Delays in the suspicion and treatment of tuberculosis among hospitalized patients

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study

OBJECTIVES

Missed opportunities to diagnose tuberculosis are costly to patients and society. In this study, we (1) estimate the frequency and duration of diagnostic delays among patients with active pulmonary tuberculosis and (2) determine the risk factors for experiencing a diagnostic delay.

DESIGN

A retrospective cohort study of patients with tuberculosis using longitudinal healthcare encounters prior to diagnosis.

SETTING

Commercially insured enrollees from the Commercial Claims and Encounters or Medicare Supplemental IBM Marketscan Research Databases, 2001-2017.

PARTICIPANTS

All patients diagnosed with, and receiving treatment for, pulmonary tuberculosis, enrolled at least 365 days prior to diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the number of visits with tuberculosis-related symptoms prior to diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern. We computed the number of visits representing a delay and used a simulation-based approach to estimate the number of patients experiencing a delay, number of missed opportunities per patient and duration of delays (ie, time between diagnosis and earliest missed opportunity). We also explored risk factors for missed opportunities.

RESULTS

We identified 3371 patients diagnosed and treated for active tuberculosis that could be followed up for 1 year prior to diagnosis. We estimated 77.2% (95% CI 75.6% to 78.7%) of patients experienced at least one missed opportunity; of these patients, an average of 3.89 (95% CI 3.65 to 4.14) visits represented a missed opportunity, and the mean duration of delay was 31.66 days (95% CI 28.51 to 35.11). Risk factors for delays included outpatient or emergency department settings, weekend visits, patient age, influenza season presentation, history of chronic respiratory symptoms and prior fluoroquinolone use.

CONCLUSIONS

Many patients with tuberculosis experience multiple missed diagnostic opportunities prior to diagnosis. Missed opportunities occur most commonly in outpatient settings and numerous patient-specific, environment-specific and setting-specific factors increase risk for delays.

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.

Increasing likelihood of advanced pulmonary tuberculosis at initial diagnosis in a low-incidence US state

SETTING

Arkansas, USA.

OBJECTIVE

To investigate the relationship between an increase in the proportion of cases with advanced disease at first diagnosis and the recently observed slowing of the decline in tuberculosis (TB) incidence in low-incidence US states.

DESIGN

We conducted descriptive statistical analyses of de-identified surveillance data of 1246 culture-confirmed TB patients reported in Arkansas during 1996-2013. We then fitted stepwise, multivariate logistic regression models to identify predictors for advanced disease at diagnosis, defined as having either smear-positive sputum or lung cavitation.

RESULTS

From 1996 to 2013, the proportion of new cases with positive sputum smear and cases with lung cavitation increased from 51.6% to 75% and from 37.7% to 50%, respectively. Patients diagnosed during 2006-2013 were more likely to have positive sputum smears (adjusted odds ratio [aOR] 2.55, 95%CI 1.95-3.35) or lung cavitation (aOR 1.49, 95%CI 1.14-1.95) than those diagnosed during 1996-2005. During 1996-2013, age 15-64 years and excessive alcohol use were predictive of positive sputum smear or lung cavitation.

CONCLUSION

Measures to reduce the proportion of cases with advanced disease at first diagnosis may be helpful to achieve further decline in TB incidence in low-incidence settings.

Risk Factors for Delayed Isolation of Patients with Active Pulmonary Tuberculosis in an Acute-care Hospital

The objective of the current study was to determine the factors associated with delayed isolation of pulmonary tuberculosis (TB). In this retrospective study, data of patients newly diagnosed with pulmonary TB from January 2015 through December 2017 at a referral hospital were reviewed. Delayed recognition of pulmonary TB was defined as failure to initiate airborne isolation within the first 3 days of admission. We analyzed the clinical, microbiological, and radiological factors associated with delayed isolation of pulmonary TB. A total of 134 patients with positive sputum acid-fast bacilli (AFB) cultures were analyzed, of which 44 (33%) were isolated within 3 days after admission. In multivariate logistic regression analysis, older age (p = 0.01), admission to departments other than Infectious Disease or Pulmonology (p = 0.005), and presence of malignancy (p = 0.02) were associated with delayed isolation. Patients with a radiologic diagnosis of active pulmonary TB were likely to be isolated early (p = 0.01). Better awareness of pulmonary TB among attending practitioners in hospital settings is required. Delay in isolation is associated with older age, malignancy, hospitalization to departments other than Infectious Disease or Pulmonology, and non-confident radiologic diagnosis of active pulmonary TB.

Distance Learning Course for Healthcare Professionals: Continuing Education in Tuberculosis

BACKGROUND

Continuing education of healthcare workers (HCWs) is an essential strategy for the control of tuberculosis (TB) transmission, enabling HCWs in early detection and appropriate treatment of TB cases.

METHODS

We developed a distance learning (DL) course on TB for nurses. We conducted a quasi-experimental before and after study to evaluate the DL community at the participant's learning level. In addition, to evaluate the DL community at the level of participant satisfaction, a cross-sectional study was carried out after the course. Nurses involved in active inpatient or outpatient care of patients were recruited to participate in the study.

RESULTS

Sixty-six participants started and completed the course and they were included in the analysis. The overall mean pretest and post-test scores were 10.3 ± 2.2 and 11.4 ± 2.7, respectively. Participants increased their knowledge to a statistically significant degree (p < 0.0001). At baseline, the frequency of correct answers was very low in some questions: number of people infected by Mycobacterium tuberculosis in the world (10.6%); number of TB cases in Brazil (36.4%); contagiousness of latent TB infection (LTBI) (28.8%); and definition of active case finding (45.5%). Course feedback was mostly positive, with majority of users saying they were satisfied or totally satisfied.

CONCLUSIONS

A brief DL course on TB was associated with some improvement in knowledge among nurses. The baseline knowledge was low regarding TB epidemiologic data, concepts on LTBI, and active case finding. This finding emphasizes the need to further improve the competencies and knowledge of nurses.

Predictors of hospitalization of tuberculosis patients in Montreal, Canada: a retrospective cohort study

BACKGROUND

Hospitalization is the most costly health system component of tuberculosis (TB) control programs. Our objectives were to identify how frequently patients are hospitalized, and the factors associated with hospitalizations and length-of-stay (LOS) of TB patients in a large Canadian city.

