Recommendations of the German Central Committee against Tuberculosis (DZK) and the German Respiratory Society (DGP) for the Diagnosis and Treatment of Non-tuberculous Mycobacterioses

Non-tuberculous mycobacterioses comprise a group of diseases caused by mycobacteria which do not belong to the Mycobacterium (M.) tuberculosis-complex and are not ascribed to M. leprae. These mycobacteria are characterized by a broad variety as to environmental distribution and adaptation. Some of the species may cause specific diseases, especially in patients with underlying immunosuppressive diseases, chronic pulmonary diseases or genetic predisposition, respectively. Worldwide, a rising prevalence and significance of non-tuberculous mycobacterioses is recognized. The present recommendations summarise current aspects of epidemiology, pathogenesis, clinical aspects, diagnostics - especially microbiological methods including susceptibility testing -, and specific treatment for the most relevant species. Diagnosis and treatment of non-tuberculous mycobacterioses during childhood and in HIV-infected individuals are described in separate chapters.

Think twice: misleading food-induced respiratory symptoms in children with food allergy

Reported food-related symptoms of patients may sometimes be misleading. A correct delineation of food-induced symptoms is often difficult and various differential diagnoses have to be considered. We report on two cases of food-induced, predominantly respiratory symptoms (in one case life-threatening) in children with food allergy. First, a two-year-old boy with no history of allergies and suspected foreign body aspiration which was finally diagnosed as an anaphylactic reaction to fish, and secondly a six-year-old girl with multiple food allergies and allergic asthma who during an electively performed oral food challenge developed severe respiratory distress, drop in blood pressure, and asphyxia not due to an anaphylactic reaction but due to choking on an unnoticed sweet. These two cases represent challenging, life-threatening symptom constellations involving food-induced reactions in food allergic children, reminding us to question first impressions.

Infektionen

Die Meldung und Erfassung von Infektionskrankheiten ist in Deutschland durch das Infektionsschutzgesetz (IfSG) geregelt. In §6 sind meldepflichtige Krankheiten nach gewissen Vorgaben geregelt.

[Interferon-gamma release assays for hospital-based tuberculosis diagnostics in children and adolescents--a retrospective analysis]

OBJECTIVE

Interferon-gamma release assays (IGRA) are well established for diagnosing latent tuberculosis infection in adults. Evidence for their diagnostic relevance in children is still insufficient. The aim of this study was to evaluate the sensitivity and specificity of IGRA compared to the tuberculin skin test (TST) in a local population of children and adolescents presenting to our lung clinic with a specialised outpatient department.

METHODS

Records from all patients evaluated for tuberculosis at our centre between 2009 and 2011 were analysed retrospectively. Complete data sets were available for 80 children and adolescents (age 3 months to 17 years) in the following diagnostic groups: active pulmonary tuberculosis (MTB, n = 13), latent tuberculosis infection (LTBI, n = 15) and controls with tuberculosis exposure (n = 40), non-tuberculous mycobacterial disease (NTM, n = 2) or other lung diseases (n = 10).

RESULTS

All 13 patients with MTB were positive on both IGRA and TST. Among the LTBI patients, 14 /15 had a positive IGRA and 14 /15 a positive TST result. In the control group 0 /52 exceeded the IGRA cut-off, while three patients had a positive TST due to a cross reaction with BCG or NTM.

DISCUSSION

IGRA and TST results are highly correlated in paediatric patients with active or latent tuberculosis. IGRA sensitivity was comparable to that of the TST with a higher specificity as expected. The importance of IGRA in the hospital setting to guide diagnostic algorithms in an unselected population should be further evaluated in prospective studies.

[Recommendations for therapy, chemoprevention and chemoprophylaxis of tuberculosis in adults and children. German Central Committee against Tuberculosis (DZK), German Respiratory Society (DGP)]

