Accuracy and consequences of using trial-of-antibiotics for TB diagnosis (ACT-TB study): protocol for a randomised controlled clinical trial.



Divala, Titus Henry, Fielding, Katherine L, Sloan, Derek J, French, Neil ORCID: 0000-0003-4814-8293, Nliwasa, Marriott, MacPherson, Peter, Kandulu, Chikondi Charity, Chiume, Lingstone, Chilanga, Sanderson, Ndaferankhande, Masiye John
et al (show 1 more authors) (2020) Accuracy and consequences of using trial-of-antibiotics for TB diagnosis (ACT-TB study): protocol for a randomised controlled clinical trial. BMJ Open, 10 (3). e033999 - e033999.

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Abstract

INTRODUCTION: Over 40% of global tuberculosis case notifications are diagnosed clinically without mycobacteriological confirmation. Standard diagnostic algorithms include 'trial-of-antibiotics'-empirical antibiotic treatment given to mycobacteriology-negative individuals to treat infectious causes of symptoms other than tuberculosis, as a 'rule-out' diagnostic test for tuberculosis. Potentially 26.5 million such antibiotic courses/year are prescribed globally for the 5.3 million/year mycobacteriology-negative patients, making trial-of-antibiotics the most common tuberculosis diagnostic, and a global-scale risk for antimicrobial resistance (AMR). Our systematic review found no randomised controlled trial (RCT) to support use of trial-of-antibiotic. The RCT aims to determine the diagnostic and clinical value and AMR consequences of trial-of-antibiotics. METHODS AND ANALYSIS: A three-arm, open-label, RCT randomising (1:1:1) Malawian adults (≥18 years) seeking primary care for cough into: (a) azithromycin 500 mg one time per day for 3 days or (b) amoxicillin 1 g three times per day for 5 days or (c) standard-of-care (no immediate antibiotic). We will perform mycobacteriology tests (microscopy, Xpert MTB/RIF (Mycobacterium tuberculosis/rifampicin) and Mycobacterium tuberculosis culture) at baseline. We will use audiocomputer-assisted self-interview to assess clinical improvement at day 8. First primary outcome will be proportion of patients reporting day 8 improvement out of those with negative mycobacteriology (specificity). Second primary outcome will be day 29 incidence of a composite endpoint of either death or hospitalisation or missed tuberculosis diagnosis. To determine AMR impact we compare proportion of resistant nasopharyngeal Streptococcus pneumoniae isolates on day 29. 400 mycobacteriology-negative participants/arm will be required to detect a ≥10% absolute difference in diagnostic specificity with 80% power. We will estimate measures of effect by comparing outcomes in antibiotic arms (combined and individually) to standard-of-care. ETHICS AND DISSEMINATION: The study has been reviewed and approved by Malawi College of Medicine Research and Ethics Committee, London School of Hygiene & Tropical Medicine (LSHTM) Research Ethics Committee and Regional Committee for Health and Research Ethics - Norway, and Malawi Pharmacy, Medicines and Poisons Board. We will present abstracts at relevant conferences, and prepare a manuscript for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: The clinical trial is registered with ClinicalTrials.gov, NCT03545373.

Item Type: Article
Uncontrolled Keywords: TB, antibiotics, antimicrobial resistance, diagnostic performance, trial-of-antibiotics, tuberculosis
Depositing User: Symplectic Admin
Date Deposited: 06 Apr 2020 10:38
Last Modified: 05 Oct 2022 22:13
DOI: 10.1136/bmjopen-2019-033999
Open Access URL: https://bmjopen.bmj.com/content/10/3/e033999.long
Related URLs:
URI: https://livrepository.liverpool.ac.uk/id/eprint/3081970