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Objective To determine if implementation of 2010 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) initiation reduced delay from tuberculosis diagnosis to initiation of ART in a Cambodian urban hospital. Methods A retrospective cohort study was conducted in a nongovernmental hospital in Phnom Penh that followed new WHO guidelines in patients with human immunodeficiency virus (HIV) and tuberculosis. All ART-naive, HIV-positive patients initiated on antituberculosis treatment over the 18 months before and after guideline implementation were included. A competing risk regression model was used. Findings After implementation of the 2010 WHO guidelines, 190 HIV-positive patients with tuberculosis were identified: 53% males; median age, 38 years; median baseline CD4+ T-lymphocyte (CD4+ cell) count, 43 cells/µL. Before implementation, 262 patients were identified; 56% males; median age, 36 years; median baseline CD4+ cell count, 59 cells/µL. With baseline CD4+ cell counts < 50 cells/µL, median delay to ART declined from 5.8 weeks (interquartile range, IQR: 3.7-9.0) before to 3.0 weeks (IQR: 2.1-4.4) after implementation (P < 0.001); with baseline CD4 + cell counts > 50 cells/µL, delay dropped from 7.0 (IQR: 5.3-11.3) to 3.6 (IQR: 2.9-5.3) weeks (P < 0.001). The probability of ART initiation Within 4 and 8 weeks after tuberculosis diagnosis rose from 23% and 65%, respectively, before implementation, to 62% and 90% after implementation. A non-significant increase in 6-month retention and antiretroviral substitution was seen after implementation. Conclusion Implementation of 2010 WHO recommendations in a routine clinical setting shortens delay to ART. Larger studies with longer follow-up are needed to assess impact on patient outcomes. Objectif Determiner si la mise en oeuvre des lignes directrices 2010 de l'Organisation mondiale de la Sante (OMS) relatives a la mise en oeuvre du traitement antiretroviral (TAR) a reduit le delai entre le diagnostic de la tuberculose et la mise en oeuvre du TAR dans un hopital cambodgien urbain. Methodes Une etude de cohorte retrospective a ete effectuee dans un hopital non gouvernemental de Phnom Penh, appliquant les nouvelles lignes directrices de l'OMS, aupres de patients atteints du virus d'immunodeficience humaine (VlH) et de la tuberculose. Ont ete inclus tous les patients VlH-positifs, n'ayant pas beneficie auparavant d'un TAR, ayant entame un traitement antituberculeux au cours des 18 mois avant et apres la mise en oeuvre des lignes directrices. Un modele de regression a risques concurrents a ete utilise. Resultats Apres la mise en oeuvre des lignes directrices 2010 de l'OMS, 190 patients seropositifs atteints de la tuberculose ont ete identifies: 53% d'hommes; age median: 38 ans; nombre median de lymphocytes T CD4+ (cellule CD4+): 43 cellules/pL. Avant la mise en oeuvre, 262 patients ont ete identifies; 56% d'hommes; age median: 36 ans; nombre median de cellules CD4+: 59 cellules/µL. Avec un nombre median de cellules CD4+ ≤ 50 cellules/µL, le delai median avant leTAR est passe de 5,8 semaines (intervalle interquartile, IIQ: 3,7 a 9) avant, a 3.0 semaines (IIQ: 2,1 a 4,4) apres la mise en oeuvre (P 50 cellules/µL, le delai est passe de 7.0 (IIQ: 5,3 a 11,3) a 3,6 semaines (IIQ: 2,9 a 5,3) (P Conclusion La mise en oeuvre des lignes directrices 2010 de l'OMS dans un contexte clinique de routine raccourcit le delai avant la mise en oeuvre du TAR. Des etudes plus importantes, avec un suivi plus long, seront necessaires pour evaluer l'impact sur les patients. Objetivo Determinar si la puesta en practica de las directrices de la Organizacion Mundial de la Salud (OMS) para el ano 2010 acerca de la iniciacion de la terapia antirretroviral (TAR)redujo la demora desde el diagnostico de tuberculosis hasta el inicio de la TAR en un hospital urbano de Camboya. Metodos Se llevo a cabo un estudio de cohorte retrospectivo en un hospital no gubernamental de Phnom Penh que siguio las directrices nuevas de la OMS en pacientes con el virus de la inmunodeficiencia humana (VIH) y tuberculosis. Se incluyeron todos los pacientes seropositivos que no recibieron TAR y que iniciaron un tratamiento contra la tuberculosis durante los 18 meses antes y despues de la puesta en practica de las directrices. Se utilizo un modelo de regresion de riesgos competitivos. Resultados Tras la puesta en practica de las directrices OMS para el ano 2010, se identificaron 190 pacientes seropositivos con tuberculosis: el 53% de ellos, varones, edad media de 38 anos y un recuento de LT CD4+ (celulas CD4+) como punto de partida con una mediana de 43 celulas/L. Antes de la puesta en practica, se identificaron 262 pacientes; el 56% de ellos, varones;, edad media de 36 anos y un recuento de celulas CD4+ como punto de partida con una mediana de 59 celulas/ µL. Con los recuentos de celulas CD4+ de ≤ 50 celulas/µL como punto de partida, la demora media hasta la TAR disminuyo de 5,8 semanas (rango intercuartilico: 3,7-9,0) antes, a 3,0 semanas (rango intercuartilico: 2,1-4,4) tras la implementacion (P < 0,001); con los recuentos de celulas CD4+ inferiores a 50 celulas/µL como punto de partida, la demora bajo de 7,0 (rango intercuartilico: 5,3-11,3) a 3,6 (rango intercuartilico: 2,9-5,3) semanas (p < 0,001). La probabilidad de iniciar TAR entre 4 y 8 semanas tras el diagnostico de tuberculosis aumento del 23% y el 65%, respectivamente, antes de la implementacion, hasta el 62% y el 90% despues de la misma. Tras la implementacion se observo un aumento no significativo de la retencion a 6 meses, asi como de la sustitucion antirretroviral. Conclusion La puesta en practica de las recomendaciones de la OMS para el ano 2010 en un entorno clinico habitual acorta la demora hasta el inicio de laTAR. Son necesarios estudios mas amplios con seguimientos mayores para evaluar el impacto sobre los resultados en los pacientes., Introduction Tuberculosis remains one of the major causes of death in patients infected with the human immunodeficiency virus (HIV) in resource-limited settings. (1) Initiating antiretroviral therapy (ART) during the treatment [...]

