The diagnosis of tuberculosis (TB) in HIV-infected patients is challenging. Both a urinary lipoarabinomannan (LAM) test (Alere TB LAM) and GeneXpert-MTB/RIF (Xpert) are useful for the diagnosis of TB. However, how to optimally integrate Xpert and LAM tests into clinical practice algorithms remain unclear. We performed a post hoc analysis of 561 HIV-infected sputum-expectorating patients (median CD4 count of 130 cells/ml) from a previously published randomized controlled trial evaluating the LAM test in hospitalized HIV-infected patients with suspected TB. We evaluated 5 different diagnostic strategies using sputum culture as a reference standard (Xpert alone, LAM alone, sequential Xpert followed by LAM and vice versa [LAM in Xpert-negative patients and Xpert in LAM-negative patients], and both tests concurrently [LAM + Xpert]). A cost-consequence analysis was performed. Strategy-specific sensitivity and specificity, using culture as a reference, were similar with the Xpert-only and sequential and concurrent strategies. However, when any positive TB-specific test was used as a reference, the incremental yield of LAM over Xpert was 29.6% (45/152) and that of Xpert over LAM was 75% (84/11). The incremental yield of LAM increased with decreasing CD4 count. The costs per TB case diagnosed were similar for the sequential and concurrent strategies ($1,617 to $1,626). In sputum-expectorating hospitalized patients with advanced HIV and access to both tests, concurrent testing with Xpert and LAM may be the best strategy for diagnosing TB. These data inform clinical practice in settings where TB and HIV are endemic.

中文翻译：

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使用 GeneXpert MTB/RIF 和 Alere 确定 TB LAM Ag 对住院 HIV 感染患者进行结核病的最佳诊断策略。

HIV 感染者的结核病 (TB) 诊断具有挑战性。尿阿拉伯糖甘露聚糖 (LAM) 检测 (Alere TB LAM) 和 GeneXpert-MTB/RIF (Xpert) 都可用于诊断结核病。然而，如何将 Xpert 和 LAM 测试最佳地集成到临床实践算法中仍不清楚。我们对 561 名 HIV 感染的咳痰患者（中位 CD4 计数为 130 个细胞/ml）进行了事后分析，这些患者来自之前发表的一项随机对照试验，该试验评估了住院 HIV 感染疑似结核病患者的 LAM 检测。我们使用痰培养作为参考标准评估了 5 种不同的诊断策略（单独 Xpert、单独 LAM、序贯 Xpert 随后 LAM，反之亦然 [Xpert 阴性患者中的 LAM 和 LAM 阴性患者中的 Xpert]，以及同时进行两种测试 [LAM] +专家]）。进行了成本后果分析。使用培养物作为参考，策略特异性的敏感性和特异性与仅 Xpert 以及顺序和并行策略相似。然而，当使用任何阳性结核病特异性检测作为参考时，LAM 相对于 Xpert 的增量产率为 29.6% (45/152)，而 Xpert 相对于 LAM 的增量产率为 75% (84/11)。LAM 的产量增量随着 CD4 计数的减少而增加。序贯策略和并行策略的每个诊断出的结核病病例的成本相似（1,617 美元至 1,626 美元）。对于患有晚期 HIV 且咳痰的住院患者并且可以进行这两种检测，同时使用 Xpert 和 LAM 进行检测可能是诊断结核病的最佳策略。这些数据为结核病和艾滋病毒流行地区的临床实践提供信息。