Mortality and HIV prevalence rose concordantly at Brooklyn Chest Hospital from 1998 to 2001. Death and unconfirmed tuberculosis (TB) (15% of adult admissions in a sample from 2000) were associated with HIV seropositivity. Excluding unconfirmed TB and shortening length of stay would increase the number of patients able to benefit from hospitalisation

Bekker, L G

Maartens, G

Post, F A

Shean, K

Thanassi, W

South African Medical Journal

Cape Town University OpenUCT

ORIGINAL ARTICLESTuberculosis (TB) case fatality rates in sub-Saharan Africa havebeen rising due to the burgeoning HIV epidemic.1 Most of thedeaths in HIV-infected patients on TB therapy are due to otherHIV-related diseases.1 The proportion of patients with HIV-associated TB is higher in hospitals than in TB clinics,2presumably because they are more ill due to immunesuppression or co-morbidity from other opportunisticinfections. The Western Cape has a high incidence rate of TB(581/100 000 in 1999), and a rapidly increasing prevalence ofHIV infection. This has resulted in a greater demand forinpatient TB treatment, with lengthening waiting lists for bedsin TB hospitals. As a result of the reduced diagnostic yield from sputumsmears in HIV-infected patients, especially inpatients,3 manyare commenced on empirical antituberculosis treatment. Aproportion of these bacteriologically unconfirmed cases aremanaged in the TB hospitals because of a poor general state ofhealth. Co-morbidity from other opportunistic infections isfrequent in these patients, resulting in increased mortality anda disease burden on TB hospitals, for which they are illequipped. This study assesses the impact of HIV on the 305-bed TB hospital, Brooklyn Chest Hospital (BCH), Cape Town.We attempt to come up with recommendations to ease thepressure on the limited number of beds available for inpatientTB treatment.MethodsAdmissions, deaths and HIV status were obtained from theBCH register from 1998 to 2001 to assess trends over time. Adetailed retrospective review of records of all adult admissions(individuals aged 13 years and above) from February throughJuly 2000 was undertaken in order to establish the number ofpatients with known HIV serostatus, type of TB, diagnosis ofTB and predictors of death. We defined TB as culture ofMycobacterium tuberculosis or smear-positive for acid-fast bacillior typical cerebrospinal fluid findings of TB meningitis (in thislatter category we excluded HIV-seropositive individuals inview of the large number of potential causes of cerebrospinalfluid pleocytosis in these patients). Patients with TB notfulfilling these definitions were categorised as unconfirmed.ResultsThe number of admissions, deaths and patients known to haveHIV infection is shown in Table I. There was a significantincrease in the proportion of deaths (15% in 1998 to 25% in2001, c 2 for trend p = 0.008) and the proportion known to beHIV-infected (18% in 1998 to 35% in 2001, p < 0.001) from 1998to 2001. The proportion of deaths in the sub-group known to beHIV-infected did not change over time (p = 0.14). In the463June 2003, Vol. 93, No. 6  SAMJImpact of HIV on admissions and deaths in a tuberculosishospital — recommendations for admission and dischargecriteriaW Thanassi, F APost, K Shean, L-G Bekker, G MaartensMortality and HIV prevalence rose concordantly at BrooklynChest Hospital from 1998 to 2001. Death and unconfirmedtuberculosis (TB) (15% of adult admissions in a sample from2000) were associated with HIV seropositivity. Excludingunconfirmed TB and shortening length of stay wouldincrease the number of patients able to benefit fromhospitalisation.S Afr Med J 2003; 93: 463-464.Section of Emergency Medicine, Yale University, New Haven, USAW Thanassi, MD   Brooklyn Chest Hospital, Cape TownK Shean, BTech Nursing(Comm Health)Infectious Diseases Unit, University of Cape TownFA Post, FCP(SA), MMed (Int Med)L-G Bekker, MB ChB, FCP(SA), DTM&H, PhDG Maartens, FCP(SA), MMed (Int Med), DTM&HTable