Delays in tuberculosis isolation and suspicion among persons hospitalized with HIV-related pneumonia

Pulmonary tuberculosis: An analysis of isolation practices and clinical risk factors in a tertiary hospital

BACKGROUND

Inadequate isolation of patients with active pulmonary tuberculosis causes exposure whereas over-cautious isolation generates time and cost inefficiencies. This study aims to ascertain the delays involved in isolating subjects and the importance of risk factors.

METHODS AND MATERIAL

Between December 2010 and January 2013, a retrospective analysis of 271 subjects was performed. Information was obtained from discharge letters, radiological and microbiological results.

RESULTS

The median time taken to isolate subjects was 0 days, and 71.7% were isolated within 1 day. Most subjects (75.3%) had sputum samples obtained after isolation, of which 14.7% were positive. The median time from admission to first sputum sample was 1 day. Smear was negative in 174 subjects (85.3%). Country of birth (high or low risk) did not significantly affect sputum positivity (25.5% vs 19.4%, p=0.52). Suspicious radiological findings were noted in 38.6% subjects, and 32.8% had a suspicious clinical history. Subjects with both clinical and radiological probability had more sputum positivity (46.2%), compared to subjects who had neither (2.7%).

CONCLUSION

There are delays with isolation and diagnosis of subjects with a high probability of tuberculosis. Clinical and radiological probability were more significant in predicting sputum positivity than country of birth.

Associated factors for treatment delay in pulmonary tuberculosis in HIV-infected individuals: a nested case-control study

BACKGROUND

The delay in initiating treatment for tuberculosis (TB) in HIV-infected individuals may lead to the development of a more severe form of the disease, with higher rates of morbidity, mortality and transmissibility. The aim of the present study was to estimate the time interval between the onset of symptoms and initiating treatment for TB in HIV-infected individuals, and to identify the factors associated to this delay.

METHODS

A nested case-control study was undertaken within a cohort of HIV-infected individuals, attended at two HIV referral centers, in the state of Pernambuco, Brazil. Delay in initiating treatment for TB was defined as the period of time, in days, which was greater than the median value between the onset of cough and initiating treatment for TB. The study analyzed biological, clinical, socioeconomic, and lifestyle factors as well as those related to HIV and TB infection, potentially associated to delay. The odds ratios were estimated with the respective confidence intervals and p-values.

RESULTS

From a cohort of 2365 HIV-infected adults, 274 presented pulmonary TB and of these, 242 participated in the study. Patients were already attending 2 health services at the time they developed a cough (period range: 1 - 552 days), with a median value of 41 days. Factors associated to delay were: systemic symptoms asthenia, chest pain, use of illicit drugs and sputum smear-negative.

CONCLUSION

The present study indirectly showed the difficulty of diagnosing TB in HIV-infected individuals and indicated the need for a better assessment of asthenia and chest pain as factors that may be present in co-infected patients. It is also necessary to discuss the role played by negative sputum smear results in diagnosing TB/HIV co-infection as well as the need to assess the best approach for drug users with TB/HIV.

Tuberculosis among health care workers in a Brazilian tertiary hospital emergency unit

The Brazilian emergency system is being reorganized as a hierarchy in the region of Ribeirão Preto, state of São Paulo. We found increased occupational risk for tuberculosis in this region tertiary reference center--a nurse technician (Incidence rate [IR] 526.3/100,000 inhabitants) had a risk of tuberculosis 12.6 (95% confidence interval [CI], 2.57-37.23) greater than the city population (41.8/100,000 inhabitants). The system reorganization will have to make the centers adequate to deal with this problem.

Intervals before tuberculosis diagnosis and isolation at a regional hospital in Taiwan

Background/Purpose

Nosocomial tuberculosis (TB) infection is still a problem in many Taiwanese hospitals. The objectives of this study were to explore the intervals before TB diagnosis and isolation at a regional hospital in Taiwan, and to provide useful knowledge to hospitals for the purpose of TB infection control.

