The use of a urine lipoarabinomannan test in clinical decision-making regarding empiric tuberculosis treatment among HIV-positive patients suspected to have tuberculosis
DOI:
https://doi.org/10.7196/Keywords:
Urine LAM, Tuberculosis treatemtns and HIVAbstract
Background. Tuberculosis (TB) is a major contributor to mortality among patients affected by HIV. TB diagnosis can be challenging, especially in those who are severely ill and unable to produce sputum. Urine lipoarabinomannan (LAM) is a rapid point‐of‐care diagnostic tool that is used on urine. The dilemma arises if a urine LAM test yields a negative result when the clinical presentation is strongly suggestive of TB.
Objective. To investigate how a urine LAM test result changes the physician’s decision to start TB treatment in people living with HIV in Kalafong Provincial Tertiary Hospital (KPTH).
Method. A cross‐sectional study was done at KPTH in the internal medicine wards, family medicine and HIV outpatient departments. Patients who were HIV positive with a strong TB diagnosis suspicion, had a CD4 count <200 cells/mm3, were aged >13 years and had a urine LAM done to investigate TB were included. Outcomes investigated were: presenting symptoms, clinical signs, radiological and haematological investigations, including CD4 count and HIV viral load, urine LAM results and whether TB treatment was initiated or not. At KPTH, a register of all patients who have been given a urine LAM test is held at the TB notification centre, which was where the information regarding urine LAM results was retrieved from, as well as whether treatment was initiated or not. The patients’ clinical hospital records and National Health Laboratory Service lab results were retrieved for necessary information.
Results. There were 430 patient records and urine LAM results retrieved: 307 (71.4%) had negative results and 123 (28.6%) had positive results. Of the 307 (71.4%) with a negative result, 120 (39.1%) were initiated on treatment, and only 3 of those who had positive results (1.6%) did not receive treatment. The urine LAM test results appeared to influence clinicians’ decisions to treat when the result was positive. If the urine LAM was negative, clinicians still initiated treatment based on adequate clinical suspicion and other investigations. There was significant incongruency between patients with a negative urine LAM test who received TB treatment (p<0.001).
Conclusion. The use of the urine LAM did not change the physician’s decision to start TB treatment where the was a high suspicion of TB based on clinical presentation and other investigations. Physicians depended more on their clinical intuition where the urine LAM was negative.
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