title: Clinical predictors and accuracy of empiric tuberculosis treatment among sputum smear-negative HIV-infected adult TB suspects in Uganda.
abstract: BACKGROUND
  The existing diagnostic algorithms for sputum smear-negative tuberculosis (TB) are complicated, time-consuming, and often difficult to implement. The decision to initiate TB treatment in resource-limited countries is often largely based on clinical predictors. We sought to determine the clinical predictors and accuracy of empiric TB treatment initiation in HIV-infected sputum smear-negative TB suspects using sputum culture as a reference standard.
  
  
  METHODS
  Out-patient HIV-TB integrated urban clinic in Kampala, Uganda.
  
  
  METHODS
  HIV-infected TB suspects were screened using sputum smear microscopy, and mycobacterial sputum liquid and solid cultures were performed. Smear results were made available to the clinician who made a clinical decision on empiric TB treatment initiation for sputum smear-negative patients. Clinic records were reviewed for patients whose sputum smears were negative to collect data on socio-demographics, TB symptomatology, chest X-ray findings, CD4 cell counts and TB treatment initiation.
  
  
  RESULTS
  Of 253 smear-negative TB suspects, 56% (142/253) were females, median age 38 IQR (31-44) years, with a median CD4 cell count of 291 IQR (150-482) cells/mm(3). Of the 85 (33.6%) smear-negative patients empirically initiated on TB treatment, 35.3% (n = 30) were sputum culture positive compared to only 18 (10.7%) of the 168 untreated patients (p<0.001). Abnormal chest X-ray [aOR 10.18, 95% CI (3.14-33.00), p<0.001] and advanced HIV clinical stage [aOR 3.92, 95% CI (1.20-12.85), p = 0.024] were significantly associated with empiric TB treatment initiation. The sensitivity and specificity of empiric TB treatment initiation in the diagnosis of TB in HIV-infected patients after negative smear microscopy was 62.5% and 73.7% respectively.
  
  
  CONCLUSIONS
  In resource-limited settings, clinically advanced HIV and abnormal chest X-ray significantly predict a clinical decision to empirically initiate TB treatment in smear-negative HIV-infected patients. Empiric TB treatment initiation correlates poorly with TB cultures. Affordable, accurate and rapid point-of-care diagnostics are needed in resource-limited settings to more accurately determine which HIV-infected TB suspects have smear-negative TB.
authors.affiliation: Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda ; School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Lydia
authors.initials: L
authors.lastname: Nakiyingi
authors.forename: John Mark
authors.initials: JM
authors.lastname: Bwanika
authors.forename: Bruce
authors.initials: B
authors.lastname: Kirenga
authors.forename: Damalie
authors.initials: D
authors.lastname: Nakanjako
authors.forename: Catherine
authors.initials: C
authors.lastname: Katabira
authors.forename: Gloria
authors.initials: G
authors.lastname: Lubega
authors.forename: Joseph
authors.initials: J
authors.lastname: Sempa
authors.forename: Barnabas
authors.initials: B
authors.lastname: Nyesiga
authors.forename: Heidi
authors.initials: H
authors.lastname: Albert
authors.forename: Yukari C
authors.initials: YC
authors.lastname: Manabe
mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D060085:Coinfection; D005260:Female; D015658:HIV Infections / Q000175:diagnosis; D006801:Humans; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D013183:Sputum / Q000382:microbiology*; D014376:Tuberculosis / Q000175:diagnosis* / Q000188:drug therapy*; D014454:Uganda
chemical_list: D000995:Antitubercular Agents
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