title: Predictors and outcomes of Mycobacterium tuberculosis bacteremia among patients with HIV and tuberculosis co-infection enrolled in the ACTG A5221 STRIDE study.
abstract: BACKGROUND
  We evaluated predictors and outcomes of Mycobacterium tuberculosis bacteremia among participants undergoing baseline mycobacterial blood culture in the ACTG A5221 STRIDE study, a randomized clinical trial comparing earlier with later ART among HIV-infected patients suspected of having tuberculosis with CD4-positive T-lymphocyte counts (CD4 counts) <250 cells/mm(3). We conducted a secondary analysis comparing participants with respect to presence or absence of M. tuberculosis bacteremia.
  
  
  METHODS
  Participants with a baseline mycobacterial blood culture were compared with respect to the presence or absence of M. tuberculosis bacteremia. Baseline predictors of M. tuberculosis bacteremia were identified and participant outcomes were compared by mycobacteremia status.
  
  
  RESULTS
  Of 90 participants with baseline mycobacterial blood cultures, 29 (32.2%) were female, the median (IQR) age was 37 (31-45) years, CD4 count was 81 (33-131) cells/mm(3), HIV-1 RNA level was 5.39 (4.96-5.83) log10 copies/mL, and 18 (20.0%) had blood cultures positive for M. tuberculosis. In multivariable analysis, lower CD4 count (OR 0.85 per 10-cell increase, p = 0.012), hemoglobin ≤8.5 g/dL (OR 5.8, p = 0.049), and confirmed tuberculosis (OR 17.4, p = 0.001) were associated with M. tuberculosis bacteremia. There were no significant differences in survival and AIDS-free survival, occurrence of tuberculosis immune reconstitution inflammatory syndrome (IRIS), or treatment interruption or discontinuation by M. tuberculosis bacteremia status. IRIS did not differ significantly between groups despite trends toward more virologic suppression and greater CD4 count increases at week 48 in the bacteremic group.
  
  
  CONCLUSIONS
  Among HIV-infected tuberculosis suspects, lower CD4 count, hemoglobin ≤8.5 g/dL, and the presence of microbiologically confirmed pulmonary tuberculosis were associated with increased adjusted odds of mycobacteremia. No evidence of an association between M. tuberculosis bacteremia and the increased risk of IRIS was detected.
  
  
  BACKGROUND
  ClinicalTrials.gov: NCT00108862 .
authors.affiliation: Department of Medicine, Division of Infectious Diseases and International Health, Durham, NC, 27710, USA. john.crump@duke.edu.|Department of Pathology, Duke University Medical Center, Box 102359, Durham, NC, 27710, USA. john.crump@duke.edu.|Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, USA. john.crump@duke.edu.|Kilimanjaro Christian Medical Centre, PO Box 3010, Moshi, Tanzania. john.crump@duke.edu.|Kilimanjaro Christian Medical University College, Tumaini University, PO Box 2240, Moshi, Tanzania. john.crump@duke.edu.
authors.forename: John A
authors.initials: JA
authors.lastname: Crump
authors.affiliation: Center for Biostatistics in AIDS Research, Harvard School of Public Health, 651 Huntington Avenue, Boston, MA, 02115, USA. xwu@sdac.harvard.edu.
authors.forename: Xingye
authors.initials: X
authors.lastname: Wu
authors.affiliation: Center for Biostatistics in AIDS Research, Harvard School of Public Health, 651 Huntington Avenue, Boston, MA, 02115, USA. kendall@sdac.harvard.edu.
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Kendall
authors.affiliation: Department of Medicine, University of the Witwatersrand, Private Bag 3, Wits 2050, Johannesburg, South Africa. pive@witshealth.co.za.
authors.forename: Prudence D
authors.initials: PD
authors.lastname: Ive
authors.affiliation: Department of Internal Medicine, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3, Malawi. jonnykumwenda@hotmail.com.
authors.forename: Johnstone J
authors.initials: JJ
authors.lastname: Kumwenda
authors.affiliation: Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation, Avenue Brasil 4365, Manguinhos 21040-360, Rio de Janeiro, Brazil. beatriz.grinsztejn@gmail.com.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.affiliation: School of Pathology, University of the Witwatersrand, Private Bag 3, Wits 2050, Johannesburg, South Africa. ujentsch@cls.co.za.
authors.forename: Ute
authors.initials: U
authors.lastname: Jentsch
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 42nd and Emile, Omaha, NE 68198, USA. sswindells@unmc.edu.
authors.forename: Susan
authors.initials: S
authors.lastname: Swindells
mesh_terms: D000328:Adult; D000367:Age Factors; D023241:Antiretroviral Therapy, Highly Active; D016470:Bacteremia / Q000097:blood / Q000150:complications / Q000401:mortality*; D018791:CD4 Lymphocyte Count; D060085:Coinfection; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D015497:HIV-1; D006801:Humans; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification*; D012737:Sex Factors; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D014397:Tuberculosis, Pulmonary / Q000150:complications*