Methods

From 2002 to 2005, we included a total of 343 patients with culture-positive pulmonary TB in a regional hospital in Southern Taiwan for this study. Their medical records were reviewed, and the time intervals between patient-hospital contact points and isolation were recorded.

Results

Of 343 culture-positive pulmonary TB patients, the majority were male, over 40 years old, and unemployed. The mean interval between the first admission and isolation was 20.5 days (median, 2.0 days). The mean intervals between the first admission from outpatient clinics, emergency department and hospitalization and suspected TB were < 1 day, 6.07 days and 25.53 days, respectively. The mean accumulated exposure time was 0.35 days, 0.61 days and 10.09 days in outpatient clinics, the emergency department and hospitalization, respectively; 75.5% of patients had their diagnosis confirmed at the chest department of the department of internal medicine.

Conclusion

Delayed diagnosis was most likely in the case of hospitalized patients and least likely in outpatient clinics. Delayed diagnosis in hospitalized patients also contributed more severely to TB exposure time than others. Enhancing the quality, speed and ability of specialists and physicians to diagnose TB, especially in emergency departments and in hospitalized patients, is essential.

Laparoscopic Nissen fundoplication during gastrostomy tube placement and noninvasive ventilation may improve survival in type I and severe type II spinal muscular atrophy

Progressive respiratory muscle weakness with bulbar involvement is the main cause of morbidity and mortality in type I and severe type II spinal muscular atrophy. Noninvasive positive pressure ventilation techniques coupled with laparoscopic gastrointestinal procedures may allow for improved morbidity and mortality. The authors present a series of 7 spinal muscular atrophy patients (6 type I and 1 severe type II) who successfully underwent laparoscopic gastrostomy tube insertion coupled with Nissen fundoplication and early postoperative extubation using noninvasive positive pressure ventilation techniques. The authors measured the length of survival and the frequencies of pneumonia and hospitalization before and after surgery as outcomes of these new surgical and medical interventions. All 7 patients had respiratory symptoms (unmanageable oropharyngeal secretions, cough, pneumonia), difficulty feeding, and weight loss. Six patients had documented reflux via diagnostic testing preoperatively. Five patients were on noninvasive positive pressure ventilation and other supportive respiratory therapies prior to surgery. All 7 patients survived the procedures. By August 2006, 5 patients with type I and 1 with severe type II spinal muscular atrophy were alive and medically stable at home 1.5 months to 41 months post-op. One patient with type I expired approximately 5 months post-op due to obstructive apnea. This case series demonstrates that laparoscopic gastrostomy tube placement coupled with Nissen fundoplication and noninvasive positive pressure ventilation can be successfully used as a treatment option to allow for early postoperative extubation and to optimize quality of life in type I and severe type II spinal muscular atrophy patients.

Religious beliefs, practices and treatment adherence among individuals with HIV in the southern United States

Nonadherence with medical treatment is a critical threat to the health of those living with HIV disease. Unfortunately the search for explanatory factors for nonadherence is still not fully developed, particularly in the area of religion and spirituality. Extant literature suggests that church attendance, religious practices and spiritual beliefs may improve health and generally benefit patients. However, religious beliefs may also play a negative role in treatment adherence due to the stigma attached to HIV disease, particularly in geographical areas and in population subgroups where religious practices are strong. In this exploratory study, HIV-positive individuals (n = 306) in a southern state were surveyed as to their attitudes and beliefs surrounding HIV disease and adherence with medical treatment for the disease. The results indicate that multiple factors influence adherence with treatment and that certain religious practices are positively associated with adherence, but certain religious beliefs are negatively related to adherence. The findings of this study reinforce the importance of remembering and addressing a patient's religious beliefs as a part of medical care.

[Prevention of tuberculosis in care settings]

INTRODUCTION

The hospital is a favourable setting for the transmission of tubercle bacilli. The presence of susceptible subjects, often immunocompromised, increases the dangers. This risk extends to the patients' visitors and to the staff. It is therefore the responsibility of the hospital to establish preventative measures capable of reducing the risk of transmission or to reduce the effects by appropriate management of exposed subjects.