METHODS

We extracted data from the Montreal TB Resource database, a retrospective cohort of all active TB cases reported to the Montreal Public Health Department between January 1996 and May 2007. Data included patient demographics, clinical characteristics, and dates of treatment and hospitalization. Predictors of hospitalization and LOS were estimated using logistic regression and Cox proportional hazards regression, respectively.

RESULTS

There were 1852 active TB patients. Of these, 51% were hospitalized initially during the period of diagnosis and/or treatment initiation (median LOS 17.5 days), and 9.0% hospitalized later during treatment (median LOS 13 days). In adjusted models, patients were more likely to be hospitalized initially if they were children, had co-morbidities, smear-positive symptomatic pulmonary TB, cavitary or miliary TB, and multi- or poly-TB drug resistance. Factors predictive of longer initial LOS included having HIV, renal disease, symptomatic pulmonary smear-positive TB, multi- or poly-TB drug resistance, and being in a teaching hospital.

CONCLUSIONS

We found a high hospitalization rate during diagnosis and treatment of patients with TB. Diagnostic delay due to low index of suspicion may result in patients presenting with more severe disease at the time of diagnosis. Earlier identification and treatment, through interventions to increase TB awareness and more targeted prevention programs, might reduce costly TB-related hospital use.

Missed Opportunities to Diagnose Tuberculosis Are Common Among Hospitalized Patients and Patients Seen in Emergency Departments

Background. Delayed diagnosis of tuberculosis (TB) may lead to worse outcomes and additional TB exposures.

Methods. To estimate the potential number of misdiagnosed TB cases, we linked all hospital and emergency department (ED) visits in California′s Healthcare Cost and Utilization Project (HCUP) databases (2005–2011). We defined a potential misdiagnosis as a visit with a new, primary diagnosis of TB preceded by a recent respiratory-related hospitalization or ED visit. Next, we calculated the prevalence of potential missed TB diagnoses for different time windows. We also computed odds ratios (OR) comparing the likelihood of a previous respiratory diagnosis in patients with and without a TB diagnosis, controlling for patient and hospital characteristics. Finally, we determined the correlation between a hospital′s TB volume and the prevalence of potential TB misdiagnoses.

Results. Within 30 days before an initial TB diagnosis, 15.9% of patients (25.7% for 90 days) had a respiratory-related hospitalization or ED visit. Also, within 30 days, prior respiratory-related visits were more common in patients with TB than other patients (OR = 3.83; P < .01), controlling for patient and hospital characteristics. Respiratory diagnosis-related visits were increasingly common until approximately 90 days before the TB diagnosis. Finally, potential misdiagnoses were more common in hospitals with fewer TB cases (ρ = −0.845; P < .01).

Conclusions. Missed opportunities to diagnose TB are common and correlate inversely with the number of TB cases diagnosed at a hospital. Thus, as TB becomes infrequent, delayed diagnoses may increase, initiating outbreaks in communities and hospitals.

Factors associated with delayed recognition of pulmonary tuberculosis in emergency departments in Taiwan

OBJECTIVE

To identify and evaluate factors associated with delayed recognition of pulmonary tuberculosis (TB) in the emergency department (ED).

BACKGROUND

Delayed recognition of pulmonary TB in ED may precipitate mortality and morbidity.

METHODS

Medical records of newly diagnosed TB patients admitted to four hospitals in Taiwan were retrospectively reviewed. Patients were divided into two groups based on ED physicians' recognition or not of TB and statistically compared to identify differences in their characteristics.

RESULTS

310 newly diagnosed TB patients were identified; 150 were unrecognized in the ED. Cough, chest tightness, general malaise, and body weight loss were more common for those with recognized TB. Older age (≥65 yrs, P = 0.035) and chronic renal insufficiency (P = 0.005) were associated with delayed TB recognition.

CONCLUSION

Older age and chronic renal insufficiency are risk factors for delayed TB while in the ED. Typical symptoms should heighten alertness for recognizing TB.

Nosocomial tuberculosis exposures at a tertiary care hospital: a root cause analysis

BACKGROUND

Exposure of health care workers (HCWs) to patients with active TB continues to occur despite implementation of TB control policies.

METHODS

We conducted a root-cause analysis of TB exposures at a tertiary care hospital. Clinical and management details of all confirmed cases identified in 2011 were summarized. Cases were independently reviewed by an expert panel that determined the type (ie, delay in initiating, incorrect use of or premature removal of control measures), preventability, and root cause(s) of each error (exposure).

RESULTS

Fifteen cases were reviewed. Ten errors were identified in 7 (47%) cases. Cases associated with errors were older than those without errors (68 y vs 40 y; P = .037). Most cases (12/15) were foreign born. A delay in initiating airborne precautions accounted for 70% (7/10) of the errors. The expert panel determined that 80% (8/10) of the errors were preventable or possibly preventable. The most common root causes were failure to consider TB and failure to obtain and interpret imaging. Advanced age, atypical presentation, and presence of comorbid illnesses were common among the preventable cases.

CONCLUSIONS

TB control policies do not prevent all exposures. Our findings suggest that consideration of TB in elderly patients with risk factors, even if their signs and symptoms can be explained by an alternative diagnosis or are atypical, followed by a review of imaging studies, can further reduce this risk.

High mortality in adults hospitalized for active tuberculosis in a low HIV prevalence setting

BACKGROUND

This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence.

METHODS

A retrospective cohort study was conducted on all adults hospitalized for pulmonary and/or extrapulmonary tuberculosis in an acute-care hospital in Hong Kong during a two-year period. Microscopy and solid-medium culture were routinely performed. The diagnosis of tuberculosis was made by: (1) positive culture of M. tuberculosis, (2) positive M. tuberculosis PCR result, (3) histology findings of tuberculosis infection, and/or (4) typical clinico-radiological manifestations of tuberculosis which resolved after anti-TB treatment, in the absence of alternative diagnoses. Time to treatment ('early', started during initial admission; 'late', subsequent periods), reasons for delay, and short- and long-term survival were analyzed.

