Treatment delay is linked to early mortality in Mycobacterium TB-HIV BSI

  • Barr DA & al.
  • Lancet Infect Dis
  • 01/06/2020

  • Liz Scherer
  • Clinical Essentials
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Takeaway

  • Mycobacterium tuberculosis bloodstream infection (BSI) in HIV-associated tuberculosis (TB) is independently associated with mortality (4 days.

Why this matters

  • Consider adding urine lipoarabinomannan (LAM) and first-line sputum testing in patients with TB and HIV who are hospitalized with >1 WHO danger signs.
  • Editorial : TB prevalence may help define appropriate strategy; consider risk/benefits of initiating treatment in all patients, including those with negative rapid TB tests.

Key results

  • 20 data sets, 5751 individualized patient data (IPD) included. 
  • Mean predicted M tuberculosis BSI probability (>1 WHO danger signs, CD4 76 cells/µL): 0.45 (95% CI, 0.38-0.52).
  • Pooled summary for urine LAM:
    • Diagnostic yield: 0.52 (95% CI, 0.35-0.69).
    • Sputum: 0.77 (95% CI, 0.63-0.87).
    • Composite: 0.89 (95% CI, 0.80-0.94).
      • Significant heterogeneity across studies (urine, sputum, P<.0001 both>
  • M tuberculosis predicted mortality risk before 30 days (adjusted HR, 2.48; 95% CI, 2.05-3.08).
  • Association observed between delayed therapy and early mortality (OR, 3.2; 95% CI, 1.2-8.8).

Study design

  • IPD metareview exploring prevalence, diagnostic yield, mortality risk, and related treatment effect of M tuberculosis in BSI in adults with HIV-associated TB.
  • Funding: None disclosed.

Limitations

  • Inclusion, patient selection bias.
  • Study design, conduct variations.
  • Overestimated diagnostic yield.
  • Missing data bias.
  • Unmeasured confounding.