bacteremia. Among patients in whom MTB was suspected, standard tests for diagnosing pulmonary MTB were inaccurate for correctly classifying patients with or without bloodstream MTB infection. A MTB bacteremia risk score can improve early diagnosis of MTB bacteremia particularly in settings with increased HIV and MTB co-infection.
Highlights
In 2011, approximately one quarter of new Mycobacterium tuberculosis (MTB) cases worldwide occurred in sub-Saharan Africa where the tuberculosis epidemic is fueled by a high prevalence of HIV infection [1,2]
Negative predictive value of test for MTB bacteremia and all the results were assumed to be negative, sensitivity would decrease considerably for both smear (19.8%) and radiograph (53.5%) but estimated specificity would increase for both tests with acid fast bacilli (AFB) smear having a high specificity for MTB bacteremia (92.6%) while the specificity of the radiograph would remain low (53.2%)
Multivariable analysis revealed that admitting clinicians were more likely to provide antituberculosis therapy in patients with cough as a chief complaint; both hyperlactatemia and hyperkalemia were associated with administration of anti-tuberculosis therapy but these covariates did not remain statistically significant in the final multivariable model
Summary
In 2011, approximately one quarter of new Mycobacterium tuberculosis (MTB) cases worldwide occurred in sub-Saharan Africa where the tuberculosis epidemic is fueled by a high prevalence of HIV infection [1,2]. In this region, MTB is the leading cause of death among HIV-infected persons and post-mortem studies have shown that a large proportion of those who die of MTB infection have undiagnosed disseminated disease [3,4]. In a cohort of hospitalized HIV-infected Ugandan patients with severe sepsis, we report the frequency, management and outcomes of patients with MTB bacteremia and propose a risk score based on clinical predictors of MTB bacteremia
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