I. Admissions, HIV status (passive surveillance) and deathsat Brooklyn Chest Hospital 1998 - 2001 (numbers in parenthesesare % of total admissions).1998 1999 2000 2001Admissions 1 178 1 286 1 143 1 117Deaths 180 (15) 212 (16) 199 (17) 280 (25)HIV-positive admissions 210 (18) 320 (25) 278 (24) 393 (35)H I V-positive deaths 77 92 89 141June 2003, Vol. 93, No. 6  SAMJORIGINAL ARTICLESdetailed record review from February to July 2000, 434 adultswere admitted (mean age 37 years, range 13 - 86 years, 60%males). HIV serostatus was recorded in 58%, of whom 71%were seropositive. TB was pulmonary (presumed drug-sensitive) in 66%,pulmonary confirmed multidrug-resistant in 16%,extrapulmonary in 3% and unconfirmed in 15%. In patientswith known HIV serostatus unconfirmed TB occurred in 5% ofHIV-seronegative compared with 24% of HIV-seropositivepatients (p < 0.001). Treatment of patients with unconfirmed TBaccounted for 2 888 hospital-bed days. HIV-infected patientshad an increased mortality compared with those who wereHIV-seronegative (relative risk 2.2, 95% confidence intervals(CI): 1.2 - 4.1, p = 0.014). HIV infection accounted for 55 excessdeaths (34% of all deaths).  The mean length of stay was 94days (range 2 - 314 days); this was shorter for HIV- seropositivethan HIV-seronegative patients (89 versus 110 days, p < 0.01).The shorter stay of HIV-seropositive patients was not explainedby increased mortality. Length of stay was not significantlydifferent for patients with confirmed or unconfirmed TB (96versus 83 days, p = 0.18). Sixty-three per cent of patients stayedmore than 2 months and 13% were hospitalised for more than 6months.DiscussionThis study is limited as it is retrospective and HIV serostatuswas only determined in 58% of adult admissions. Neverthelessit is clear that there has been an increased death rate, which isalmost certainly due to an increase in HIV-seropositiveadmissions. A substantial proportion of HIV-infected patientshad no bacteriological confirmation of their TB. Arguably,unconfirmed cases should not be admitted to a TB hospital. Asthese patients are not highly infectious, and some may nothave TB at all, it does not seem appropriate to admit them to aTB hospital where they run the risk of acquiring multidrug-resistant TB.4 Patients with unconfirmed TB who are too ill forambulatory treatment could be cared for by home-based careorganisations. Restricting adult admissions to patients with adiagnosis of confirmed pulmonary TB or TB meningitis wouldallow the treatment of an extra 110 cases per annum. The mean length of stay was shorter for HIV-infectedpatients. Patients with multidrug resistance and meningitisgenerally have prolonged admissions. It is our view that byadopting a more aggressive discharge policy it should bepossible to reduce the mean length of stay to 2 months. If thiscould be achieved our data indicate that a further 263 patientsa year could have received inpatient treatment. In conclusion, restricting adult admissions to patients withconfirmed TB and reducing mean length of stay to 2 monthswould considerably ease the pressure on TB hospital beds andshorten waiting lists. We thank the superintendent of BCH, Dr Peter Morris, forallowing access to patient charts and for his helpful comments.References1. Mukadi YD, Maher D, Harries A. Tuberculosis case fatality rates in high HIV prevalencepopulations in sub-Saharan Africa. AIDS 2001; 15: 143-152.2. Colebunders RL, Ryder RW, Nzilambi N, et al. HIV infection in patients with tuberculosis inKinshasa, Zaire. Am Rev Respir Dis 1989; 139: 1082-1085.3. Hudson CP, Wood R, Maartens G. Diagnosing HIV-associated tuberculosis: reducing costsand diagnostic delay. Int J Tuberc Lung Dis 2000; 4: 240-245.4. Sacks LV, Pendle S, Orlovic D, Blumberg L, Constantinou C. A comparison of outbreak- andnonoutbreak-related multidrug-resistant tuberculosis among human immunodeficiencyvirus-infected patients in a South African hospital. Clin Infect Dis 1999; 29: 96-101.