RESULTS

Altogether 349 patients were studied [median(IQR) age 62(48-77) years; non-HIV immunocompromised conditions 36.7%; HIV/AIDS 2.0%]. 57.9%, 16.3%, and 25.8% had pulmonary, extrapulmonary, and pulmonary-extrapulmonary tuberculosis respectively. 58.2% was smear-negative; 0.6% multidrug-resistant. 43.4% developed hypoxemia. Crude 90-day and 1-year all-cause mortality was 13.8% and 24.1% respectively. 57.6% and 35.8% received 'early' and 'late' treatment respectively, latter mostly culture-guided [median(IQR) intervals, 5(3-9) vs. 43(25-61) days]. Diagnosis was unknown before death in 6.6%. Smear-negativity, malignancy, chronic lung diseases, and prior exposure to fluoroquinolones (adjusted-OR 10.6, 95%CI 1.3-85.2) delayed diagnosis of tuberculosis. Failure to receive 'early' treatment independently predicted higher mortality (Cox-model, adjusted-HR 1.8, 95%CI 1.1-3.0).

CONCLUSIONS

Mortality of hospitalized tuberculosis patients is high. Newer approaches incorporating methods for rapid diagnosis and initiation of anti-tuberculous treatment are urgently required to improve outcomes.

Community-acquired pneumonia and tuberculosis: differential diagnosis and the use of fluoroquinolones

The respiratory fluoroquinolones moxifloxacin, gemifloxacin, and high-dose levofloxacin are recommended in guidelines for effective empirical antimicrobial therapy of community-acquired pneumonia (CAP). The use of these antibiotics for this indication in areas with a high prevalence of tuberculosis (TB) has been questioned due to the perception that they contribute both to delays in the diagnosis of pulmonary TB and to the emergence of fluoroquinolone-resistant strains of Mycobacterium tuberculosis. In this review, we consider some of the important questions regarding the potential use of fluoroquinolones for the treatment of CAP where the burden of TB is high. The evidence suggests that the use of fluoroquinolones as recommended for 5-10 days as empirical treatment for CAP, according to current clinical management guidelines, is appropriate even in TB-endemic regions. It is critical to quickly exclude M. tuberculosis as a cause of CAP using the most rapid relevant diagnostic investigations in the management of all patients with CAP.

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.

Immunochromatographic IgG/IgM test for rapid diagnosis of active tuberculosis

For rapid diagnosis and discrimination between active tuberculosis (TB) and other pulmonary diseases, we evaluated the clinical usefulness of detection of serum immunoglobulin IgG and IgM antibodies raised against mycobacterial 38-kDa, 16-kDa, and 6-kDa antigens by a commercial rapid immunochromatographic IgG/IgM test (Standard Diagnostics, South Korea) in 246 serum samples from three groups of patients: (i) 171 patients with active TB (128 with pulmonary TB [pTB] and 43 with extrapulmonary TB [epTB]), (ii) 73 patients with pulmonary non-TB diseases, and (iii) two leprosy patients. The sensitivities of IgG and IgM in patients with active TB (pTB and epTB) were 68.4% and 2.3%, respectively. IgG had the best performance characteristics, with sensitivities of 78.1% and 39.5% in sera from patients with active pTB and epTB, respectively, and a specificity of 100%. The sensitivities of IgM were poor and were similar for pTB and epTB (2.3%). In contrast, specificity was very elevated (100%). The combination of IgG with IgM did not improve its sensitivity. IgG-mediated responses against the mycobacterial 38-kDa, 16-kDa, and 6-kDa antigens might constitute a clinically useful tool for presumptive diagnosis and discrimination of active pTB from other pulmonary diseases. Moreover, based on its simplicity and rapidity of application, it could be a screening tool for active pTB in poorly equipped laboratories.

Why is in-hospital diagnosis of pulmonary tuberculosis delayed in southern Taiwan?

BACKGROUND/PURPOSE

In-hospital diagnosis delay (IHDD) of pulmonary tuberculosis (TB) has a significant impact on nosocomial TB transmission. We investigated the risk factors associated with prolonged IHDD in Taiwan, a high-resource, mid-incidence area.

METHODS

Between January 2005 and August 2006, we retrospectively enrolled 193 consecutive hospitalized patients. All of them had culture-proven pulmonary TB and did not receive antitubercular treatment at admission. IHDD was defined as the interval between admission and initiation of antitubercular treatment. Patients were grouped according to the median value of IHDD.

RESULTS

The median IHDD was 7 days. Patients with IHDD > 7 days were considered the prolonged-delay group, and those with IHDD <or= 7 days, the short-delay group. Independent risk factors [with adjusted odd ratios (95% confidence intervals)] for prolonged IHDD were: negative sputum smear [47.53 (13.20-171.18), p < 0.001]; non-cavitary lesions on chest radiographs [14.90 (3.46-64.14), p < 0.001]; admission to hospital departments other than chest medicine/infectious diseases [6.60 (1.95-22.41), p = 0.002]; exposure to fluoroquinolones before antitubercular treatment [5.29 (1.13-24.75), p = 0.034]; underlying malignancy [4.59 (1.13-18.67), p = 0.033); and age > 65 years [3.19 (1.01-10.05), p = 0.048]. Death attributed to tuberculosis was associated with positive sputum smear (hazard ratio = 21.85; 95% CI = 2.74-174.44; p = 0.004) but not prolonged IHDD (p = 0.325).

CONCLUSION

To minimize IHDD, clinicians should carefully manage hospitalized patients with risk factors for prolonged delay, such as those with negative sputum smears, non-cavitary lesions on chest radiographs, admission to departments other than chest medicine/infectious diseases, exposure to fluoroquinolones before antitubercular treatment, underlying malignancy, and age > 65 years.

Delayed suspicion, treatment and isolation of tuberculosis patients in pulmonology/infectious diseases and non-pulmonology/infectious diseases wards

Background/Purpose

Delayed diagnosis and isolation increases the risk of nosocomial transmission of tuberculosis (TB). To assess the risk of delayed management of TB, we analyzed the risk factors of prolonged delay in isolation of smear-positive TB patients in pulmonology/infectious diseases and other wards in a tertiary teaching hospital.

Methods

We enrolled smear-positive TB patients aged > 16 years with delayed respiratory isolation following hospitalization. Medical records were reviewed retrospectively. Time intervals between admission, order of sputum acid-fast staining, initiation of anti-tuberculous treatment and isolation were compared between pulmonology/infectious diseases wards (PIWs) and other wards. Risk factors were analyzed in patients with prolonged isolation delay of > 7 days in individual groups.

Results

Isolation was delayed in 191 (73.7%) of 259 hospitalized smear-positive TB patients. Median suspicion, treatment and isolation delays were 0, 3 and 4 days in PIWs and 1, 5 and 7 days in other wards. For patients admitted to non-PIWs, atypical chest radiographs, symptoms without dyspnea or not being admitted from the emergency department (ED) were risk factors for prolonged isolation delay exceeding 7 days. The only risk factor for delayed isolation in patients admitted to PIWs was age ≥ 70 years.