Several new international recommendations have been published since the German Central Committee against Tuberculosis (DZK) published its recommendations for drug treatment of tuberculosis (TB) in 2001 and for chemoprevention of latent tuberculosis infection (LTBI) in 2004. These international publications have been integrated in the present new recommendations which describe both the treatment of active TB and preventive treatment, pointing out specific adaptations for Germany. Separate sections deal with the current management of mono-, poly-, and multiresistance or drug intolerance, of TB in children, of different forms of extrapulmonary TB, of LTBI and of special situations such as HIV infection, renal or hepatic insufficiency, infection following BCG instillation in bladder cancer or in case of adverse drug reactions. The following aspects differ from the previous recommendations: A three-drug regimen for the so-called fully susceptible minimal TB is no longer recommended in adults. A dosage of 15 mg/kg body weight of ethambutol for adults is regarded as sufficient. Four secondline drugs (supplemented by pyrazinamide, where appropriate) are recommended for multidrug-resistant tuberculosis (MDR-TB). MDR-TB should be treated over a period of at least 20 months, with an injectable drug administered for a minimum of 8 months (initial phase). Ciprofloxacine and ofloxacine are no longer used to treat TB. It is also recommended to offer an HIV test to all TB patients to complement antiretroviral therapy, if necessary, and to adapt the antituberculous therapy accordingly.

[New recommendations for contact tracing in tuberculosis. German Central Committee against Tuberculosis]

In 2007, the German Central Committee against Tuberculosis (DZK) published recommendations for contact tracing that introduced the new interferon gamma release assays (IGRAs). Meanwhile, substantial progress has been made in documenting the utility of IGRAs. Because IGRAs are usually superior to the tuberculin skin test (TST) in detecting latent TB infection (LTBI) with respect to sensitivity and specificity in adult contact populations that are at least partially BCG vaccinated, it is now recommended that instead of two-step testing only IGRAs be used.[nl]As the literature does not yet provide sufficient data on the accuracy of IGRAs in children younger than 5 years, the TST remains the method of choice in that age group. To date, also, no clear body of data exists to substantiate better performance for IGRAs than for the TST in older children, thus in this age group using of either test is recommended. The new recommendations also underscore the importance of a diligent preselection of close contacts in order to achieve a high probability that positive test results represent recent infection and to thus increase the benefit of chemopreventive treatment for those identified as requiring it. In a third point of update, it is noted that re-testing of contacts individuals found positive for LTBI may produce a considerable number of false-negative results and should thus be avoided in case of documented exposure.

Rifampicin serum levels in childhood tuberculosis

BACKGROUND

Rifampicin (RMP) is an essential drug in paediatric anti-tuberculosis treatment. The current World Health Organization (WHO) guidelines recommend an oral dosage of 10 (8-12) mg per kg body weight.

OBJECTIVE

To present a study investigating RMP serum levels in children after oral medication of RMP alone and after combination treatment with ethambutol (EMB).

DESIGN

RMP serum levels in children of different age groups were determined after a single oral administration of 10 mg/kg RMP alone as well as after combination with 35 mg/kg EMB.

RESULTS

RMP serum levels were lower than those expected in adults receiving a similar oral dose. RMP serum levels in combination treatment were even lower than in monotherapy.

CONCLUSION

Currently recommended RMP dosages in childhood tuberculosis lead to serum levels lower than those recommended for adults, probably due to different pharmacokinetics and pharmacodynamics in children. In children, it appears to be more valid to calculate RMP dosage on the basis of body surface area rather than body weight, leading to higher dosages especially in younger children.

[Characteristics of childhood tuberculosis]

In spite of a decline in the western industrialised countries, tuberculosis remains one of the commonest causes of childhood mortality in the world. In most cases, children become infected by adults in their immediate environment. The clinical manifestation as a consequence of the primary infection reflects the community transmission of tuberculosis. Children with untreated infection remain a lifelong pool for future disease and therefore infectivity. Thus, prevention and therapy of latent tuberculosis infection are fundamental duties of the public health system. The risk of developing active disease following infection with MYCOBACTERIUM TUBERCULOSIS is especially high in children. Compared to adults, childhood tuberculosis manifests differently and is often more severe. At the same time, the diagnosis is complicated by the unspecific clinical presentation and difficulty of culture confirmation in children. This article gives an overview of the special features of the epidemiology, clinical presentation, diagnosis and management of childhood tuberculosis.

Pyrazinamide serum levels in childhood tuberculosis

Pyrazinamide (PZA) is one of the first-line drugs in anti-tuberculosis treatment. In the present study, PZA serum levels in 34 children aged 1 to 14 years were measured either after oral application of PZA alone or after combination therapy with isoniazid and rifampicin. Serum levels did not differ statistically with age, in PZA monotherapy or in combination therapy. With a dosage of 30 mg/kg PZA, efficient serum levels were reached. Because PZA is distributed uniformly in the body, serum levels are related to body weight, and a dose of 30 mg/kg bodyweight is appropriate in children.

