Impact of radiology reports on timely tuberculosis diagnosis

PURPOSE

As tuberculosis becomes less common in higher income countries, clinician familiarity with the disease is declining. Little is known about how chest radiograph interpretations affect tuberculosis care. We sought to determine how tuberculosis-related terminology in an initial chest radiograph reading impacted patient care.

STUDY DESIGN

We examined a retrospective cohort of patients with pulmonary tuberculosis in North Carolina from 1 January 2011 to 31 December 2014. Tuberculosis-related terminology was categorised into four mutually exclusive categories. The primary outcomes of interest were the time from the chest radiograph to (1) obtaining the first sputum specimen for acid-fast smear and mycobacterial culture, and (2) initiation of antituberculous treatment.

RESULTS

Of 550 available chest radiograph reports, 175 (31.8%) contained the word 'tuberculosis', 30 (5.5%) contained the word 'mycobacteria' or 'granulomatous', 43 (7.8%) contained the word 'cavity', and 301 (54.7%) had none of the above terms mentioned. Patients with the word 'tuberculosis' in the radiology report had a significantly shorter time to collection of the initial sputum specimen for acid-fast smear and mycobacterial culture (median 2 days) and to the start of antituberculous treatment (median 4 days) than patients with none of the keywords. Use of the term 'cavity' in the report was associated with a shorter time to initiation of antituberculous treatment (median 4 days) than if none of the keywords were used.

CONCLUSION

Chest radiograph reports that contained keywords for pulmonary tuberculosis, such as 'tuberculosis' or 'cavity', were associated with less time to collection of sputum and antituberculous treatment.

Association Between Staff Experience and Effective Tuberculosis Contact Tracing in North Carolina, 2008-2009

BACKGROUND

Effective investigation of tuberculosis (TB) contacts is essential for continued progress toward TB elimination. As the incidence of TB declines, staff experience will also decline. Little is known about the association between the experience level of public health TB staff and the quality of contact investigations.

METHODS

Contact investigations involving fewer than 30 contacts during the period 2008-2009 were included in this analysis. Multivariable models were used to examine associations between staff TB experience (assessed by a standardized survey) and measures of contact investigation quality: time from case identification to contact identification and number of contacts identified per case investigated.

RESULTS

A total of 501 cases and 3,230 contacts met the inclusion criteria. Data were stratified by the number of cases in the county and whether the case was smear-positive or smear-negative. For contacts of smear-positive cases, greater staff experience was associated with more rapid contact identification both in counties with high case counts (hazard ratio [HR] = 2.43; 95% CI, 1.79-3.31) and in counties with low case counts (HR = 1.142; 95% CI, 0.95-1.37). However, for smear-negative cases, staff in counties with low case counts identified contacts more slowly as years of experience increased (HR = 0.82; 95% CI, 0.62-1.07). For contacts of smear-negative cases, more contacts (relative risk [RR] = 1.20; 95% CI, 1.07-1.35) were identified per case in high case-count counties (more than 20 cases during 2008-2009). Conversely, in low case-count counties, fewer contacts were identified per case (RR = 0.94; 95% CI, 0.82-1.08); however, this finding was not significant.

DISCUSSION

Speed of identification and number of contacts are imperfect surrogates for the most important outcome of contact investigations-that is, the rapid identification and treatment of infected contacts.

CONCLUSION

More TB experience was associated with more rapid and thorough TB contact investigations. Retaining experienced staff and mentoring staff new to case management should be high priorities for TB control programs.

Integrated screening for tuberculosis and HIV in tuberculosis contact investigations: lessons learned in North Carolina

Combating the syndemics of tuberculosis (TB) and HIV in the United States will require increasing efficiency as the incidence of TB declines. Fortunately, new tools such as the interferon gamma release assays can be combined with existing strategies such as opt-out HIV testing to facilitate simultaneous, integrated testing for both infections. We describe the lessons learned from our experience with integrated testing for TB and HIV in the setting of TB contact investigations in North Carolina. Integrated testing represents a unique opportunity to leverage TB and HIV program resources to enhance case detection and improve linkages to care. However, joint training in field investigations and diagnostics is critical prior to conducting contact investigations. Furthermore, integrated testing must be tightly coupled to treatment and prevention programs to reduce disease transmission and morbidity from untreated disease in communities.

HIV-specific health care utilization and mortality among tuberculosis/HIV coinfected persons

Persons coinfected with tuberculosis (TB) and HIV are at high risk of death, in part due to suboptimal utilization of HIV-specific health care. We sought to better understand HIV-associated health care utilization and mortality in a retrospective cohort of TB/HIV coinfected cases reported in North Carolina 1993-2003. In this cohort, HIV was newly diagnosed during TB presentation for 34.2% of coinfected patients. Patients had advanced HIV (median CD4 104 cells/mm(3)) at TB diagnosis. Of 260 patients previously known to be HIV positive, 32.3% had seen a physician for HIV care in the previous 6 months and only 18.5% were taking antiretrovirals when TB was diagnosed; 34.8% of patients started antiretrovirals during TB treatment. Twenty-seven (5%) patients died prior to starting TB treatment; of those who survived, 13.6% (70/515) died prior to completing TB treatment, and 42.7% (220/515) died during a median 1408 days of follow-up. CD4 count (relative risk [RR] 0.53 per 100 cell increase, 95% confidence interval [CI] 0.34, 1.02) and highly active antiretroviral therapy (HAART) use during TB therapy (RR 0.37, 95% CI 0.13, 1.02) were independently associated with decreased mortality, while age greater than 45 (RR 2.18, 95% CI 1.11, 4.29) was independently associated with increased mortality during TB treatment. We conclude that TB/HIV coinfected patients had low utilization rates of HIV-specific care prior to TB diagnosis. Many did not receive potentially lifesaving HIV treatment while on TB therapy, and mortality was high as a result. Interventions to enhance utilization of HIV-related health care and integration of TB and HIV services should be studied to improve outcomes.

