Open Access Research article

A randomized controlled trial of standard versus intensified tuberculosis diagnostics on treatment decisions by physicians in Northern Tanzania

Elizabeth A Reddy12*, Boniface N Njau2, Susan C Morpeth4, Kathryn E Lancaster5, Alison C Tribble6, Venance P Maro23, Levina J Msuya23, Anne B Morrissey1, Gibson S Kibiki23, Nathan M Thielman17, Coleen K Cunningham1, Werner Schimana8, John F Shao23, Shein-Chung Chow9, Jason E Stout1, John A Crump136, John A Bartlett136 and Carol D Hamilton110

Author Affiliations

1 Duke University Medical Center, Durham, NC, USA

2 Kilimanjaro Christian Medical Centre, Box 3010, CCFCC Duke Projects, Moshi, Tanzania

3 Kilimanjaro Christian Medical University College, Moshi, Tanzania

4 KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya

5 Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA

6 Children’s Hospital of Philadelphia, Philadelphia, PA, USA

7 Duke Global Health Institute, Duke University, Durham, NC, USA

8 Elizabeth Glaser Pediatric AIDS Foundation Tanzania, Dar Es Salaam, Tanzania

9 Duke Clinical Research Institute, Duke University, Durham, NC, USA

10 FHI 360, Durham, NC, USA

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BMC Infectious Diseases 2014, 14:89  doi:10.1186/1471-2334-14-89

Published: 20 February 2014

Abstract

Background

Routine tuberculosis culture remains unavailable in many high-burden areas, including Tanzania. This study sought to determine the impact of providing mycobacterial culture results over standard of care [unconcentrated acid-fast (AFB) smears] on management of persons with suspected tuberculosis.

Methods

Adults and children with suspected tuberculosis were randomized to standard (direct AFB smear only) or intensified (concentrated AFB smear and tuberculosis culture) diagnostics and followed for 8 weeks. The primary endpoint was appropriate treatment (i.e. antituberculosis therapy for those with tuberculosis, no antituberculous therapy for those without tuberculosis).

Results

Seventy participants were randomized to standard (n = 37, 53%) or intensive (n = 33, 47%) diagnostics. At 8 weeks, 100% (n = 22) of participants in follow up randomized to intensive diagnostics were receiving appropriate care, vs. 22 (88%) of 25 participants randomized to standard diagnostics (p = 0.14). Overall, 18 (26%) participants died; antituberculosis therapy was associated with lower mortality (9% who received antiuberculosis treatment died vs. 26% who did not, p = 0.04).

Conclusions

Under field conditions in a high burden setting, the impact of intensified diagnostics was blunted by high early mortality. Enhanced availability of rapid diagnostics must be linked to earlier access to care for outcomes to improve.

Keywords:
Mycobacterium tuberculosis; Diagnosis; Health resources; Sputum/microbiology; HIV; adult; Child