Ethambutol in paediatric tuberculosis: aspects of ethambutol serum concentration, efficacy and toxicity in children

SETTING

Ethambutol (EMB) is used as a fourth drug in paediatric anti-tuberculosis treatment. In current recommendations the dosage of EMB is calculated per kg body weight.

OBJECTIVE

To present two studies investigating an appropriate EMB dosage in children, and observational data on its toxicity and efficacy.

DESIGN

EMB serum levels in children of different age groups were determined after single oral administration of EMB alone as well as after EMB combined with rifampicin, and optimal dosages were established. The efficacy and toxicity of these EMB dosages were examined retrospectively.

RESULTS

EMB serum levels were lower than those expected in adults receiving a similar oral dose, due to different pharmacokinetics and pharmacodynamics in childhood. Thereafter, children were treated with EMB doses calculated by body surface (867 mg/m2). Ocular toxicity occurred in 0.7% of cases and relapses in 0.8%.

CONCLUSION

Current recommended EMB dosages in childhood tuberculosis lead to subtherapeutic serum levels. It appears to be more valid to calculate the EMB dosage on the basis of body surface rather than body weight, leading to higher dosages especially in younger children. With these dosages, therapeutic serum levels are reached in all age groups, leading to a high efficacy of anti-tuberculosis treatment without increased ocular toxicity.

Interferon- Release Assays Improve the Diagnosis of Tuberculosis and Nontuberculous Mycobacterial Disease in Children in a Country with a Low Incidence of Tuberculosis

BACKGROUND

Diagnosis of childhood tuberculosis (TB) is challenging. The widely used tuberculin skin test (TST) may produce -positive results because of cross-reactivity with nontuberculous mycobacteria or bacille Calmette-Guerin vaccination, resulting in unnecessary treatment. Two recently developed interferon- gamma release assays (IGRAs) show good diagnostic accuracy for active TB in adults; pediatric data are limited, particularly in areas with a low incidence of TB. We assessed the diagnostic accuracy of IGRAs for TB in children in an area with a low incidence of TB.

METHODS

In a hospital-based study, the diagnostic accuracy of the TST and 2 IGRAs (T SPOT-TB [T-SPOT; Oxford Immunotec] and QuantiFERON-TB Gold In-Tube [QFT-IT; Cellestis]) were assessed in a cohort of 73 children (median age, 39 months); 28 children with bacteriologically confirmed TB were compared with children without TB (23 with bacteriologically confirmed nontuberculous mycobacterial lymphadenitis and 22 with other nonmycobacterial respiratory tract infections).

RESULTS

The specificity for TB of QFT-IT was 100% (95% confidence interval [CI], 91%-100%), and the specificity of T-SPOT was 98% (95% CI, 87%-100%), both of which were considerably higher than the specificity of TST (58%; 95% CI, 42%-73%). The specificity of the TST was 10.5% (95% CI, 1%-33%) in children with nontuberculous mycobacterial lymphadenitis and was 100% (95% CI, 83%-100%) in children with other nonmycobacterial respiratory tract infections. The sensitivity of both QFT-IT and T-SPOT was 93% (95% CI, 77%-99%), and the sensitivity of the TST was 100% (95% CI, 88%-100%). Agreement between the IGRAs was 95.6% ( kappa =0.91); 6.8% of the IGRAs showed indeterminate results.

CONCLUSIONS

Both IGRAs showed high diagnostic value in bacteriologically confirmed childhood TB. Their advantage in this study, when performed in addition to the TST, was the ability to distinguish -positive TST results caused by nontuberculous mycobacterial disease, thereby reducing overdiagnosis of TB and guiding clinical management.