BACKGROUND

The modes and vectors of transmission are well established. The standardised prevention of transmission is achieved by isolation, the indications and duration of which are based on incomplete information. The surveillance of the carers by the doctor in charge, is based on precise recommendations depending on the risk of exposure.

VIEWPOINT

The objectives are a reduction diagnostic delay, a better determination of infectivity and its duration during treatment, and a more complete census of cases of hospital acquired tuberculosis.

CONCLUSIONS

The management of tuberculosis in hospital requires co-ordination of all involved including those outside the institution and a deliberate policy in the institution itself.

Respiratory management of the infant with type 1 spinal muscular atrophy

A recent paper has highlighted the differences in the respiratory management offered to infants with type 1 spinal muscular atrophy (SMA-1). Current views appear polarised between those who would offer nothing, to those who would proceed as far even as tracheostomy and long term invasive ventilation for these infants. Here we offer a personal view, as a possible template for managing a vexed and emotional problem. The complex non-respiratory aspects of the holistic care of these infants will not be discussed.

Indicadores relacionados ao retardo no diagnóstico e na instituição das precauções para aerossóis entre pacientes com tuberculose pulmonar bacilífera em um hospital terciário

INTRODUÇÃO: Há risco de transmissão de tuberculose em instituições de cuidados à saúde. OBJETIVO: Avaliar indicadores relacionados ao risco de transmissão entre pacientes com tuberculose pulmonar bacilífera atendidos em um hospital universitário. MÉTODO: Estudo retrospectivo, descritivo, de 01/1997 a 09/1999. Foram estudados os pacientes internados com tuberculose pulmonar bacilífera no Hospital de Clínicas da Universidade Estadual de Campinas. Foram avaliados três intervalos: entre admissão e coleta da pesquisa de BAAR no escarro; entre admissão e instituição das precauções para aerossóis; entre coleta do escarro e início do tratamento. RESULTADOS: Foram incluídos 63 casos. Associação ao vírus da imunodeficiência humana ocorreu em 31,7%. Quarenta pacientes foram admitidos pelo pronto-socorro (63,5%). Suspeita de tuberculose esteve presente na admissão em 42 pacientes (66,7%). O intervalo entre admissão e coleta de escarro excedeu 12 horas em 27,5% dos casos admitidos pelo pronto-socorro e em 30,4% dos internados nas enfermarias (p = 0,803). Retardo no isolamento respiratório ocorreu em 31 casos (49,2%). Os fatores associados ao retardo de isolamento foram ausência de tuberculose no diagnóstico de admissão (p < 0,000) e carga bacilar mais baixa no escarro (p = 0,032). Infecção pelo vírus da imunodeficiência humana (p = 0,530), enfermaria de hospitalização (p = 0,284) e presença de co-morbidades (p = 0,541) não foram associados ao retardo de isolamento. O intervalo entre coleta e início de tratamento foi superior a 24 horas em 15,9% dos casos. CONCLUSÃO: Observou-se retardo de isolamento em muitos casos. São necessárias políticas de educação continuada, sobretudo nas áreas de maior risco.

Nosocomial pulmonary infections in HIV-positive patients

PURPOSE OF REVIEW

Nosocomial infections (NI) constitute a significant public health problem and contribute to prolonged hospitalization, additional healthcare costs, and excess morbidity and mortality. Immunocompromised patients, including HIV-infected individuals, are at increased risk for NI, and 15-18.3% of them are represented by lower respiratory tract infections. Nosocomial pulmonary infections (NPI) appear to be more common in patients with acquired immunodeficiency syndrome (AIDS), as a result of the degree of immunosuppression, prior use of antibiotics, and exposure to invasive procedures.

RECENT FINDINGS

This article reviews the epidemiologic and clinical evidences and reports on the occurrence of NPI in HIV-infected inpatients.