Conclusion

Delays in suspicion, treatment and isolation of TB patients were longer in non-PIWs. Clinicians should be alert to those admitted to non-PIWs with atypical chest radiographs, atypical symptoms, or not admitted from the ED.

Delayed diagnosis of active pulmonary tuberculosis in emergency department

BACKGROUND AND PURPOSE

Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED.

METHODS

We used a retrospective chart review.

PATIENTS

A total of 103 patients were enrolled between December 2003 and March 2006.

RESULTS

Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis.

CONCLUSION

Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

Costs for tuberculosis care in Canada

OBJECTIVES

We have estimated tuberculosis (TB)-related expenditures by governments and other third parties in Canada in 2004, in order to compare spending on different activities, by various jurisdictions, and in different regions.

METHODS

To ascertain health system costs (including public health costs), a self-administered questionnaire was completed by all federal, provincial, and territorial health departments and laboratories involved in TB activities and a sample of local health departments. Hospitalization information was obtained from the Canadian Institute for Health Information, while costs for care were derived from published literature. Costs borne by patients and families were not included. All costs were ascertained for 2004 and expressed in Canadian dollars.

RESULTS

In 2004, total TB-related expenditures in Canada were $74 million, equivalent to $47,290 for every active TB case diagnosed in that year. Research accounted for $4.5 million (or 6% of the total). Non-research-related federal spending accounted for $16.3 million (22%) and provincial/territorial expenditures accounted for $53.1 million (72%). Active tuberculosis accounted for $31 million or 59% of provincial/territorial expenditures. There were substantial regional differences in TB-related expenditures; the highest expenditures were in the Northern Territories ($72,441 per active TB case), followed by the four Western provinces ($35,914), and lowest in the Atlantic provinces ($28,259).

CONCLUSIONS

Total TB-related expenditures in Canada in 2004 were considerable, of which almost 60% were for curative services and only 40% for prevention and control activities. Regional differences likely reflect differences in accessibility of the populations to health care services, and greater interventions in communities with ongoing TB transmission.

Tuberculosis suspicion and knowledge among private and public general practitioners: Questionnaire Based Study in Oman

BACKGROUND

Early detection of smear positive TB cases by smear microscopy requires high level of suspicion of TB among primary care physicians. The objective of this study is to measure TB suspicion and knowledge among private and public sector general practitioners using clinical vignette-based survey and structured questionnaire.

METHODS

Two questionnaires were distributed to both private and public GPs in Muscat Governorate. One questionnaire assessed demographic information of the respondent and had 10 short clinical vignettes of TB and non-TB cases. The second questionnaire had questions on knowledge of TB, its diagnosis, treatment, follow up and contact screening based on Ministry of Health policy. TB suspicion score and TB Knowledge score were computed and analyzed.

RESULTS

A total of 257 GPs participated in the study of which 154 were private GPs. There was a significant difference between private and public GPs in terms of age, sex, duration of practice and nationality. Among all GPs, 37.7% considered TB as one of the three most likely diagnoses in all 5 TB clinical vignettes. Private GPs had statistically significantly lower TB suspicion and TB knowledge scores than public GPs.

CONCLUSION

In Oman, GPs appear to have low suspicion and poor knowledge of TB, particularly private GPs. To strengthen TB control program, there is a need to train GPs on TB identification and adopt a Private Public Mix (PPM) strategy for TB control.

U.S. medical resident familiarity with national tuberculosis guidelines

Background

The ability of medical residents training at U.S. urban medical centers to diagnose and manage tuberculosis cases has important public health implications. We assessed medical resident knowledge about tuberculosis diagnosis and early management based on American Thoracic Society guidelines.

Methods

A 20-question tuberculosis knowledge survey was administered to 131 medical residents during a single routinely scheduled teaching conference at four different urban medical centers in Baltimore and Philadelphia. Survey questions were divided into 5 different subject categories. Data was collected pertaining to institution, year of residency training, and self-reported number of patients managed for tuberculosis within the previous year. The Kruskal-Wallis test was used to detect differences in median percent of questions answered correctly based on these variables.

Results

The median percent of survey questions answered correctly for all participating residents was 55%. Medical resident knowledge about tuberculosis did not improve with increasing post-graduate year of training or greater number of patients managed for tuberculosis within the previous year. Common areas of knowledge deficiency included the diagnosis and management of latent tuberculosis infection (median percent correct, 40.7%), as well as the interpretation of negative acid-fast sputum smear samples.

Conclusion

Many medical residents lack adequate knowledge of recommended guidelines for the management of tuberculosis. Since experience during training influences future practice pattterns, education of medical residents on guidelines for detection and early management of tuberculosis may be important for future improvements in national tuberculosis control strategies.

Variations of care quality for infectious pulmonary tuberculosis in Taiwan: a population based cohort study

Background

Effective and efficient care is required to prevent the spread of infectious pulmonary tuberculosis (PTB). We attempted to compare care quality among different healthcare institutions in Southern Taiwan.

Methods

This study conducted population-based retrospective cohort design. One tuberculosis sanatorium, 2 medical centers, 11 regional hospitals, and 15 district hospitals and primary practitioners in the study area had reported tuberculosis cases, registered from January 1 to June 30 2003. Those cases with sputum positive PTB were followed 15 months after anti-tuberculosis treatment initiation. Meanwhile, Level of conformance with diagnostic guidelines, efficiency of diagnostic and treatment process, and treatment were measured as main outcome. Association was investigated using Chi-square tests, Kruskal Wallis tests, Mann-Whiteney U tests, and multiple logistic regression analysis to evaluate outcome differences among different levels of institutions.

Results

The analyses included 421 patients. In comparison with patients receiving treatment at medical centers, regional hospitals, and district hospitals/primary practitioners, patients at the Chest Specialty Hospital were more likely to provide at least three sputum specimens (74.1% vs. 48.2%, 36.8%, and 50.0%), shorter workdays examining sputum smears (2.4 ± 2.4 days vs. 2.6 ± 2.1, 4.5 ± 3.1, and 3.5 ± 2.6 days), shorter interval between the first consultation and treatment (10.1 ± 18.3 days vs. 31.0 ± 53.6, 31.2 ± 70.4, and 25.4 ± 37.6 days), and a higher successful treatment rate (92.6% vs. 65.2%, 63.9%, and 68.0%). Furthermore, after adjusting age and gender, the patients treated by the pulmonologists and treated at Chest Specialty Hospital had significantly more successful treatment rate, of which odds ratios were 1.74 and 4.58 respectively.