Interferon-γ-Tests in der Tuberkulose-Diagnostik - Aktueller Stand

Up to now the diagnosis of latent tuberculosis infection (LTBI) was based solely on the tuberculin skin test. However, this method offers neither 100 % sensitivity nor -- and this is in particular due to its cross-reactivity with BCG and environmental mycobacteria -- a 100 % specificity. The demand in Germany for a more reliable in vitro test is currently enhanced by the change from the multipuncture test to the intradermal (Mendel-Mantoux) test and by the uncertainty resulting from the ceased production of the tuberculin previously used in Germany. The manufacturers of immunologic test methods such as the QuantiFERON-TB Gold In-Tube (ELISA assay) and the T SPOT-TB Test (ELISPOT assay), which are based on the Interferon-gamma (IFN-gamma) production of sensitized T lymphocytes, offer their products as possible alternatives. This article explains the function of the IFN-gamma tests and gives an overview of the most recent data, possible indications and the open scientific questions to be investigated by future clinical studies. Although the new test methods have the potential to eventually prevail as an additional helpful diagnostic tool, the authors consider a complete replacement of the tuberculin skin test as premature. The IFN-gamma tests may, however, prove already now to be a useful additional diagnostic method.

[Future supply of tuberculin in Germany]

The manufacturers of the only tuberculin available up to now in Germany for intradermal TB tests according to Mantoux, Chiron Vaccines Behring, in 2004 unexpectedly stopped the production of the tuberculin Behring GT (GT="gereinigtes Tuberkulin"-purified protein derivative tuberculin). Only residual stocks were sold during the preceding months. The stocks of GT 10 were already depleted at the beginning of 2005, while there are small supplies left of GT 100 and GT 1000. As a temporary solution, Chiron Vaccines Behring is offering to import the Italian tuberculin Biocine PPD 5 IE lyophil produced by Chiron S.r.l. in Siena. As this is not licensed for sale in Germany, it is necessary to obtain an exceptional prescription (Einzelverordnung) according to section sign 73 (3) of the Federal Law Relating to the Manufacture and Distribution of Medicine (Arzneimittelgesetz, AMG). In the long term, Chiron Vaccines Behring plan to secure the supply of tuberculin in Germany by importing, starting in the summer of 2006, the tuberculin produced by Chiron Vaccines Evans in the UK (PPD Evans). However, these plans involve changing over to a different type of tuberculin twice within a very short period of time. Another problem is the unresolved issue of bioequivalence. Besides the above-mentioned tuberculins produced by Chiron Vaccines, a further possibility would be the import of the tuberculin PPD RT23 SSI of the Statens Serums Institute (Copenhagen/Denmark), which is recommended by the World Health Organization (WHO) as the standard tuberculin and which has already been introduced in several European countries, or of other tuberculins such as Tubersol (PPD CT68), which is used in the US. Together with the Robert Koch Institute (RKI) and the Paul Ehrlich Institute (PEI), the German Central Committee against Tuberculosis (DZK) is striving to find a solution, in view of the urgent need for an uninterrupted supply of tuberculin in Germany for diagnostic purposes and contact tracing. A uniform tuberculin should be used in all German regions as a basis to secure a standardized testing procedure and national comparability of test results. The estimated annual requirement for Germany is two million tuberculin test doses. The Statens Serum Institute is currently evaluating the possibility of licensing PPD RT23 SSI in Germany. Chiron Vaccines Behring communicated that it is not aiming to have the Biocine tuberculin licensed for Germany but intends to apply for a license for the tuberculin PPD Evans. Sanofi Pasteur MSD at this point does not intend to have a tuberculin like Tubersol (PPD CT68) licensed for Germany. Until a licensed tuberculin is again available in Germany, it would be very useful if, especially in settings where stocks of tuberculin are essential (e.g. public health services or hospital dispensaries), an exceptional import license could be obtained.

Der Tuberkulose-Schnelltest von DiaVita - keine Alternative zum Tuberkulinhauttest

New methods for diagnosing active tuberculosis (TB) and/or latent tuberculosis infection have been offered increasingly during recent years, also in Germany. The Tuberculosis Rapid Assay ('Tuberkulose Schnelltest [TB-ST]') from DiaVita is a serologic test method aiming to detect, within a few minutes, tuberculosis-specific antibodies in whole blood or serum of tuberculosis patients. Due to a lack of data, it is, however, hardly possible to assess this test on a scientific basis. With a relatively high specificity (according to DiaVita over 95 %) but inadequate sensitivity (approximately 60 - 80 %), particularly in paucibacillary types of TB, we consider this method of limited value for routine testing. If active TB is strongly suspected, a positive test result may corroborate the tentative diagnosis, whereas a negative test result is not helpful for differential diagnosis considering the great number of false-negative test results to be expected. The greatest value of the test seems to be in bacteriologically confirmed TB, in which however there may be no need for additional diagnostics. The test has not been evaluated, and in our opinion is probably unsuitable for detecting latent TB infection. Data is also lacking for a number of patient groups in urgent need of a reliable alternative to the tuberculin skin test (e. g., immunocompromised patients, children). It is not clear whether this method will find a place in routine TB diagnostics. We therefore cannot recommend this test as a routine diagnostic tool for TB at present.