SUMMARY

Although underestimated, NI occur commonly in HIV-infected patients, and among them nosocomial pneumonia, including tuberculosis and bacterial pneumonia, are associated with significant morbidity and mortality. The improvement of antiretroviral therapeutic options in developed countries has resulted in a decreased hospitalization rate of HIV-infected individuals. Healthcare delivery in the in- and outpatient setting represents a potential for infections, including lower respiratory tract ones, according to the degree of immunosuppression and the intensity of invasive procedures. To minimize the risk of acquisition of healthcare associated low respiratory tract infections, adherence of healthcare workers to common infection practices, specific respiratory precautions, and early identification of persons who have tuberculosis or are at high risk for active tuberculosis, should be strengthened.

Delays in suspicion and isolation among hospitalized persons with pulmonary tuberculosis at public and private US hospitals during 1996 to 1999

BACKGROUND

While prior studies have shown that public and private hospitals differ in their rates of suspicion and isolation of patients who are at risk for tuberculosis (TB), no study has investigated whether this variation is due to differences in the impact of patient case-mix on hospitals or to variations attributable to specific hospital practice patterns.

OBJECTIVE

To investigate patient-level and hospital-level factors associated with delays in TB suspicion and isolation among inpatients with pulmonary TB disease.

DESIGN

Retrospective cohort study of patients hospitalized with culture-positive pulmonary TB during 1996 to 1999.

SETTING

Patients with culture-proven pulmonary TB treated at three public hospitals (765 patients) and seven not-for-profit private hospitals (172 patients) in Chicago, Los Angeles, and southern Florida that provided care for five or more patients with TB per year during the study period.

MEASUREMENTS

Two-day rates (within 48 h from admission) of acid-fast bacilli (AFB) smear orders and 1-day rates (within 24 h from admission) of TB isolation.

RESULTS

Two-day rates of ordering AFB smears were > 80% at three public and two private hospitals vs 65 to 75% at five private hospitals. One-day rates of TB isolation at the three public hospitals were 64%, 79%, and 86%, respectively, vs 39 to 58% at the seven private hospitals. Delays of > 2 days in ordering AFB smears were associated with patient-level factors: absence of cough (adjusted odds ratio [AOR], 6.02; 95% confidence interval [CI], 3.82 to 9.52), cavitary lung lesion (AOR, 5.17; 95% CI, 1.98 to 13.50), night sweats (AOR, 3.38; 95% CI, 1.90 to 5.99), chills (AOR, 1.70; 95% CI, 1.01 to 2.88), and female gender (AOR, 1.66; 95% CI, 1.06 to 2.60). Delays of > 1 day in ordering pulmonary isolation were associated with patient-level factors: absence of cough (AOR, 3.40; 95% CI, 2.31 to 5.03), cavitary lung lesion (AOR, 2.66; 95% CI, 1.57 to 4.50), night sweats (AOR, 1.98; 95% CI, 1.35 to 2.92), and history of noninjecting drug use (AOR, 1.86; 95% CI, 1.16 to 2.99) and one hospital-level factor: receiving care at a nonpublic hospital. Even after adjustment for patient-level factors, TB patients at private hospitals were half as likely as those at public hospitals to be placed in pulmonary isolation (AOR, 0.47; 95% CI, 0.30 to 0.72), while odds of suspecting TB in these same patients were similar at both hospitals.

CONCLUSION

Private hospitals should order TB isolation for all patients for whom AFB smears are ordered, a policy that has been instituted previously at public hospitals in our study.