Conclusion

Differences in care quality exist among different types of healthcare institutions and among individual physicians. The implementation of practice guidelines should contribute to an improvement in the care quality of the treatment and diagnosis of PTB.

Impact of a T cell-based blood test for tuberculosis infection on clinical decision-making in routine practice

New T cell-based blood tests for tuberculosis infection could improve diagnosis of tuberculosis but their clinical utility remains unknown. We describe the role of the ELISpot test in the diagnostic work-up of 13 patients presenting with suspected tuberculosis in routine practice. Of the seven patients with a final diagnosis of active tuberculosis, all were positive by ELISpot including three with false-negative tuberculin skin test results. Rapid determination of tuberculosis infection by ELISpot accelerated the diagnosis of tuberculosis, enabling early treatment initiation.

Patterns of delays in diagnosis amongst patients with smear-positive pulmonary tuberculosis at a teaching hospital in Turkey

In total, 151 newly diagnosed patients with smear-positive pulmonary tuberculosis were studied. The mean time from the onset of symptoms to the first visit to a physician was 46.4 days; the mean referral delay was 28.9 days; the mean delay in diagnosis was 2.4 days; and the mean delay in treatment initiation was 0.8 days. There was a delay in consulting a physician by 49% of patients. A low index of suspicion for tuberculosis on the part of the physician and healthcare system and laboratory delays were the most common reasons for delays in diagnosis.

Patient and health care system delays in the start of tuberculosis treatment in Norway

Background

Delay in start of tuberculosis (TB) treatment has an impact at both the individual level, by increasing the risk of morbidity and mortality, and at the community level, by increasing the risk of transmission. The aims of this study were to assess the delays in the start of treatment for TB patients in Oslo/Akershus region, Norway and to analyze risk factors for the delays.

Methods

This study was based on information from the National TB Registry, clinical case notes from hospitals and referral case notes from primary health care providers. Delays were divided into patient, health care system and total delays. The association with sex, birthplace, site of the disease and age group was analyzed by multiple linear regression.

Results

Among the 83 TB patients included in this study, 71 (86%) were born abroad. The median patient, health care system and total delays were 28, 33 and 63 days respectively, with a range of 1–434 days. In unadjusted analysis, patient delay and health care system delay did not vary significantly between men and women, according to birthplace or age group. Patients with extra-pulmonary TB had a significantly longer patient, health care system and total delay compared to patients with pulmonary TB. Median total delay was 81 and 56 days in the two groups of TB patients respectively. The health care system delay exceeded the patient delay for those born in Norway. The age group 60+ years had significantly shorter patient delay than the reference group aged 15–29 years when adjusted for multiple covariates. Also, in the multivariate analysis patients born in Norway had significantly longer health care system delay than patients born abroad.

Conclusion

A high proportion of patients had total delays in start of TB treatment exceeding two months. This study emphasizes the need of awareness of TB in the general population and among health personnel. Extra-pulmonary TB should be considered as a differential diagnosis in unresolved cases, especially for immigrants from high TB prevalence countries.

[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.

American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Controlling Tuberculosis in the United States

During 1993-2003, incidence of tuberculosis (TB) in the United States decreased 44% and is now occurring at a historic low level (14,874 cases in 2003). The Advisory Council for the Elimination of Tuberculosis has called for a renewed commitment to eliminating TB in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. In this statement, the American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of America (IDSA) propose recommendations to improve the control and prevention of TB in the United States and to progress toward its elimination. This statement is one in a series issued periodically by the sponsoring organizations to guide the diagnosis, treatment, control, and prevention of TB. This statement supersedes the previous statement by ATS and CDC, which was also supported by IDSA and the American Academy of Pediatrics (AAP). This statement was drafted, after an evidence-based review of the subject, by a panel of representatives of the three sponsoring organizations. AAP, the National Tuberculosis Controllers Association, and the Canadian Thoracic Society were also represented on the panel. This statement integrates recent scientific advances with current epidemiologic data, other recent guidelines from this series, and other sources into a coherent and practical approach to the control of TB in the United States. Although drafted to apply to TB-control activities in the United States, this statement might be of use in other countries in which persons with TB generally have access to medical and public health services and resources necessary to make a precise diagnosis of the disease; achieve curative medical treatment; and otherwise provide substantial science-based protection of the population against TB. This statement is aimed at all persons who advocate, plan, and work at controlling and preventing TB in the United States, including persons who formulate public health policy and make decisions about allocation of resources for disease control and health maintenance and directors and staff members of state, county, and local public health agencies throughout the United States charged with control of TB. The audience also includes the full range of medical practitioners, organizations, and institutions involved in the health care of persons in the United States who are at risk for TB.

Validity of clinical prediction rules for isolating inpatients with suspected tuberculosis. A systematic review

OBJECTIVE

Declining rates of tuberculosis (TB) in the United States has resulted in a low prevalence of the disease among patients placed on respiratory isolation. The purpose of this study is to systematically review decision rules to predict the patient's risk for active pulmonary TB at the time of admission to the hospital.

DATA SOURCES

We searched MEDLINE (1975 to 2003) supplemented by reference tracking. We included studies that reported the sensitivity and specificity of clinical variables for predicting pulmonary TB, used Mycobacterium TB culture as the reference standard, and included at least 50 patients.

REVIEW METHOD

Two reviewers independently assessed study quality and abstracted data regarding the sensitivity and specificity of the prediction rules.

RESULTS

Nine studies met inclusion criteria. These studies included 2,194 participants. Most studies found that the presence of TB risk factors, chronic symptoms, positive tuberculin skin test (TST), fever, and upper lobe abnormalities on chest radiograph were associated with TB. Positive TST and a chest radiograph consistent with TB were the predictors showing the strongest association with TB (odds ratio: 5.7 to 13.2 and 2.9 to 31.7, respectively). The sensitivity of the prediction rules for identifying patients with active pulmonary TB varied from 81% to 100%; specificity ranged from 19% to 84%.

CONCLUSIONS

Our analysis suggests that clinicians can use prediction rules to identify patients with very low risk of infection among those suspected for TB on admission to the hospital, and thus reduce isolation of patients without TB.

