Systematic Review With Meta-Analyses and Critical Appraisal of Clinical Prediction Rules for Pulmonary Tuberculosis in Hospitals (original) (raw)
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Validity of clinical prediction rules for isolating inpatients with suspected tuberculosis
Journal of General Internal Medicine, 2005
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.
Archives of Internal Medicine, 2005
Background: Current guidelines for the control of nosocomial transmission of tuberculosis (TB) recommend respiratory isolation for all patients with suspected TB. Application of these guidelines has resulted in many patients without TB being isolated on admission to the hospital, significantly increasing hospital costs. This study was conducted to prospectively validate a clinical decision rule to predict the need for respiratory isolation in inpatients with suspected TB.
Evaluation of Clinical Parameters to Predict Mycobacterium tuberculosis in Inpatients
Archives of Internal Medicine, 2000
Background: Respiratory isolation has been recommended for all patients with suspected tuberculosis (TB) to avoid transmission to other patients and health care personnel. In implementing these guidelines, patients with and without TB are frequently isolated, significantly increasing hospital costs. The objective of this study was to derive a clinical rule to predict the need for respiratory isolation of patients with suspected TB. Methods: To identify potential predictors of the need for isolation, 56 inpatients with sputum cultures positive for TB were retrospectively compared with 56 controls who were isolated on admission to the hospital based on clinically suspected TB but whose sputum cultures tested negative for TB. Variables analyzed included TB risk factors, clinical symptoms, and findings from physical examination and chest radiography. Results: Multivariate analysis revealed that the following factors were significantly associated with a culture positive for TB: presence of TB risk factors or symptoms (odds ratio [OR], 7.9 [95% confidence interval (CI), 4.4-24.2]), a positive purified protein derivative tuberculin test result (OR, 13.2 [95% CI, 4.4-40.7]), high temperature (OR, 2.8 [95% CI, 1.1-8.3]), and upper-lobe disease on chest radiograph (OR, 14.6 [95% CI, 3.7-57.5]). Shortness of breath (OR, 0.2 [95% CI, 0.12-0.53]) and crackles noted during the physical examination (OR, 0.29 [95% CI, 0.15-0.57]) were negative predictors of TB. A scoring system was developed using these variables. A patient's total score of 1 or higher indicated the need for respiratory isolation, accurately predicting a culture positive for TB (98% sensitivity [95% CI, 95%-100%]; 46% specificity [95% CI, 33%-59%]). Conclusion: Among inpatients with suspected active pulmonary TB, a prediction rule based on clinical and chest radiographic findings accurately identified patients requiring respiratory isolation.
ACR Appropriateness Criteria Routine Chest Radiographs in Intensive Care Unit Patients
Journal of the American College of Radiology, 2013
Daily routine chest radiographs in the intensive care unit (ICU) have been a tradition for many years. Anecdotal reports of misplacement of life support items, acute lung processes, and extra pulmonary air collections in a small number of patients served as a justification for routine chest radiographs in the ICU.
A Prediction Rule to Stratify Mortality Risk of Patients with Pulmonary Tuberculosis
PLOS ONE, 2016
Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted to develop a severity assessment tool for stratifying mortality risk in pulmonary tuberculosis (PTB) patients. A derivation cohort of 681 PTB cases was retrospectively reviewed to generate a model based on multiple logistic regression analysis of prognostic variables with 6-month mortality as the outcome measure. A clinical scoring system was developed and tested against a validation cohort of 103 patients. Five risk features were selected for the prediction model: hypoxemic respiratory failure (OR 4.7, 95% CI 2.8-7.9), age 50 years (OR 2.9, 95% CI 1.7-4.8), bilateral lung involvement (OR 2.5, 95% CI 1.4-4.4), 1 significant comorbidity-HIV infection, diabetes mellitus, liver failure or cirrhosis, congestive heart failure and chronic respiratory disease-(OR 2.3, 95% CI 1.3-3.8), and hemoglobin <12 g/dL (OR 1.8, 95% CI 1.1-3.1). A tuberculosis risk assessment tool (TReAT) was developed, stratifying patients with low (score 2), moderate (score 3-5) and high (score 6) mortality risk. The mortality associated with each group was 2.9%, 22.9% and 53.9%, respectively. The model performed equally well in the validation cohort. We provide a new, easy-to-use clinical scoring system to identify PTB patients with high-mortality risk in settings with good healthcare access, helping clinicians to decide which patients are in need of closer medical care during treatment.
Study objective: Many patients with pneumonia are admitted to respiratory isolation for possible tuberculosis (TB), but most do not have active TB. We created a decision instrument to predict which pneumonia patients do not need admission to a TB isolation bed. Methods: The design was a prospective case series conducted in 11 university-affiliated, urban, US emergency departments (EDs) (EMERGEncy ID NET). Participants were patients admitted to the hospital through the ED with a diagnosis of pneumonia or suspected TB. The main outcome measure was derivation and validation of a sensitive decision instrument to identify patients not having TB (and not requiring isolation) according to clinical data and chest radiographs. Results: Of 5,079 pneumonia patients, 224 (4.4%) had pulmonary TB according to sputum cultures or tissue staining. The instrument derived to predict which patients did not have pulmonary TB included no TB history or previous positive tuberculin skin test result, nonimmigrant, not homeless, not recently incarcerated, no recent weight loss, and no apical infiltrate or cavitary lesion on plain chest radiograph. When tested on the validation subgroup, the decision instrument exhibited a negative predictive value of 99.7% (95% confidence interval [CI] 99.1% to 99.9%), and a sensitivity of 96.4% (95% CI 91.1% to 99.0%). Conclusion: A decision instrument can accurately predict which patients with pneumonia do not require admission to TB isolation rooms. [Ann Emerg Med. 2009;53:625-632.]
Cough Due to Tuberculosis and Other Chronic Infections: CHEST Guideline and Expert Panel Report
Chest, 2017
Cough is common in pulmonary tuberculosis (TB) and other chronic respiratory infections. Identifying features that predict whether pulmonary TB is the cause would help target appropriate individuals for rapid and cost-effective screening, potentially limiting disease progression, and preventing transmission to others. A systematic literature search for individual studies to answer 8 Key questions (KQ) was conducted according to established Chest Organization methods using the following databases: MEDLINE via PubMed, EMBASE, Scopus and the Cochrane Database of Systematic Reviews from 1/1/1984 to April 2014. Searches for KQ1 and KQ3 were updated in February 2016. An updated KQ 2 search was undertaken in March 2017. Even where TB prevalence is greatest, most individuals with cough do not have pulmonary TB. There was no evidence that one, 3 or 4 weeks' duration were better predictors than cough lasting ≥2 weeks to screen for pulmonary TB. In people living with HIV infection (PLWHIV)...