Melioidosis, an infectious disease caused by Burkholderia pseudomallei, is endemic to Southeast Asia and tropical Australia (1,2). B. pseudomallei is a gram-negative bacterium that causes lung or soft tissue infections [...]

The study attempts to develop an evidence-based clinical algorithm for people with human immunodeficiency virus (HIV) for tuberculosis screening and diagnosis. The results indicate that screening should include asking questions about the presence or absence of three symptoms and then treatment can be started.

The sensitivity, specificity, and accuracy of 2003 World Health Organization (WHO) criteria was determined to start antiretroviral treatment based on clinical criteria or based on combination of clinical symptoms and the total lymphocyte count. The data suggest that, in settings with limited access to CD4 count testing, it might be useful to target this test to patients in WHO stage 3 whose staging is based on weight loss alone, to avoid unnecessary treatment.

Background: Over the last decade, the availability and use of mobile phones have grown exponentially globally and in Cambodia. In the Sihanouk Hospital Centre of Hope(SHCH) in Cambodia about half of all tuberculosis patients referred out to peripheral health facilities for TB treatment initiation or continuation were lost to contact after referral ranging from 19 to 69% between 2008 and 2013. To address this, we implemented a mobile phone-based patient tracking intervention. Here, we report the number and proportion of referred TB patients who could be contacted through a mobile phone and retained in care after the introduction of mobile phone tracking.Methods: A descriptive study involving follow-up of TB patients referred out from SHCH to peripheral health facilities during May-October 2014. Standard operating procedures were used to contact individual patients and/or health facilities using a mobile phone.Results: Among 109 TB patients referred to peripheral health facilities, 107(98%) had access to a mobile phone of whom, 103(97%) could be contacted directly while 5(2%) were contacted through their health care providers. A total of 108(99%) of 109 referred TB patients in intervention period were thus placed on TB treatment.Conclusions: This study provides preliminary, but promising evidence that using mobile phones was accompanied with improved retention of referred TB patients compared to historical cohorts. Given the limitations associated with historical controls, we need better designed studies with larger sample size to strengthen the evidence before national scale-up. [ABSTRACT FROM AUTHOR]

Background Given the lack of detailed studies on tuberculosis (TB) in patients on antiretroviral treatment (ART) in South-East Asia, we aimed to determine the incidence and risk factors for early (after ≤6 months of ART) and late (after >6 months of ART) incident TB in Cambodia. Methods We conducted a retrospective analysis of all patients started on ART at a non-governmental hospital in Phnom Penh (March 2003–December 2010). TB diagnosis was performed according to WHO algorithms. Risk factor analysis was performed using multivariate Cox regression modeling. Results Overall, 2984 patients started ART. The median baseline CD4 count was 89 cells µl−1 (IQR 25–209), median age 34 years (IQR 29–40). Fifty-three percent of the patients were female. Median follow-up time on ART was 2.4 years. In addition to 932 (31.2%) patients already on TB treatment at ART initiation, 313 (10.5%) developed TB, with an overall incidence rate of 3.9/100 patient-years. Of those developing TB, 179 (6.0%) patients were diagnosed with early TB and 134 (4.5%) with late TB, corresponding with a rate of 13.5 and 2.0 per 100 patient-years respectively. Risk factors for early TB included low body mass index, low baseline CD4 count and low hemoglobin levels. Low on-treatment CD4 counts and hemoglobin levels, being underweight while on ART and prevalent TB were identified as risk factors for late TB. Conclusion The incidence of early TB was high, and predominantly associated with advanced HIV progression markers. Earlier ART initiation and enhanced TB screening prior to and after ART initiation is warranted. Late TB amounts to almost half of the total TB burden, meriting specific preventive and diagnostic approaches. [ABSTRACT FROM AUTHOR]