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.

Prognostic variables for high titres in a fluorescent antibody test to diagnose tuberculosis

SETTING

The four hospitals and a tuberculosis clinic in the province of Zeeland, The Netherlands.

OBJECTIVE

To assess the usefulness of PPD antibody measurement in the diagnosis of tuberculosis in patients admitted to hospital.

PATIENTS AND METHODS

Sixty-one patients presenting with active tuberculosis, and 215 control patients were included in the study. Initial serum PPD antibody titres were determined with a macrophage uptake Fluorescent antibody test (MuFat) to construct a discrimination model between Tuberculosis (TB) and non-TB. We also retrospectively collected clinical parameters of the TB patients at presentation. Univariate and multivariate logistic regression are used to identify variables predicting high antibody titres.

RESULTS

In TB patients, the presence of clinical symptoms (OR=10.63) and the presence of at least two concurrent non-lymph node disease localizations outside thorax and abdomen (OR=13.94) are necessary and sufficient to predict high titres. The logistic model shows a significant contribution of the 2log (titre) to the discrimination between TB and non-TB patients. At a cut-off value of 128, a specificity, sensitivity, and positive predictive and negative predictive values of 97%, 39%, 80% and 85%, respectively, are calculated in the study cohort.

CONCLUSION

Our data suggest an application of the test at high cut-off values for timely diagnosis of difficult-to-diagnose TB patients. The results of this retrospective study will have to be confirmed in further prospective studies.

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.

Laboratory reporting of tuberculosis test results and patient treatment initiation in California

Prompt laboratory reporting of tuberculosis (TB) test results is necessary for TB control. To understand the extent of and factors contributing to laboratory reporting delays and the impact of reporting delays on initiation of treatment of TB patients, we analyzed data from 300 consecutive culture-positive TB cases reported in four California counties in 1998. Laboratory reporting to the specimen submitter was delayed for 26.9% of smear-positive patients and 46.8% of smear-negative patients. Delays were associated with the type of laboratory that performed the testing and with delayed transport of specimens. Referral laboratories (public health and commercial) had longer median reporting time frames than hospital and health maintenance organization laboratories. Among patients whose treatment was not started until specimens were collected, those with delayed laboratory reporting were more likely to have delayed treatment than patients with no laboratory reporting delays (odds ratio [OR] of 3.9 and 95% confidence interval [CI] of 1.6 to 9.7 for smear-positive patients and OR of 13.1 and CI of 5.3 to 32.2 for smear-negative patients). This relation remained after adjustment in a multivariate model for other factors associated with treatment delays (adjusted OR of 25.64 and CI of 7.81 to 83.33 for smear-negative patients). These findings emphasize the need to reduce times of specimen transfer between institutions and to ensure rapid communication among laboratories, health care providers, and health departments serving TB patients.

[Pulmonary symptomatic tuberculosis' diagnostic delay study]

OBJECTIVE

To study symptomatic pulmonary tuberculosis (PTB) diagnostic delay.

PATIENTS AND METHODS

Prospective study of new symptomatic PTB cases (aged > or = 15 years) by structured interview with the patients and their families. The main variables analyzed were patient's delay (PD), doctor's delay (DD), diagnostic process delay (DPD), health care system delay (HCSD) and total delay between the onset of symptoms and start of treatment (TD). Univariate and multivariate statistical analyses were performed for each component of delay.

RESULTS

Two hundred eighty-seven patients were studied. The mean delays in days standard deviations were TD 81.8 77.3; PD 43.3 55.7; DD 28.4 59.6; DPD 10.0 17.7, and HCSD 38.5 62.5.

CONCLUSIONS

Patients are responsible for 50% of excess delay in diagnosing symptomatic PTB. Patients in the health care system experienced diagnostic delays over 60 days in 18.5% of cases, doctors being responsible for 75% of the diagnostic delay attributable to the system.

Factors associated with tuberculin conversion in Canadian microbiology and pathology workers

The risk of occupational tuberculosis (TB) infection and associated factors was estimated among all microbiology and pathology technicians and compared with a sample of nonclinical personnel in 17 Canadian acute care hospitals. Participants underwent tuberculin skin testing and completed questionnaires. Prior skin tests and vaccinations and all patients with TB hospitalized in the preceding 3 years were reviewed. Of the work areas where direction of air flow and air changes per hour were measured, only 51% were adequately ventilated. Among participating lab workers the average annual risk of tuberculin conversion was 1.0%. This was associated with lower hourly air exchange rates (16.7 versus 32.5 in workers with no conversion, p < 0.001) work in pathology (adjusted odds ratio [OR]: 5.4; [95% confidence interval: 1.3, 22], higher proportion of patients with missed diagnosis in the first 24 hours (per 20% increase-OR: 2.0; [1.3, 3.2], treatment delayed 1 week or more (per 20% increase-OR: 2.0; [3.2, 3.2]), and higher mortality (per 20% increase-OR: 2.5; [1.1, 5.6]). We conclude that laboratory workers, with no direct patient contact, have increased risk of tuberculin conversion in hospitals where a greater proportion of patients with TB die, or have delayed, or missed diagnosis, although this may be modified by workplace ventilation.

Empiric treatment of community-acquired pneumonia with fluoroquinolones, and delays in the treatment of tuberculosis

Fluoroquinolones, which are widely used to treat community-acquired pneumonia, also have excellent in vitro activity against Mycobacterium tuberculosis. A retrospective cohort study was conducted among adults with culture-confirmed tuberculosis to assess the effect of empiric fluoroquinolone therapy on delays in the treatment of tuberculosis. Sixteen (48%) of 33 patients received fluoroquinolones for presumed bacterial pneumonia before tuberculosis was diagnosed and treated. There were no differences between the group who did and the group who did not receive fluoroquinolones, except that patients who received fluoroquinolones were more likely to present with shortness of breath. Among patients treated empirically with fluoroquinolones, the median time between presentation to the hospital and initiation of antituberculosis treatment was 21 days (interquartile range, 5-32 days); among those who were not, it was 5 days (interquartile range, 1-16 days; P=.04). Initial empiric therapy with a fluoroquinolone was associated with a delay in the initiation of appropriate antituberculosis treatment.