Impact of HIV on admissions and deaths in a tuberculosis hospital - recommendations for admission and discharge criteria

Post, F.A.

Bekker, L-G

AJOL - African Journals Online

ORIGINAL ARTICLES Impact of HIV on admissions and deaths in a tuberculosis hospital - recommendations for admission and discharge criteria W Thanassi, F A Post, K Shean, L-G Bekker, G Maartens Mortality and HIV prevalence rose concordantly at Brooklyn Chest Hospital from 1998 to 2001. Death and unconfirmed tuberculosis (TB) (15% of adult admissions in a sample from 2000) were associated with HIV seropositivity. Excluding Tuberculosis (TB) case fatality rates in sub-Saharan Africa have been rising due to the burgeoning HIV epidemic.1 Most of the deaths in HIV-infected patients on TB therapy are due to other HIV-related diseases. 1 The proportion of patients with HIV-associated TB is higher in hospitals than in TB clinics,' presumably because they are more ill due to immune suppression or co-morbidity from other opportunistic infections. The Western Cape has a high incidence rate of TB (581/100 000 in 1999), and a rapidly increasing prevalence of HIV infection. This has resulted in a greater demand for inpatient TB treatment, with lengthening waiting lists for beds in TB hospitals. As a result of the reduced diagnostic yield from sputum smears in HIV-infected patients, especially inpatients,' many are commenced on empirical antituberculosis treatment. A proportion of these bacteriologically unconfirmed cases are managed in the TB hospitals because of a poor general state of health. Co-morbidity from other opportunistic infections is frequent in these patients, resulting in increased mortality and a disease burden on TB hospitals, for which they are ill equipped. This study assesses the impact of HIV on the 305-bed TB hospital, Brooklyn Chest Hospital (BCH), Cape Town. We attempt to come up with recommendations to ease the pressure on the limited number of beds available for inpatient TB treatment. Section of Emergency Medicine, Yale University, New Haven, USA W Thanassi, MD Brooklyn Chest Hospital, Cape Town K Shean, BTech Nursing (Comm Health) Injfxtious Diseases Unit, University of Cape Town FA Post, FCP (SA), MMed (Int Med) L-G Bekker, MB ChB, FCP (SA), DTM&H, PhD G Maartens, FCP (SA), MMed (Int Med), DTM&H June 2003, Vol. 93, No. 6 SAMJ unconfirmed TB and shortening length of stay would increase the number of patients able to benefit from hospitalisation. S Afr Med J 2003; 93: 463-464. Methods Admissions, deaths and HIV status were obtained from the BCH register from 1998 to 2001 to assess trends over time. A detailed retrospective review of records of all adult admissions (individuals aged 13 years and above) from February through July 2000 was undertaken in order to establish the number of patients with known HIV serostatus, type of TB, diagnosis of TB and predictors of death. We defined TB as culture of Mycobacterium tuberculosis or smear-positive for acid-fast bacilli or typical cerebrospinal fluid findings of TB meningitis (in this latter category we excluded HIV-seropositive individuals in view of the large number of potential causes of cerebrospinal fluid pleocytosis in these patients). Patients with TB not fulfilling these definitions were categorised as unconfirmed. Results The number of admissions, deaths and patients known to have HIV infection is shown in Table I. There was a significant increase in the proportion of deaths (15% in 1998 to 25% in 2001, X' for trend p = 0.008) and the proportion known to be HIV-infected (18% in 1998 to 35% in 2001, p < 0.001) from 1998 to 2001. The proportion of deaths in the sub-group known to be HIV-infected did not change over time (p = 0.14). In the Table I. Admissions, HIV status (passive surveillance) and deaths at Brooklyn Chest Hospital1998 • 2001 (numbers in parentheses are o/o of total admissions). 