The edition · Infectious Diseases
Expanded tuberculosis screening of HIV inpatients did not get more people onto treatment, or reduce deaths
EXULTANT randomised 1,172 hospital admissions in Tanzania and Mozambique to universal Xpert Ultra and urine LAM testing or to symptom-triggered testing. Confirmed tuberculosis started within 72 hours in 16.0% against 15.3%, and eight-week mortality was 25.8% against 28.8%. Separately, dihydroartemisinin-piperaquine cut Plasmodium vivax recurrence from 27.3% to 2.4%.
The edition in brief
The lead finding is a negative one, and it is about implementation rather than about the tests. EXULTANT gave every adult admitted with HIV in Tanzania and Mozambique sputum Xpert Ultra and urine lipoarabinomannan testing regardless of symptoms, and compared that with testing triggered by symptoms. Microbiologically confirmed tuberculosis started within 72 hours in 16.0% of the intervention arm and 15.3% of the control, a difference of 0.7%. Eight-week mortality was 25.8% against 28.8%, with a hazard ratio of 0.86 whose interval crosses 1.0. Note what the control arm actually achieved: 60.6% of eligible patients produced a sputum sample. The bottleneck was never the assay. The positive finding of the day is malaria. Curavivax randomised 419 patients with uncomplicated Plasmodium vivax in Brazil across four schedules. With primaquine delayed to day 42 — which isolates the schizontocide — day-42 recurrence was 2.4% with dihydroartemisinin-piperaquine and 27.3% with chloroquine, a hazard ratio of 0.08. Where primaquine was given from day 0, both partners performed the same. Also today: a dose-sparing adjuvanted inactivated polio vaccine was immunologically non-inferior in 643 Indian infants, and delivering antimicrobial prescribing guidelines by smartphone rather than on paper did not improve adherence in Lao hospitals — 25.6% against 17.0%, which disappeared once time and clustering were accounted for.
Testing everyone for tuberculosis did not beat testing those with symptoms
Universal Xpert Ultra and urine LAM testing of HIV inpatients did not increase confirmed tuberculosis treatment starts or reduce eight-week mortality compared with symptom-triggered testing.
Dihydroartemisinin-piperaquine cut vivax recurrence more than tenfold against chloroquine
Where primaquine is delayed, dihydroartemisinin-piperaquine reduced day-42 Plasmodium vivax recurrence from 27.3% to 2.4% compared with chloroquine; with day-0 primaquine the two were equivalent.
A dose-sparing polio vaccine was non-inferior in Indian infants
A dose-sparing adjuvanted inactivated polio vaccine achieved non-inferior seroconversion to standard IPV across all three serotypes in 643 Indian infants, with a similar safety profile.
Putting prescribing guidelines on a phone did not improve adherence
Delivering antimicrobial prescribing guidelines by smartphone rather than on paper did not improve adherence once time and clustering were accounted for, and both arms left three-quarters of prescriptions off-guideline.
No new regulatory action today; an oral option for ESBL infections is heading to phase 3
Nothing new from the regulators; an oral ceftibuten–avibactam combination has completed dose-finding and is proposed for phase 3 in complicated urinary tract infection caused by ESBL producers.
When a test performs and the programme does not, look at who never got tested
Before reading an implementation trial's effect estimate, find out what fraction of eligible patients actually received the intervention — a strategy can fail while every component of it works.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for infectious diseases, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free