Background Empirical TB treatment in HIV-positive inpatients is common and may undermine the impact of new diagnostics. We sought to describe empirical TB treatment and compare characteristics and outcomes with patients treated for TB after screening. Methods Retrospective observational cohort study of HIV-positive inpatients treated empirically for TB prior to TB screening. Data on clinical characteristics, investigations and outcomes were collected from medical records. Comparison cohorts with microbiologically-confirmed or empirical TB treatment after TB screening with Xpert MTB/RIF and urine lipoarabinomannan assays were taken from South African STAMP trial site. In-hospital mortality was compared using a competing-risks analysis adjusted for age, sex and CD4 count. Results Between January 2016 and September 2017, 100 patients excluded from STAMP were treated for TB empirically prior to TB screening. After enrolment in STAMP and TB screening, 240/1177 (20.4%) patients received TB treatment, of whom 123 had positive TB tests and 117 were treated empirically. Characteristics were similar among early empirically treated patients and those treated after TB screening. 50% of early empirical TB treatment was based on radiological investigations, 22% on cerebrospinal or pleural fluid testing, and 28% on clinical features alone. Only 11/100 empirically treated patients had subsequent microbiological confirmation. In-hospital mortality was lower in patients with microbiologically-confirmed TB compared to those treated empirically (adjusted sub-distribution HR 0.5, 95% CI 0.3-0.9). Conclusions Empirical TB treatment remains common in severely ill HIV-positive inpatients. These patients may benefit from TB screening using existing rapid diagnostics, both to improve confirmation of TB disease and reduce over-treatment for TB.
Preterm birth is an important cause of neonatal morbidity and mortality globally. Uganda has one of the highest rates of preterm birth in East Africa but few resources to care for these infants. This case highlights the clinical course of an extremely premature infant born at 26 weeks gestation to a nulliparous 24-year-old woman. Her mother was involved in her care and taught the principles of kangaroo mother care. After initial problems establishing feeds she progressed well and was discharged in the fifth week of life. The case describes some of the low technology conservative and medical measures which can be used to care for neonates, such as antenatal steroids and kangaroo care. The use of antibiotics and aminophylline are also discussed. The approach to the common challenges faced by premature infants such as respiratory disease, sepsis and necrotising enterocolitis in a resource-poor environment are discussed.
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