1998 1999 2000 2001 Admissions 1 178 1 286 1143 1117 Deaths 180 (15) 212 (16) 199 (17) 280 (25) HIV-positive admissions 210 (18) 320 (25) 278 (24) 393 (35) HN-positive deaths 77 92 89 141 mJ ORIGINAL ARTICLES detailed record review from February to July 2000, 434 adults were admitted (mean age 37 years, range 13 - 86 years, 60% males). HIV serostatus was recorded in 58%, of whom 71% were seropositive. TB was pulmonary (presumed drug-sensitive) in 66%, pulmonary confirmed multidrug-resistant in 16%, extrapulmonary in 3% and unconfirmed in 15%. In patients with known HIV serostatus unconfirmed TB occurred in 5% of HIV-seronegative compared with 24% of HIV-seropositive patients (p < 0.001). Treatment of patients with unconfirmed TB accounted for 2 888 hospital-bed days. HIV-infected patients had an increased mortality compared with those who were HIV-seronegative (relative risk 2.2, 95% confidence intervals (CI): 1.2- 4.1, p = 0.014). HIV infection accounted for 55 excess deaths (34% of all deaths). The mean length of stay was 94 days (range 2.- 314 days); this was shorter for HIV- seropositive than HIV-seronegative patients (89 versus 110 days, p < 0.01). The shorter stay of HIV-seropositive patients was not explained by increased mortality. Length of stay was not significantly different for patients with confirmed or unconfirmed TB (96 versus 83 days, p = 0.18). Sixty-three per cent of patients stayed more than 2 months and 13% were hospitalised for more than 6 months. Discussion This study is limited as it is retrospective and HIV serostatus was only determined in 58% of adult admissions. Nevertheless it is clear that there has been an increased death rate, which is almost certainly due to an increase in HIV-seropositive admissions. A substantial proportion of HIV-infected patients had no bacteriological confirmation of their TB. Arguably, June 2003, Vol. 93, No. 6 SAMJ unconfirmed cases should not be admitted to a TB hospital. As these patients are not highly infectious, and some may not have TB at all, it does not seem appropriate to admit them to a TB hospital where they run the risk of acquiring multidrug-resistant TB.< Patients with unconfirmed TB who are too ill for ambulatory treatment could be cared for by home-based care organisations. Restricting adult admissions to patients with a diagnosis of confirmed pulmonary TB or TB meningitis would allow the treatment of an extra 110 cases per annum. The mean length of stay was shorter for HIV-infected patients. Patients with multidrug resistance and meningitis generally have prolonged admissions. It is our view that by adopting a more aggressive discharge policy it should be possible to reduce the mean length of stay to 2 months. If this could be achieved our data indicate that a further 263 patients a year could have received inpatient treatment. In conclusion, restricting adult admissions to patients with confirmed TB and reducing mean length of stay to 2 months would considerably ease the pressure on TB hospital beds and shorten waiting lists. We thank the superintendent of BCH, Dr Peter Morris, for allowing access to patient charts and for his helpful comments. References 1. Mukadi YD, Maher D, Harries A. Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa. AIDS 2001; 15: 14..1-152. 2. Colebunders RL, Ryder RW, Nzilambi N, et al. HIV infection in patients with tuberculosis in Kinshasa, Zaire. Am Rev Respir Dis1989; 139: 1082-1085. 3. Hudson CP, Wood R, Maarten.<; G. Diagnosing HIV-associated tuberculosis: reducing costs and diagnostic delay. Int J Tuberc Lung Dis 2000; 4: 240-245. 4. Sacks LV, Pendle S, Orlovic D, Blumberg L, Constantinou C. A comparison of outbreak- and nonoutbreak-re1"1ted multidrug-resistant htberculosis among human immunodeficiency virus-infected patients in a South African hospital. Clin Infect Dis 1999; 29:96-101. 

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Impact of HIV on admissions and deaths in a tuberculosis hospital - recommendations for admission and discharge criteria

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