Severe atherosclerosis of the aorta and development of peripheral T-cell lymphoma in an adolescent with angiolymphoid hyperplasia with eosinophilia

We report an adolescent girl with a history of angiolymphoid hyperplasia with eosinophilia (ALHE) diagnosed at the age of 10 years. The patient also suffered from chronic persistent multiresistant herpes simplex virus infection. Atherosclerotic occlusive disease of the abdominal aorta and its major branches was observed at the age of 17 years, necessitating vascular surgical intervention 1 year later because of disease progression. Histological examination of the aorta disclosed widespread atherosclerosis and high levels of gene expression of both T-helper cell type (Th) 1- and Th2-derived cytokines. This suggests that a highly stimulated systemic immune response including increased production of both Th1- and Th2-derived cytokines such as interferon-gamma and interleukin-4 may result in severe atherosclerotic lesions at a very young age. In addition, the patient developed a peripheral T-cell lymphoma at the age of 18 years. Neither systemic atherosclerosis nor T-cell lymphoma has been reported in association with ALHE. It is suggested that a highly stimulated dysfunctional immune response may play a key role in persistent inflammatory disease and premature development of atherosclerosis as well as malignant transformation of T cells.

[Latent tuberculosis infection: recommendations for preventive therapy in adults in Germany]

The immunologic mechanisms of latent tuberculosis (TB) infection are complex and hitherto not completely understood. The lifelong risk of an immunocompetent individual of developing active TB after infection with M. tuberculosis is 5-10 % and highest during the first two years after infection. Various factors may considerably increase the risk of developing active TB, e. g., immunosuppressive disease or immunosuppressive medication. However, the development of active TB may be avoided by preventive chemotherapy, the therapy of choice being isoniazid over a 9-month period. Alternative treatment regimens may be indicated in special cases, but it must be borne in mind that the efficacy of these regimens has not been studied sufficiently while they seem to be less well tolerated than isoniazid monotherapy. The tuberculin skin test is still the only sufficiently documented method to detect latent infection with M. tuberculosis which is also suitable for routine application. This test today should be performed exclusively as described by Mendel and Mantoux. Its sensitivity and specificity depend on the prevalence of tuberculosis infection. It should therefore be restricted to individuals at increased risk of latent TB infection. When interpreting the tuberculin skin test, it is necessary to know whether an individual belongs to one of the defined risk groups or has an elevated risk of developing active TB. Among the risk groups are individuals who may have been infected recently with M. tuberculosis (contacts of contagious TB patients) or in whom other factors increase their risk of developing active TB. The indication for chemotherapy for latent TB infection must be based on a careful individual risk-benefit analysis and, besides patient compliance, requires full information of the patient and careful monitoring during therapy. Before initiating treatment, active TB must always be excluded by the proven methods.

Late clinical manifestation of cerebral tuberculomas in two children with tuberculous meningoencephalitis

We report on two children with cerebral tuberculomas leading to late dramatic clinical exacerbation after appropriate antituberculous chemotherapy and high-dose corticosteroids. A 6-year-old girl with tuberculous meningoencephalitis initially fully recovered. However, after 9 months of continuous therapy she presented with acute increased intracranial pressure caused by tuberculomas requiring rapid drainage of CSF. A 16-year-old boy with miliary pulmonary tuberculosis and severe meningoencephalitis had reached a stable condition for more than 10 months although still suffering from a left-dominant spasticity and motor dysphasia. Fifteen months after initiation of therapy he presented with an acute central paralysis of the left facial nerve, progressive hemiplegia, severe ataxia and increasing lethargy caused by a cerebral tuberculoma with a perifocal oedema. Prolonged treatment with antituberculous chemotherapy and high-dose corticosteroids led to complete recovery in the younger patient and marked improvement in the older patient who remains severely handicapped.

CONCLUSION

Patients with initially successful treatment of central nervous system tuberculosis should undergo an alert follow-up for the development of late cerebral tuberculomas. Treatment should consist of prolonged courses of antituberculous chemotherapy and high-dose corticosteroids.