Background: Although routine viral load (VL) monitoring currently is too costly for poor countries, clinical failure criteria perform poorly. We previously developed an algorithm combining a clinical predictor score (CPS) with targeted VL testing in a Cambodian patient population (derivation population). We now prospectively validate the algorithm in the same clinical setting (validation population), assess its operational performance, and explore its cost-saving potential., Methods: We performed a cross-sectional study in a tertiary hospital in Phnom Penh, Cambodia, applying the CPS in adults on first-line antiretroviral treatment for at least 1 year. Treatment failure was defined as a VL >1000 copies per milliliter. The area under the receiver-operating characteristic (AUROC) curve of the CPS to detect treatment failure in the current study population (validation population) was compared with the AUROC of the CPS obtained in the patient population where the CPS was derived from in 2008 in the same study setting (derivation population). Costs related to VL testing and second-line regimens with the different testing strategies were compared., Results: One thousand four hundred ninety individuals {56.6% female, median age 38 years [interquartile range (IQR): 33-44]} were included, with a median baseline CD4 cell count of 94 cells per microliter (IQR: 28-205). Median time on antiretroviral treatment was 3.6 years (IQR: 2.1-5.1), 45 (3.0%) individuals had treatment failure. The AUROC of the CPS in validation was 0.75 (95% confidence interval: 0.67 to 0.83), relative to an AUROC of 0.70 in the derivation population. At the CPS cutoff ≥ 2, VL was indicated for 164 (11%) individuals, preventing inappropriate switching to second line in 143 cases. Twenty-four cases of treatment failure would be missed. When applied in routine care, the AUROC was 0.69 (95% confidence interval: 0.60 to 0.77). Overall 1-year program costs with targeted VL testing were 4-fold reduced., Conclusions: The algorithm performed well in validation and has cost-saving potential. Further studies to assess its performance, feasibility, and impact in different settings are warranted.

Background: In resource-limited settings, abdominal ultrasound is often used to assist the diagnosis of tuberculosis (TB) in people with HIV (PLHIV), although data on performance characteristics are missing., Methods: Cross-sectional study of PLHIV in Cambodia receiving a standardized TB diagnostic evaluation, including history, physical examination, chest radiography, microscopy and culture of various specimens, and abdominal ultrasound. Patients with at least one specimen culture positive for Mycobacterium tuberculosis were classified as having TB., Results: TB was diagnosed in 37 (18%) of 212 PLHIV. Abdominal ultrasound was abnormal in 15 of 37 (41%) patients with TB compared with 14 of 175 (8%) without TB (P < 0.01). Predictors of TB disease included multiple enlarged (1.2 cm or greater) abdominal lymph nodes on ultrasound (adjusted odds ratio [OR], 6.4; 95% confidence interval [CI], 1.8-22.4), abnormal chest radiography (OR, 6.8; CI, 2.7-17.0), anorexia (OR, 4.6; CI, 1.8-11.7), and CD4 less than 200 cells/mm (OR, 3.3; CI, 1.2-9.1). Having multiple enlarged abdominal lymph nodes on ultrasound was 97.1% (CI, 93.5%-99.1%) specific for TB with a positive likelihood ratio of 11.4 (CI, 4.3-30.3)., Conclusions: Abdominal ultrasound is a useful diagnostic test for TB disease in PLHIV, increasing the posttest probability of TB when multiple enlarged abdominal lymph nodes are visualized. Its wider use may accelerate access to TB treatment, potentially reducing mortality in PLHIV.

Objective: To develop an algorithm for optimal use of viral load testing in patients with suspected first-line antiretroviral treatment (ART) failure., Methods: Data from a cohort of patients on first-line ART in Cambodia were analyzed in a cross-sectional way to detect markers for treatment failure. Markers with an adjusted likelihood ratio <0.67 or >1.5 were retained to calculate a predictor score. The accuracy of a 2-step algorithm based on this score followed by targeted viral load testing was compared with World Health Organization criteria for suspected treatment failure., Results: One thousand eight hundred three viral load measurements of 764 patients were available for analysis. Prior ART exposure, CD4 count below baseline, 25% and 50% drop from peak CD4 count, hemoglobin drop of > or =1 g/dL, CD4 count <100 cells per microliter after 12 months of treatment, new onset of papular pruritic eruption, and visual analog scale <95% were included in the predictor score. A score >or=2 had the best combination of sensitivity and specificity and required confirmatory viral load testing for only 9% of patients. World Health Organization criteria had a similar sensitivity but a lower specificity and required viral load testing for 24.9% of patients., Conclusion: An algorithm combining a predictor score with targeted viral load testing in patients with an intermediate probability of failure optimizes the use of scarce resources.