HIV-related pneumonia care in older patients hospitalized in the early HAART era

Age-related variations in care have been identified for HIV-associated Pneumocystis carinii pneumonia (PCP) in both the 1980s and 1990s. We evaluated if age-related variations affected all aspects of HIV-specific and non-HIV-specific care for HIV-infected individuals with PCP or community-acquired pneumonia (CAP), or whether age-related variations were primarily limited to HIV-specific aspects of care. Subjects were HIV-infected persons with PCP (n = 1855) or CAP (n = 1415) hospitalized in 8 cities from 1995 to 1997. Nine percent of our study patients had received protease inhibitors and 39% had received any type of antiretroviral therapy prior to hospitalization. Data were abstracted from medical records and included severity of illness, HIV-specific aspects of care (initiation of PCP medications), general measures of care [initiation of CAP medications, intubation, and intensive care units (ICU)], and inpatient mortality. Compared to younger patients, pneumonia patients 50 years of age or older were significantly more likely to: be severely ill (PCP, 20.4% vs. 10.4%; CAP, 27.5% vs. 14.9%; each p = 0.001), receive ICU care (PCP, 22.0% vs. 12.8%, p = 0.002; CAP: 15.1% vs. 9.4%; p = 0.02), and be intubated (PCP, 14.6% vs. 8.4%, p = 0.01; CAP, 9.9% vs. 5.6%, p = 0.03). Compared to younger patients, older patients (>/=50 years) had similar rates of timely medications for CAP (48.5% vs. 50.8%) but had lower rates of receiving anti-PCP medications (85.8% vs. 92.9%, p = 0.002). Differences by age in timely initiation of PCP medications, ICU use, and intubation were limited to the nonseverely ill patients. Older hospitalized patients were more likely to die (PCP, 18.3% vs. 10.4%; CAP, 13.4% vs. 8.5%; each p < 0.05). After adjustment for disease severity and timeliness of antibiotic use, mortality rates were similar for both age groups. Physicians should develop strategies that increase awareness of the possibility of HIV infection in older individuals.

Relationship between health insurance and medical care for patients hospitalized with human immunodeficiency virus-related Pneumocystis carinii pneumonia, 1995-1997: Medicaid, bronchoscopy, and survival

In the late 1980s, Medicaid-insured human immunodeficiency virus (HIV)-infected patients with Pneumocystis carinii pneumonia (PCP) were 40% less likely to undergo diagnostic bronchoscopy and 75% more likely to die than were privately insured patients, whereas rates of use of other, less resource-intensive aspects of PCP care were similar. We reviewed 1395 medical records at 59 hospitals in 6 cities for the period 1995-1997 to examine the impact of insurance status on PCP-related care. Medicaid patients were only one-half as likely to undergo diagnostic bronchoscopy as were privately insured patients, yet we found no evidence that mortality was greater among patients who received empirical treatment. The bronchoscopy rates were primarily related to patients' personal insurance status. A weaker hospital-level effect was seen that was related to hospitals' Medicaid/private insurance case mix ratios. The situation has evolved from one in which Medicaid coverage was associated with underuse of bronchoscopy and poorer survival among empirically treated persons with HIV-related PCP to one in which empirical therapy is effective in treating this disease and expensive diagnostic procedures may be overused for privately insured patients.

Evaluation of a human immunodeficiency virus rule out tuberculosis critical pathway as an intervention to decrease nosocomial transmission of tuberculosis in the inpatient setting

Nosocomial transmission of Mycobacterium tuberculosis (TB) is a recognized risk in health care settings, and is a particular concern in settings where human immunodeficiency virus (HIV)-infected persons receive care. TB control guidelines have been effective in prevention of nosocomial TB outbreaks and protection of patients and health care workers. In 1993 a South Florida academic medical center noted an increase in TB cases, particularly in HIV-infected persons who had been inpatients. A multidisciplinary team developed an HIV Rule Out TB Critical Pathway as an intervention to deter nosocomial transmission of TB. The pathway was implemented in 1995 on the Special Immunology/Infectious Disease (SI/ID) inpatient unit. This paper describes an evaluation study conducted to determine the effectiveness of the pathway as an intervention to deter nosocomial TB in relation to two areas: (1) early identification of HIV-infected patients with potential TB, followed by immediate placement in respiratory isolation and (2) protection of SI/ID unit personnel from occupational TB exposure. A retrospective review was conducted in June 1999 on the medical records of all patients who had been placed on the HIV Rule Out TB Critical Pathway from 1995-1998. A review was also done of the medical center's confirmed TB cases, and employee health records for tuberculin skin testing (TST) of employees during this time period. The review demonstrated that all HIV-infected patients with confirmed TB had been identified, placed on the pathway and admitted to respiratory isolation at the onset of hospital admission, deterring the potential for a nosocomial TB outbreak. However, in 1998 two SI/ID staff converted from a nonreactive to a reactive TST. Although the pathway was only partially successful in TB protection for staff members, other factors may have caused the TST conversions. A study recommendation is that institutions develop an HIV Rule Out TB Critical Pathway, along with a Rule Out TB Pathway for patients who are not HIV-infected but present with symptoms that may be indicative of TB infection.