[Leprosy - An overview from a pediatric perspective]

Worldwide tourism is an increasing industry. One result of this phenomenon is the occurrence of imported infectious diseases, as recently observed even in Germany. Leprosy ranks high among dreaded infectious diseases from tropical and subtropical countries. It remains a major health threat despite marked improvements in diagnosis and therapy. This was achieved by a better understanding of bacteriological and immunological mechanisms over the past decades, resulting in a decline of Leprosy's incidence.

Increasing dose of methylprednisolone pulse therapy treats desquamative interstitial pneumonia in a child

A 10 yr old male with hypoxaemia, progressive infiltration on the chest radiograph and biopsy-proven desquamative interstitial pneumonia was treated with daily oral prednisolone for 6 months. Intravenous methylprednisolone pulses were concomitantly administered in doses averaging 10 mg x kg body weight(-1) on three consecutive days every 4-6 weeks. After 6 months improvement could be noted and oral steroids were stopped, while pulse therapy continued. Three months later, when seven pulses had been administered, a relapse occurred and the clinical status deteriorated. Instead of reinstating daily systemic steroids, the dose of methylprednisolone pulses was increased to 20 mg x kg body weight(-1) i.v. given on three consecutive days and repeat pulses every 4 weeks. This was followed by continuous improvement. After 24 months corticosteroid pulses were terminated. Normal lung function, serum lactate dehydrogenase, blood gases upon exertion and regular development was achieved. During the course of treatment, the child has grown 10 cm. It is concluded that the effect of corticosteroid pulse therapy on interstitial lung disease in childhood is dose-dependent and that the dose can be adjusted to the effect observed.

[Ambulatory vs. inpatient intravenous antibiotic therapy in mucoviscidosis patients--a controlled study]

METHODS

14 patients with cystic fibrosis and chronic pulmonary pseudomonas infection received four courses of two-week intravenous antibiotic therapy at home and during hospitalisation over an 18-month period. Following a controlled, intra-individual cross-over design, two courses of home therapy were followed by two courses of hospital treatment or vice versa. Parameters for inflammation, lung function, and body mass index were obtained at the beginning and end of each intravenous antibiotic therapy. Health-related quality of life, i.e. physical, emotional, social and functional components as well as happiness and medical care, was assessed at the end of each course.

RESULTS

There was a trend towards better reduction of infection (p = 0.20 for leukocyte reduction) and improvement of lung function (p = 0.20 for FEV1 improvement) with hospital intravenous antibiotic therapy, although the differences did not attain statistical significance. Quality of life during therapy was significantly higher with home therapy regarding social (p < 0.01), functional and emotional subscales and happiness (all p < 0.05). The necessity for professional help and support from family and/or partner was emphasised. Individual answers showed that home therapy has the advantage of self-determination and continuity of daily life. Parents and partners felt impaired by day and night intravenous therapy at home.

CONCLUSION

From our data we conclude that home intravenous antibiotic therapy is a useful option for a selected subgroup of patients with cystic fibrosis, but professional support and family aid is important to gain an effect similar to hospital treatment.

Childhood tuberculosis in Germany between 1985 and 1994: comparison of three selected patient groups

SETTING

Clinical and epidemiologic features of childhood tuberculosis in Germany are unknown for recent years. The characteristics of patient groups may show typical differences, depending on the source of data.

OBJECTIVE

To identify typical features of childhood tuberculosis in Germany, and to relate the characteristics of patient groups to the purpose of the reporting centres.

DESIGN

Comparative, retrospective, descriptive analysis of clinical and notification records by standardized data sheet. Evaluation of cases of active tuberculosis in children recorded between 1985 and 1994 at three study centres.

RESULTS

One clinical study centre was a referral centre for sick children with an unclear diagnosis, the second specialized in tuberculosis, and the third was a public health office. Almost two thirds (64%) of the 285 evaluated patients were four years of age and under. Between 73% and 96% of children suffered from pulmonary disease and 17% to 58% were culture positive (range between study centres). Source cases had been found for 23% to 52% of children, and the primary reason for clinical evaluation was a positive tuberculin test for between 12% and 57%. Foreign-born children showed characteristic differences.

