In a cross-sectional study among hospitalized human immunodeficiency virus (HIV)-infected patients in Ethiopia, we sought to determine the rates and predictors of cryptococcal disease and evaluate the test performance of a recently introduced point-of-care test for Cryptococcus neoformans detection in various biological samples. We tested serum, urine, and fingerstick blood samples from each patient with a cryptococcal antigen lateral flow assay (CRAG LFA; Immuno Mycologic Inc., Norman, OK). Cerebrospinal fluid was collected at the discretion of the treating physician. Logistic regression was used to identify risk factors for a positive test result. Agreement between different sample types was also assessed. Among 198 hospitalized HIV-infected patients with a median CD4 count of 93 cells/mm 3 , 18 patients (9.1%) had a positive serum CRAG LFA. Of these, 16 (8.1%) had confirmed cryptococcal meningitis (CM), all of whom had a positive fingerstick blood LFA result. There was a very high agreement between CRAG LFA tests in serum and fingerstick blood samples (κ = 0.97, 95% confidence interval [CI] = 0.91-1.00); this was higher than that between serum and urine samples (κ = 0.76, 95% CI = 0.58-0.93). A CD4 count < 100 cells/mm 3 was significantly associated with a positive CRAG LFA. The absence of fever, headache, meningismus, and neck stiffness had a negative predictive value of 100% for CM. In addition to finding high rates of cryptococcal disease, our study demonstrated that the use of the LFA on fingerstick whole blood is less invasive, and an effective method for CM case finding among hospitalized patients with HIV.
Summary Setting An HIV clinic in Addis Ababa, Ethiopia. Objective The World Health Organization (WHO) recommends active tuberculosis (TB) case finding among people living with HIV (PLHIV) in resource-limited settings using a symptom-based algorithm and those without active TB disease should be offered isoniazid preventive therapy (IPT). We evaluated rates of adherence to these recommendations and the impact of a quality improvement (QI) intervention. Design A prospective study design was utilized to compare TB symptom screening and IPT administration rates before and after a QI intervention consisting of 1) educational sessions, 2) visual reminders and 3) use of a screening checklist. Results A total of 751 HIV-infected patient visits were evaluated. The proportion of patients screened for TB symptoms increased from 22% at baseline to 94% following the intervention (P<0.001). Screening rates improved from 51% to 81% (P<0.001) for physicians and from 3% to 100% (P<0.001) for nurses. Of the 281 patients with negative TB symptom screens and eligible for IPT, 4% were prescribed IPT before the intervention compared to 81%(P<0.001) afterward. Conclusions We found a QI intervention significantly increased WHO recommended TB screening rates and IPT administration. Utilizing nurses can help increase TB screening and IPT provision in resource-limited settings.
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