Risk of death from intercurrent disease is not excessively increased by modern postoperative radiotherapy for high-risk resected non-small-cell lung carcinoma

PURPOSE

Some studies report a high risk of death from intercurrent disease (DID) after postoperative radiotherapy (XRT) for non-small-cell lung cancer (NSCLC). This study determines the risk of DID after modern-technique postoperative XRT.

PATIENTS AND METHODS

A total of 202 patients were treated with surgery and postoperative XRT for NSCLC. Most patients (97%) had pathologic stage II or III disease. Many patients (41%) had positive/close/uncertain resection margins. The median XRT dose was 55 Gy with fraction size of 1.8 to 2 Gy. The risk of DID was calculated actuarially and included patients who died of unknown/uncertain causes. Median follow-up was 24 months for all patients and 62 months for survivors.

RESULTS

A total of 25 patients (12.5%) died from intercurrent disease, 16 from confirmed noncancer causes and nine from unknown causes. The 4-year actuarial rate of DID was 13.5%. This is minimally increased compared with the expected rate for a matched population (approximately 10% at 4 years). On multivariate analysis, age and radiotherapy dose were borderline significant factors associated with a higher risk of DID (P =.06). The crude risk of DID for patients receiving less than 54 Gy was 2% (4-year actuarial risk 0%) versus 17% for XRT dose > or = 54 Gy. The 4-year actuarial overall survival was 34%; local control was 84%; and freedom from distant metastases was 37%.

CONCLUSION

Modern postoperative XRT for NSCLC does not excessively increase the risk of intercurrent deaths. Further study of postoperative XRT, particularly when using more sophisticated treatment planning and reasonable total doses, for carefully selected high-risk resected NSCLC is warranted.

HIV-related Pneumocystis carinii pneumonia in older patients hospitalized in the early HAART era

OBJECTIVE

To determine whether older age continues to influence patterns of care and in-hospital mortality for hospitalized persons with HIV-related Pneumocystis carinii pneumonia (PCP), as determined in our prior study from the 1980s.

DESIGN

Retrospective chart review.

PATIENTS/SETTING

Patients (1,861) with HIV-related PCP at 78 hospitals in 8 cities from 1995 to 1997.

MEASUREMENTS

Medical record notation of possible HIV infection; alveolar-arterial oxygen gradient; CD4 lymphocyte count; presence or absence of wasting; timely use of anti-PCP medications; in-hospital mortality.

MAIN RESULTS

Compared to younger patients, patients > or =50 years of age were less likely to have HIV mentioned in their progress notes (70% vs 82%, P <.001), have mild or moderately severe PCP cases at admission (89% vs 96%, P <.002), receive anti-PCP medications within the first 2 days of hospitalization (86% vs 93%, P <.002), and survive hospitalization (82% vs 90%, P <.003). However, age was not a significant predictor of mortality after adjustment for severity of PCP and timeliness of therapy.

CONCLUSIONS

While inpatient PCP mortality has improved by 50% in the past decade, 2-fold age-related mortality differences persist. As in the 1980s, these differences are associated with lower rates of recognition of HIV, increased severity of illness at admission, and delays in initiation of PCP-specific treatments among older individuals--factors suggestive of delayed recognition of HIV infection, pneumonia, and PCP, respectively. Continued vigilance for the possibility of HIV and HIV-related PCP among persons > or =50 years of age who present with new pulmonary symptoms should be encouraged.