Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients

Background: The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill HIV-infected patients recommends that treatment for Pneumocystis jiroveciipneumonia (PJP) should be considered without giving clear guidance on selecting patients for empiric PJP therapy. PJP...

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Main Authors: Gary Maartens, Annemie Stewart, Rulan Griesel, Andre P. Kengne, Felix Dube, Mark Nicol, Molebogeng X. Rangaka, Marc Mendelson
Format: Article
Language:English
Published: AOSIS 2018-07-01
Series:Southern African Journal of HIV Medicine
Subjects:
HIV
Online Access:https://sajhivmed.org.za/index.php/hivmed/article/view/851
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spelling doaj-9e08131925814b26b704eab77ed9796c2020-11-24T21:17:18ZengAOSISSouthern African Journal of HIV Medicine1608-96932078-67512018-07-01191e1e610.4102/sajhivmed.v19i1.851594Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patientsGary Maartens0Annemie Stewart1Rulan Griesel2Andre P. Kengne3Felix Dube4Mark Nicol5Molebogeng X. Rangaka6Marc Mendelson7Division of Clinical Pharmacology, Department of Medicine, University of Cape TownDivision of Clinical Pharmacology, Department of Medicine, University of Cape TownDivision of Clinical Pharmacology, Department of Medicine, University of Cape TownNon-Communicable Diseases Research Unit, South African Medical Research CouncilDivision of Medical Microbiology, Department of Pathology, University of Cape Town, South Africa; National Health Laboratory ServiceDivision of Medical Microbiology, Department of Pathology, University of Cape Town, South Africa; National Health Laboratory ServiceDepartment of Medicine and School of Public Health, University of Cape Town, South Africa; Institute for Global Health, Department of Infection and Population Health, University College London, United Kingdom; IIDMM, University of Cape TownDivision of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape TownBackground: The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill HIV-infected patients recommends that treatment for Pneumocystis jiroveciipneumonia (PJP) should be considered without giving clear guidance on selecting patients for empiric PJP therapy. PJP is a common cause of hospitalisation in HIV-infected patients in resource-poor settings where diagnostic facilities are limited. Methods: We developed clinical prediction rules for PJP in a prospective cohort of HIV-infected inpatients with WHO danger signs and cough of any duration. The reference standard for PJP was > 1000 copies/mL of P. jirovecii DNA on real-time sputum polymerase chain reaction (PCR). Four potentially predictive variables were selected for regression models: dyspnoea, chest X-ray, haemoglobin and oxygen saturation. Respiratory rate was explored as a replacement for oxygen saturation as pulse oximetry is not always available in resource-poor settings. Results: We enrolled 500 participants. After imputation for missing values, there were 56 PJP outcome events. Dyspnoea was not independently associated with PJP. Oxygen saturation and respiratory rate were inversely correlated. Two clinical prediction rules were developed: chest X-ray possible/likely PJP, haemoglobin ≥ 9 g/dL and either oxygen saturation < 94% or respiratory rate. The area under the receiver operating characteristic curve of the clinical prediction rule models was 0.761 (95% CI 0.683–0.840) for the respiratory rate model and 0.797 (95% CI 0.725–0.868) for the oxygen saturation model. Both models had zero probability for PJP for scores of zero, and positive likelihood ratios exceeded 10 for high scores. Conclusion: We developed simple clinical prediction rules for PJP, which, if externally validated, could assist decision-making in the WHO seriously ill algorithm.https://sajhivmed.org.za/index.php/hivmed/article/view/851HIVpneumocystis jirovecii pneumoniaclinical prediction rulequantitative real time PCRbeta-D-glucantuberculosis
collection DOAJ
language English
format Article
sources DOAJ
author Gary Maartens
Annemie Stewart
Rulan Griesel
Andre P. Kengne
Felix Dube
Mark Nicol
Molebogeng X. Rangaka
Marc Mendelson
spellingShingle Gary Maartens
Annemie Stewart
Rulan Griesel
Andre P. Kengne
Felix Dube
Mark Nicol
Molebogeng X. Rangaka
Marc Mendelson
Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients
Southern African Journal of HIV Medicine
HIV
pneumocystis jirovecii pneumonia
clinical prediction rule
quantitative real time PCR
beta-D-glucan
tuberculosis
author_facet Gary Maartens
Annemie Stewart
Rulan Griesel
Andre P. Kengne
Felix Dube
Mark Nicol
Molebogeng X. Rangaka
Marc Mendelson
author_sort Gary Maartens
title Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients
title_short Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients
title_full Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients
title_fullStr Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients
title_full_unstemmed Development of a clinical prediction rule to diagnose Pneumocystis jirovecii pneumonia in the World Health Organization’s algorithm for seriously ill HIV-infected patients
title_sort development of a clinical prediction rule to diagnose pneumocystis jirovecii pneumonia in the world health organization’s algorithm for seriously ill hiv-infected patients
publisher AOSIS
series Southern African Journal of HIV Medicine
issn 1608-9693
2078-6751
publishDate 2018-07-01
description Background: The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill HIV-infected patients recommends that treatment for Pneumocystis jiroveciipneumonia (PJP) should be considered without giving clear guidance on selecting patients for empiric PJP therapy. PJP is a common cause of hospitalisation in HIV-infected patients in resource-poor settings where diagnostic facilities are limited. Methods: We developed clinical prediction rules for PJP in a prospective cohort of HIV-infected inpatients with WHO danger signs and cough of any duration. The reference standard for PJP was > 1000 copies/mL of P. jirovecii DNA on real-time sputum polymerase chain reaction (PCR). Four potentially predictive variables were selected for regression models: dyspnoea, chest X-ray, haemoglobin and oxygen saturation. Respiratory rate was explored as a replacement for oxygen saturation as pulse oximetry is not always available in resource-poor settings. Results: We enrolled 500 participants. After imputation for missing values, there were 56 PJP outcome events. Dyspnoea was not independently associated with PJP. Oxygen saturation and respiratory rate were inversely correlated. Two clinical prediction rules were developed: chest X-ray possible/likely PJP, haemoglobin ≥ 9 g/dL and either oxygen saturation < 94% or respiratory rate. The area under the receiver operating characteristic curve of the clinical prediction rule models was 0.761 (95% CI 0.683–0.840) for the respiratory rate model and 0.797 (95% CI 0.725–0.868) for the oxygen saturation model. Both models had zero probability for PJP for scores of zero, and positive likelihood ratios exceeded 10 for high scores. Conclusion: We developed simple clinical prediction rules for PJP, which, if externally validated, could assist decision-making in the WHO seriously ill algorithm.
topic HIV
pneumocystis jirovecii pneumonia
clinical prediction rule
quantitative real time PCR
beta-D-glucan
tuberculosis
url https://sajhivmed.org.za/index.php/hivmed/article/view/851
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