Delay in diagnosis among hospitalized patients with active tuberculosis--predictors and outcomes

Delayed diagnosis of active pulmonary tuberculosis (TB) among hospitalized patients is common and believed to contribute significantly to nosocomial transmission. This study was conducted to define the occurrence, associated patient risk factors, and outcomes among patients and exposed workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17 acute-care hospitals in four Canadian cities, initiation of appropriate treatment was delayed 1 week or more in 127 (30%). This was associated with atypical clinical and demographic patient characteristics, and after adjustment for these characteristics, with admission to hospitals with low TB admission rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR: 2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In hospitals with low TB admission rates, initially missed diagnosis, smear-positive patients undergoing bronchoscopy, late intensive care unit admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more common than in hospitals with high TB admissions (> 10/ 10,000); a similar trend was seen in hospitals with intermediate TB admissions. Even after adjustment for workers' characteristics and ventilation in patients' rooms tuberculin conversions were disproportionately high in hospitals with low and intermediate TB admission rates and significantly higher in hospitals with overall TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied, as the rate of TB admissions decreased, the likelihood of poor outcomes and risk of transmission of TB infection per hospitalized patient with TB increased. Institutional risk of TB transmission was poorly correlated with number of patients with TB and better correlated with indicators of patient care such as delayed diagnosis and treatment and overall TB-related patient mortality.

Delays in the diagnosis and treatment of hospitalized patients with smear-positive pulmonary tuberculosis

The aim of present study was to investigate whether there was any delay in the diagnosis and treatment of inpatients with smear-positive pulmonary tuberculosis followed-up in our centre. We reviewed clinical records in February 1999 and identified 134 hospitalized patients with smear-positive pulmonary tuberculosis. Clinical files of the patients were analysed and a questionnaire was completed. Several intervals and delays were calculated. Median application interval was 17.5 days [95% confidence interval (CI) 21.3-32.4 days], median referral interval was 3.5 days (95% CI 6.8-11.4 days), median diagnosis interval was 3 days (95% CI 3.3-4.5 days) and median initiation of treatment interval was 1 day (95% CI 1.1-1.6 days). Patients delay was present in 28.4% of cases. The referral interval was longer than 2 days in 82 patients (institutional delay). Ninety-three patients (69.4%) had delays in the diagnosis and 34 patients (25.4%) had delays in the treatment. There was a doctor's delay in 119 of 134 patients (88.8%) and clinic's delay in 98 patients (73.2%). Our results have suggested that hospitalized patients with smear-positive pulmonary tuberculosis experience several delays. These delays may result in increased risk for transmission of infection. Decrease in the risk of infection for community and medical personal may only be obtained by preventing these delays.

Tuberculin skin testing of physicians at a midwestern teaching hospital: a 6-year prospective study

The epidemiology of tuberculin reactivity among physicians practicing in regions of moderate tuberculosis prevalence is unknown. We prospectively assessed the epidemiology of tuberculin skin test (TST) reactivity among physicians in training in St. Louis between 1992 and 1998. Of 1574 physicians who were tested, 267 (17%) had positive TST results. Older age, birth outside of the United States, prior bacille Calmette-Guérin (BCG) vaccination, and practice in the fields of medicine, anesthesiology, or psychiatry were associated with a positive TST result. Among physicians born in the United States, 63 (5.7%) had positive TST results. Among physicians with > or = 2 documented TSTs, 12 had conversion to a positive TST (1.6%; 1.03 conversions per 100 person-years). Physicians in this study had a high rate of tuberculin reactivity, despite a low conversion rate. The relationship between TST conversion and birth outside of the United States and BCG vaccination suggests a booster phenomenon rather than true new TST conversions.

Tuberculosis tracking: determining the frequency of the booster effect in patients and staff

BACKGROUND

Two-step tuberculin skin testing, which is recommended to exclude the booster effect as a cause of converting nonreactive skin test responses to reactive responses, can be expensive and logistically challenging. We studied the booster effect in our patients and staff to determine its frequency and to identify factors that might predict its occurrence.

METHODS

Hospital staff members and long-term care patients were given 2-step Mantoux tests and evaluated prospectively.

RESULTS

Of 619 staff members tested, the initial tuberculin response was reactive in 39 (6.3%). Of the 97 nonreactive staff members who presented for retesting 6 to 30 days later, 6 were now reactive (6.2%; [95% CI, 2.3%-11.8%]). Twelve (13.6%) of eighty-eight patients were tuberculin reactive on their initial skin test. Of the 37 nonreactive patients appropriately administered their second test, 2 (5.4%, [95% CI, 0.7-18.2%]) were tuberculin-reactive. Thirteen percent of tuberculin-reactive staff members and 16% of tuberculin-reactive patients were identified only after their second skin test. Foreign birth (P =.02) was associated with purified protein derivative response boosting in staff members; anemia was associated with boosting in patients (P =.05).

CONCLUSIONS

Our results support 2-step skin testing of all new employees and patients who are likely to receive periodic retesting. In our population, age alone is an inadequate criterion for selecting candidates for retesting.

The emergency department presentation of patients with active pulmonary tuberculosis

OBJECTIVE

To determine the clinical presentation of emergency department (ED) patients with active pulmonary tuberculosis (TB).

METHODS

This was a retrospective medical record review of adult patients, identified through infection control records, diagnosed as having active pulmonary TB by sputum culture over a 30-month period at an urban teaching hospital. The ED visits by these patients from one year before to one year after the initial positive sputum culture were categorized as contagious or noncontagious, using defined clinical and radiographic criteria. The medical records of patients with contagious visits to the ED were reviewed to determine chief complaint, presence of TB risk factors and symptoms, and physical examination and chest radiograph findings.

RESULTS

During the study period, 44 patients with active pulmonary TB made 66 contagious ED visits. Multiple contagious ED visits were made by 12 patients (27%; 95% CI = 15% to 43%). Chief complaints were pulmonary 33% (95% CI = 22% to 46%), medical but nonpulmonary 41% (95% CI = 29% to 54%), infectious but nonpulmonary 14% (95% CI = 6% to 24%), and traumatic/orthopedic 12% (95% CI = 5% to 22%). At least one TB risk factor was identified in 57 (86%; 95% CI% = 76 to 94%) patient visits and at least one TB symptom in 51 (77%; 95% CI = 65% to 87%) patient visits. Cough was present during only 64% (95% CI = 51% to 75%) of the patient visits and hemoptysis during 8% (95% CI = 3% to 17%). Risk factors and symptoms that, if present, were likely to be detected at triage were foreign birth, homelessness, HIV positivity, hemoptysis, and chest pain.