Therapeutic drug monitoring of antimycobacterial drugs in patients with both tuberculosis and advanced human immunodeficiency virus infection

STUDY OBJECTIVE

To determine the feasibility of therapeutic drug monitoring for adjusting low serum antimycobacterial concentrations in patients with both tuberculosis and advanced human immunodeficiency virus (HIV).

DESIGN

Retrospective cohort study.

DATA SOURCE

De-identified dataset from a tuberculosis clinic.

PATIENTS

Twenty-one patients (median age 38 yrs, range 25-68 yrs) with advanced HIV infection (CD4(+) cell count < 100 cells/mm(3)) who received treatment for active tuberculosis between March 2002 and September 2007.

MEASUREMENTS AND MAIN RESULTS

We evaluated data based on the practices performed at the tuberculosis clinic. After the daily doses of isoniazid and rifamycins (rifampin or rifabutin) were ingested, serum concentrations were obtained at 2 hours for isoniazid and rifampin, at 3 hours for rifabutin, and, when possible, at 6 hours for all three drugs to detect delayed absorption. Antimycobacterial drug concentrations were compared with published reference levels, and dosages were adjusted to achieve desired concentrations. Costs of monitoring were recorded for all patients. Of the 21 patients, 18 (86%) had low serum concentrations of at least one drug 2 hours after ingestion: 2 (10%) had low isoniazid concentrations, 5 (24%) had low rifamycin concentrations, and 11 (52%) had low serum concentrations of both drugs. The median number of dosage adjustments to attain normal concentrations was 1 (range 0-4 adjustments). The median cost/patient for therapeutic drug monitoring was $619 (range $230-1948). The median final doses to achieve normal concentrations were isoniazid 600 mg/day (range 300-1500 mg/day), rifampin 1050 mg/day (range 600-1200 mg/day), and rifabutin 300 mg (range 150-450 mg) 3 times/week. No patient demonstrated any adverse effects attributed to these higher doses.

CONCLUSION

Low serum concentrations of antituberculous drugs, which suggest malabsorption, are common among patients with advanced HIV who also have tuberculosis but can be overcome with higher doses. Therapeutic drug monitoring may be an effective tool to optimize therapy, but needs further study.

Outbreak of tuberculosis among homeless persons coinfected with human immunodeficiency virus

We investigated a cluster of patients with tuberculosis (TB) in North Carolina and determined the extent of transmission of 1 strain of Mycobacterium tuberculosis. A retrospective cohort study was conducted. Homeless shelter attendance and medical records for 1999 and 2000 were reviewed. The period of exposure to M. tuberculosis was determined, and shelter residents were offered TB screening. DNA fingerprinting was performed on 72 M. tuberculosis isolates. In addition to the initial index cluster of 9 patients, another 16 patients were identified. Isolates of M. tuberculosis from all 25 patients shared a matching DNA fingerprint pattern. All but 1 patient was male, 22 (88%) were African American, and 14 (56%) were human immunodeficiency virus-infected. An epidemiological link to a single shelter was identified for all but 1 patient. Earlier recognition of this shelter as a site of M. tuberculosis transmission could have been facilitated through innovative approaches to contact investigation and through genetic typing of isolates.

Safety of 2 months of rifampin and pyrazinamide for treatment of latent tuberculosis

An alternative regimen for the treatment of latent tuberculosis infection is 2 months of rifampin and pyrazinamide, but some patients have died of hepatitis associated with this therapy. One hundred fourteen patients received rifampin/pyrazinamide in Wake County, North Carolina, between December 1999 and May 2002; 60.5% of these patients were homeless, and at least 17% drank alcohol to excess. Seventy-seven patients (67.5%) completed a full 2-month course. Nine patients had a history of viral hepatitis or chronic liver disease. Four of 114 (3.5%; 95% confidence interval, 1.0-8.7%) patients developed hepatitis on therapy, and another two had symptoms consistent with hepatitis but did not report for laboratory testing (total confirmed plus suspected hepatitis rate 5.3%; 95% confidence interval, 2.0-11.1%). No patient who developed hepatitis had a history of viral hepatitis or liver disease, and none had been previously treated with isoniazid. No patients died or were hospitalized due to drug side effects. Rifampin/pyrazinamide was associated with a significantly higher rate of hepatitis than previously described with isoniazid therapy for latent tuberculosis but resulted in a high completion rate. The rifampin/pyrazinamide regimen for latent tuberculosis infection may be useful for high-risk, traditionally nonadherent patient groups, but careful monitoring for toxicity is required.