CONCLUSION

The characteristics of reported childhood tuberculosis differ depending on the reporting centre. A significant number of notified cases were probably wrongly diagnosed.

Childhood tuberculosis: an index measuring the ability to detect cases early

SETTING

Tuberculosis control programmes are conventionally monitored using data from sputum smear positive adult patients. Good overall results may mask significant and avoidable shortcomings with tuberculosis control in children.

OBJECTIVE

To develop a specific surveillance tool for child patients, using the ability to detect cases early as a parameter for the impact of control measures.

DESIGN

A simple index of early detection was compiled with values ranging from 0 to 100. Three groups of tuberculous children diagnosed in Germany between 1985 and 1994 (n = 303), and five other groups from the literature, were used to make a preliminary assessment of the validity of the index.

RESULTS

The index values of 10, 13 and 24 for the German groups correlate well with other analysed patient data and the different functions of the institutions where the patients were diagnosed. Comparable characteristics could be found when applying the index to published data of other cases, with values of between 12 and 74.

CONCLUSION

The proposed index seems suitable for monitoring early detection of child cases. Unexpected trends can be disclosed or effects of changed programme activities assessed. Routine use of the index would help the health services focus their attention on problem areas and specific patient groups with extremely low or falling index values. Conclusions can be drawn regarding the overall impact of the control programme.

Distribution and transmission of Pseudomonas aeruginosa and Burkholderia cepacia in a hospital ward

Genotyping and antibiotic susceptibility testing were used to analyze Pseudomonas aeruginosa and Burkholderia cepacia strains from sink drain from 14 pediatric patients with cystic fibrosis (CF) and from hospital personnel as part of a 4 week prospective study of strain transmission in a pediatric ward. A total of 87.5% of all washbasin drains were contaminated with P. aeruginosa [10(2) to 10(5) colony forming units (CFU)/ml sink fluid], whereas B. cepacia was found only once in a sink drain. From the eight CF patients already infected with P. aeruginosa upon entering the ward, we isolated six genotypes that were identical with strains found in sink drains of the ward. Four of the 16 members of the personnel had one positive P. aeruginosa hand culture. B. cepacia was never found in patients or on personnel hands. Hand washing in contaminated sinks (> or = 10(3) CFU/ml) led to positive P. aeruginosa or B. cepacia hand cultures. P. aeruginosa or B. cepacia embedded in sputum were transmissable by hand shaking for up to 180 min, whereas both pathogens suspended in physiological saline were transmissable to other hands only up to 30 min. Genotyping of P. aeruginosa revealed strain transmission from CF patients or the environment to other patients or the personnel, as well as one transmission from the environment to a CF patient. The ability of CF sputum to prolong survival of P. aeruginosa and B. cepacia may be important for strain transmission. The results suggest that improved hygienic measures are required to prevent routes of bacterial transmission via the hands and sink drains.

Distribution and transmission of Pseudomonas aeruginosa and Burkholderia cepacia in a hospital ward

Genotyping and antibiotic susceptibility testing were used to analyze Pseudomonas aeruginosa and Burkholderia cepacia strains from sink drain from 14 pediatric patients with cystic fibrosis (CF) and from hospital personnel as part of a 4 week prospective study of strain transmission in a pediatric ward. A total of 87.5% of all washbasin drains were contaminated with P. aeruginosa [10(2) to 10(5) colony forming units (CFU)/ml sink fluid], whereas B. cepacia was found only once in a sink drain. From the eight CF patients already infected with P. aeruginosa upon entering the ward, we isolated six genotypes that were identical with strains found in sink drains of the ward. Four of the 16 members of the personnel had one positive P. aeruginosa hand culture. B. cepacia was never found in patients or on personnel hands. Hand washing in contaminated sinks (> or = 10(3) CFU/ml) led to positive P. aeruginosa or B. cepacia hand cultures. P. aeruginosa or B. cepacia embedded in sputum were transmissable by hand shaking for up to 180 min, whereas both pathogens suspended in physiological saline were transmissable to other hands only up to 30 min. Genotyping of P. aeruginosa revealed strain transmission from CF patients or the environment to other patients or the personnel, as well as one transmission from the environment to a CF patient. The ability of CF sputum to prolong survival of P. aeruginosa and B. cepacia may be important for strain transmission. The results suggest that improved hygienic measures are required to prevent routes of bacterial transmission via the hands and sink drains.