CONCLUSIONS

Patients with active pulmonary TB may have multiple ED visits, and often have nonpulmonary complaints. Tuberculosis risk factors and symptoms are usually present in these patients but often missed at ED triage. The diversity of clinical presentations among ED patients with pulmonary TB will likely make it difficult to develop and implement high-yield triage screening criteria.

Implementation of an emergency department triage procedure for the detection and isolation of patients with active pulmonary tuberculosis

STUDY OBJECTIVES

To investigate the ability of an emergency department screening protocol to initiate respiratory isolation of patients with pulmonary tuberculosis at ED triage before chest radiography.

METHODS

We conducted a prospective cohort study with retrospective medical record review of adult patients who presented for care to an urban, university-affiliated hospital in Los Angeles County over a 4-month period. Ambulatory patients were administered a triage screening protocol that used patient-reported tuberculosis risk factors and symptoms in combination with selective chest radiography to screen patients at ED triage for active pulmonary tuberculosis.

RESULTS

A total of 10,674 patients were screened; 2, 218 were isolated at triage and underwent chest radiography, and 378 were kept in isolation in the ED. The respiratory isolation of pulmonary tuberculosis (RIPT) protocol detected 17 of 27 visits made by patients with unsuspected pulmonary tuberculosis, yielding a sensitivity of 63% (95% confidence interval [CI] 42% to 81%). The estimated specificity was 78%. For each patient with tuberculosis who was detected by the RIPT protocol, 624 patients were screened at triage, 130 chest radiographs were taken, and 22 patients were placed in respiratory isolation in the ED. Patients with undetected pulmonary tuberculosis more commonly had nonpulmonary chief complaints (76% versus 20%; odds ratio [OR] 13, 95% CI 2.1 to 78.3), and only 60% (95% CI 26% to 88%) were ultimately isolated in the hospital. Among RIPT screen-positive patients, radiographic findings predictive of pulmonary tuberculosis were cavitary lesions (OR 84.3, 95% CI 22.6 to 315), upper lobe infiltrates (OR 24.2, 95% CI 9.1 to 64.4), pleural effusions (OR 8.9, 95% CI 2.5 to 31.8), diffuse/interstitial infiltrates (OR 5.7, 95% CI 1.8 to 17.9), and non-upper lobe infiltrates (OR 3.1, 95% CI 1.0 to 9.5).

CONCLUSION

The RIPT screening protocol was only moderately sensitive for isolating patients with pulmonary tuberculosis at ED triage. Future studies should evaluate modified and abridged screening protocols, as well as the cost-effectiveness of triage screening.

Tuberculosis diagnosed during pregnancy: a prospective study from London

BACKGROUND

A study was undertaken to characterise the presentation of tuberculosis in pregnancy and the difficulties in diagnosis in an area of the UK with a high incidence of tuberculosis.

METHODS

A prospective case series was investigated at Northwick Park Hospital, a university affiliated district general hospital in Brent and Harrow health authority in north-west London which incorporates a regional infectious diseases unit. Patients diagnosed with tuberculosis over the study period were included if the onset of symptoms occurred during pregnancy.

RESULTS

Thirteen patients were diagnosed during a 30 month period from December 1995 to May 1998 during which 9069 mothers were delivered, a prevalence of 143.3/100 000 deliveries. Symptoms began at a median of 22 weeks gestation (range 9-40 weeks). All patients were recent immigrants of Indian subcontinent or Somali origin and their median duration of residence in the UK was 31 months (range 1-72). Prevalence broken down for racial origin of mothers was 466.3/100 000 for mothers of black African origin and 239.1/100 000 for mothers of Indian origin. Nine of the 13 patients had extrapulmonary tuberculosis. Four patients with widely disseminated disease had a negative Mantoux response and five with localised disease had a strongly positive Mantoux response. HIV co-infection was absent. The median delay between the onset of symptoms and diagnosis was seven weeks (range 2-30). The response to standard treatment was excellent and all patients were cured.

CONCLUSIONS

Tuberculosis occurring in pregnancy is common in recent immigrants. Diagnosis during pregnancy is delayed because the disease is frequently extrapulmonary with few symptoms.

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

BACKGROUND

Despite awareness of HIV-related tuberculosis (TB), nosocomial outbreaks of multidrug-resistant TB among HIV-infected individuals occur.

OBJECTIVE

To investigate delays in TB isolation and suspicion among HIV-infected inpatients discharged with TB or Pneumocystis carinii pneumonia (PCP), common HIV-related pneumonias.

DESIGN

Cohort study during 1995 to 1997.

SETTING

For PCP, 1,227 persons who received care at 44 New York City, Chicago, and Los Angeles hospitals. For TB, 89 patients who received care at five Chicago hospitals.

MEASUREMENTS

Two-day rates of TB isolation/suspicion.

RESULTS

For HIV-related PCP, Los Angeles hospitals had the lowest 2-day rates of isolation/suspicion of TB (24.3%/26.6% vs 65.5%/66.4% for New York City and 62.8%/58.3% for Chicago, respectively; p < 0.001 for overall comparison by chi(2) test for each outcome measure). Within cities, hospital isolation/suspicion rates varied from < 35 to > 70% (p < 0.001 for interhospital comparisons in each city). The Chicago hospital with a nosocomial outbreak of multidrug-resistant TB from 1994 to 1995 isolated 60% of HIV-infected individuals who were discharged with a diagnosis of HIV-related TB and 52% discharged with HIV-related PCP, rates that were among the lowest of all Chicago hospitals in both data sets.

CONCLUSION

Low 2-day rates of TB isolation/suspicion among HIV-related PCP patients were frequent. One Chicago hospital with low 2-day rates of TB isolation/suspicion among persons with HIV-related PCP also had low 2-day rates of isolation/suspicion among confirmed TB patients. That hospital experienced a nosocomial multidrug-resistant TB outbreak. Educational efforts on the benefits of early TB suspicion/isolation among HIV-infected pneumonia patients are needed.

Current management of tuberculosis

Current chemotherapeutic regimens against tuberculosis give excellent cure rates and low relapse rates if implemented and monitored correctly. This is fortunate since only two new drugs have been approved for use in this condition in the last 30 years. However, shortcomings in management and in patient compliance have resulted in an increasing prevalence of drug-resistant organisms. The global decline in the disease has been reversed due to a combination of factors including the HIV epidemic, ageing populations, poverty, and translocation of refugee populations due to conflict.