Ram Breen

P255 Utility of a screening protocol incorporating an interferon-gamma release assay (IGRA) on detection and decision to treat latent tuberculosis infection (LTBI) prior to anti-TNF therapy

Introduction Anti-TNFα treatment is associated with a significant risk of LTBI reactivation (median onset 12 weeks for infliximab). Patients are therefore recommended to undergo prior LTBI screening but current NICE and BTS guidance differ in their approach. In particular, the BTS places more emphasis on demographic factors (age, ethnicity, birth outside the UK) in stratifying risk and does not mandate routine IGRA use.1 We describe the effect of local Trust screening protocol, incorporating IGRA, in the diagnosis and decision to start anti-TB chemoprophylaxis in a large cohort of patients being worked-up for anti-TNFα therapy. Methods Data on adult patients undergoing LTBI screening before anti-TNFα commencement were collected prospectively between Jan ‘13 and Dec ‘14. The local screening protocol included clinical assessment, chest X-ray (CXR) and an ELISpot-TB assay. Where required, routine chemoprophylaxis was isoniazid for 6 months (anti-TNFα was started ≥1 month). Clinical follow-up data was obtained for 6 months post anti-TNFα commencement. Results 472 patients received anti-TNFα for a minimum of 6 months after LTBI screening. According to the local protocol 21 cases (4.5%) received chemoprophylaxis vs. 66 patients (14%) who would have received chemoprophylaxis if the BTS guideline had been applied (Table 1). Moreover, 5 white, UK born, patients were identified that would not have been risk stratified to receive chemoprophylaxis according to the BTS. 2 cases receiving adalimumab for psoriasis developed active TB during the follow-up period. Both had negative IGRA at screening and were not given chemoprophylaxis however, both would have received treatment according to the BTS protocol. One case resulted from a subsequent TB exposure. The other had an abnormal screening CXR. This result was not appropriately followed up hence the case did not necessarily represent protocol failure per se.Abstract P255 Table 1 Characteristics of patients included in the study Conclusions These preliminary data demonstrate the value of an LTBI screening IGRA based protocol by decreasing the need for chemoprophylaxis by 69% if BTS recommendations had been applied. Reference 1 Ormerod, et al. BTS recommendations for assessing risk and for managing Mycobacterium tuberculosis infection and disease in patients due to start anti-TNF-α. Thorax 2005;60:800–805

P85 Hiv-related Acute Respiratory Admissions – Good Outcomes And An Opportunity For Testing

Introduction The burden, changing pattern and outcome of HIV-associated lung disease following the introduction of anti-retroviral therapy (ART) remains to be defined. We sought to investigate these factors in an unselected cohort of individuals admitted acutely to our London teaching hospital. Methods Consecutive admissions were prospectively collected between June 2013 and May 2014. In those where the cause for admission was an acute respiratory illness, patient notes and electronic records were interrogated. Patients were allowed >1 diagnoses and in-hospital outcomes only were reported. Results Fifty-three of 149 (35%) acute HIV admissions were with respiratory causes, (3 patients had 2 admissions >30 days apart). Median age was 45 years and 28% (15) were female. Median CD4 count was 109 (range 3–867) cells/uL; 14 (26%) had fully suppressed HIV loads (VL <20 copies/ml). 4 of 53 (8%) were admitted with non-infectious diagnoses: 2 with lung cancer, 1 non-infective COPD exacerbation and 1 non-specific interstitial pneumonia. The remainder had infections: 12 (23%) had culture-confirmed bacterial pneumonia, 11 (21%) were treated for PCP, 8 (15%) had culture-confirmed Mycobacterium tuberculosis (1 MDR), 4 had confirmed viral pneumonia (8%). 20 (38%) patients completed treatment for pneumonia with no specific laboratory confirmation. The most common bacterial isolates were streptococcus pneumoniae (4 cases), haemophilus influenzae (3), pseudomonas aureginosa (2) and klebsiella pneumoniae (2). In 11 of 53 (22%) a new diagnosis of HIV was made at the time of admission, 10 of whom presented as acute community acquired pneumonia (CAP). In 9 of 11 (82%) CD4 count was <200 cells/uL and 6 of 11 (55%) required ICU care. In total 20 of 53 (38%) were admitted to ICU, and 8 (15%) required mechanical ventilation. Median length of stay in hospital was 9 (2–397) days. 1 of 53 (2%) patients died. Conclusions Acute respiratory illness remains a significant cause of HIV admissions, with opportunistic and non-opportunistic pathogens commonly identified. Outcomes were reassuringly good despite the frequent need for ICU support. We believe our data underlines the important opportunity that a presentation with acute respiratory illness provides to test for and diagnose HIV infection.

