Delay in Diagnosis among Hospitalized Patients with Active Tuberculosis—Predictors and Outcomes

Abstract

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.

Tuberculose ativa entre profissionais de saúde em Portugal

“…(15) Factors related to the increased risk for HCWs include delayed diagnosis, (16) misdiagnosis in the initial evaluation, advanced age, absence of suspicious clinical signs (e.g., coughing), lack or inadequacy of personal protective equipment and preventive measures, and inadequate ventilation, especially in polyvalent hospital wards. (16,17) The control of TB as a nosocomial disease requires, above all, the adoption of collective measures, such as the rapid identification of suspected or confirmed cases of active TB, the rapid implementation of airborne precautions, and the use of surgical masks or N95 respirators by the HCWs. (18) Although BCG vaccination has proven effective in reducing the most severe forms of TB, its efficacy in preventing pulmonary TB is variable.…”

Características clínicas e evolução de pacientes imunocomprometidos não HIV com diagnóstico intra-hospitalar de tuberculose

“…(1) Despite the availability of curative treatment, a significant proportion of TB patients continue to be hospitalized, and in-hospital mortality remains high, with estimates ranging from 2% to 12%. (2,3) The presence of comorbidities, including HIV infection, and the delayed initiation of treatment have been considered causes of the high in-hospital mortality rates. In addition, hospitalized patients might be more susceptible to the adverse effects of anti-TB drugs, due to the concomitant use of multiple drugs and the presence of comorbidities.…”

An Uncommon Presentation of Tuberculosis with Cervical Pott's Disease Initially Suspected as Metastatic Lung Cancer

“…Moreover, awareness of Pott's disease has progressively declined in the last few years. This reduction can be attributed to the wrong conviction that spinal TB has been eradicated from Western countries [7], while global epidemiological findings highlighted an increase in TB infections of the spine because of aging population and increased prevalence of HIV infection and other immunosuppressive conditions [8]. Misdiagnosis of Pott's disease, which may occur in up to 41% of cases, is often associated with the onset of neurological disorders or TB dissemination which leads to a possible fatal outcome [9].…”