P114 Non-tuberculous mycobacteria–An increasing problem with many companions

Introduction Infections secondary to non-tuberculous mycobacteria (NTM) are emerging with increasing frequency in various clinical settings. The determination of the clinical and prognostic significance of NTM isolates remains challenging and, in the absence of large trials, the evidence around the different therapeutic options is limited[1]. We aimed to identify the number of patients with single/multiple NTM isolates in our hospitals and evaluate their complexity with respect to coexistent microbiology. Method A retrospective case review of patients in whom NTM were isolated over the last two years in two large teaching hospitals. Results 195 patients were diagnosed with an NTM within the specified time period. Of those, 29 patients (14.8%) had cystic fibrosis (CF) and 11 patients (5.6%) were HIV-positive. In the non-CF population, in 112 of 166 patients (67.5%) NTM were isolated in 1 sample, in 24 patients (14.5%) in 2 samples and in 30 patients (18%) in 3 or more samples. In 8 patients (4.8%) 2 or more different NTM species were isolated in the same samples. The NTM source was: sputum in 130 patients (78.3%), bronchial washings in 23 patients (13.8%) and other pulmonary/non-pulmonary sites in 13 patients (7.9%). Table 1 shows the NTM species isolated. 61 patients (36.7%) were co-infected with other organisms; most commonly with Pseudomonas aeruginosa, Staphylococcus aureus and Haemophilus influenzae. Co-infection with other organisms was not related to the NTM species, or to the number of NTM isolates. 114 patients (68.7%) were reviewed by a respiratory physician; this included all patients with 3 or more NTM isolates. 122 patients (73.5%) underwent CT imaging. 36 patients (21.7%) were commenced on treatment. Abstract P114 Table 1. NTM species isolated and number of patients treated Mycobacterium species Number of patients growing NTM Number of patients treated M. avium complex (MAC) 36 10 M. fortuitum 34 2 M. kansasii 28 17 M. gordonae 22 1 M. xenopi 17 2 M. peregrinum 12 0 M. chelonae 7 1 M. abscessus 6 1 M. mucogenicum 4 0 M. malmoense 4 1 M. scrofulaceum 2 0 M. hassiacum 1 0 M. szulgai 1 1 M. smegmatis 1 0 M. marinum 1 0 M. neoaurum 1 0 Conclusion NTM infection is an increasing and often complex challenge in respiratory medicine that requires specialist input. Further studies are needed to clarify whether co-infection with other organisms is related to the nature (e.g. bronchiectasis, cavitation) or severity of respiratory disease. References Griffith DE et al; “An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases”, AJRCCM 175: 367–416 (2007)

P24 Diagnosing tuberculosis using EBUS–Cytology is not enough

Introduction Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) provides a technique for safely sampling mediastinal and hilar lymph nodes. In the diagnosis of tuberculosis (TB) published data has shown excellent performance in identifying suggestive cytology but with disappointing culture-confirmation rates of <50%. We sought to investigate the proportion of TB cases referred to our tertiary referral service in whom culture and sensitivities were obtained. Methods EBUS-TBNA was performed by 2 experienced consultants with on-site cytology review. Data was abstracted from our prospective database of all EBUS-TBNA cases between 01/2008 and 01/2013, our hospital electronic record and by contacting referring clinicians. A final diagnosis of active TB was made if treatment for active TB was commenced subsequent to EBUS-TBNA. Treated TB was defined as anyone who had received at least 2 months of anti-TB treatment prior to EBUS-TBNA. Results A final diagnosis of active or treated TB was made in 142 of 2121 EBUS-TBNA cases (6.7%). Sampled nodes were: right para-tracheal 32%, left para-tracheal 9%, right hilar 16%, left hilar 8%, sub-carinal 35%. A median of 7 passes (range: 4–14) were performed per case. Granulomas with and without necrosis were identified in 91.5%, necrosis alone in 4.9% and lymphocytes alone in 3.5%. Of 118 (73%) diagnosed with active TB, culture-confirmation was obtained in 89 (75%) with a median time to positive liquid culture of 27 days (range: 4–42). Cytology from cases of treated TB and active TB with and without culture-confirmation are compared in the Table. Discussion These data suggest that EBUS-TBNA can obtain higher proportions of culture-confirmed TB than has been previously reported. The similar cytology profile seen in active TB cases regardless of smear status, culture result or treatment history highlights the need for both adequate samples to be sent for culture and for improved TB diagnostics. Abstract P24 Table 1. Comparison of AFB smear and cytology results in cases with treated TB and untreated active TB. AFB smear Ziehl-Neelsen AFB smear auramine Granulomas present Necrosis present Treated TB n = 24 19% 0% 92% 50% Active TB (total) n = 118 37% 6% 92% 54% Active TB (culture +ve) n = 89 43% 8% 90% 58% Active TB (culture -ve) n = 29 19% 0% 97% 41%