Clinical diagnosis of smear-negative pulmonary tuberculosis: an audit of diagnostic practice in hospitals in Malawi.
Harries AD, Hargreaves NJ, Kwanjana JH, Salaniponi FM
National Tuberculosis Control Programme, Ministry of Health, Lilongwe, Malawi. adharries@malawi.net
Int J Tuberc Lung Dis 2001 Dec;5(12):1143-7
SETTING: Thirty-seven hospitals in Malawi. OBJECTIVE: To audit the hospital practice of clinically diagnosing adults with smear-negative pulmonary tuberculosis (PTB). DESIGN: A cross-sectional survey of adults aged 15 years or above who were registered and receiving inpatient treatment for smear-negative PTB. An assessment of each patient was carried out to determine 1) the number of recommended diagnostic guidelines (cough >3 weeks, no response to antibiotics, negative sputum smears and a chest radiograph compatible with PTB) used by hospital staff in making the diagnosis of PTB, and 2) whether the clinical diagnosis of smear-negative PTB was correct according to criteria set by the study. RESULTS: There were 259 patients, 127 men and 132 women, with a mean age of 37 years; 93% had a cough >3 weeks, 95% had received one or more courses of antibiotics, 92% had submitted sputum samples for smear examination and 97% had chest radiographs performed. In 148 (57%) patients, all four diagnostic guidelines were used, and in 238 (92%) patients three or more were used. The diagnosis of smear-negative PTB was considered correct by study criteria in 203 (78%) patients. In the remainder, 22 (8%) were considered to have extrapulmonary TB and 34 (14%) another diagnosis. CONCLUSION: Hospital practices in the diagnosis of smear-negative PTB are reasonable, although there is room for improvement with in-service training and regular audits of practice.
.
Drug
Resistance
In a retrospective study published in the
International Journal of Tuberculosis and Lung
diseases(2001;5(1):40-45 the Tuberculosis Research centre has found that
standardised short-course treatment carries only a minimal risk of
emergence of rifampicin resistance.This study relates to the data from
randomised clinical trials using the following regimens: 2HRZE7/6HE7,
2HRZE2/4HRE2, 2HRZE3/4HR2 and 3HRZE3/3HR2. Emergence of resistance was
analysed in patients with unfavourable response/relapse based on culture
and susceptibility reports.It is reported that the overall emergence of
resistance to rifampicin occurred in only 2% of patients, despite the high
level (18%) of initial resistance to isoniazid. Thus, standardised
short-course treatment carries only a minimal risk of emergence of
rifampicin resistance
Tuberculosis diabetes and MDR TB
Chest. 2001;120:1514-1519;Tuberculosis and diabetes: Patients on the Bellevue Chest Service, 1987 to
1997; Mona Bashar, MD; Phil Alcabes, PhD; William N. Rom, MD, MPH, FCCP and
Rany, Condos, MD.
These investigators at Bellevue Hospital carried out a case-control study
and retrospectively reviewed records of patients from 1987 to 1997 with a
discharge diagnosis of tuberculosis and diabetes mellitus. They found that
53 identified patients had verified tuberculosis infection and diabetes; of
these, 50 charts were available for review. They selected 105 control cases
from nondiabetic patients with a discharge diagnosis of tuberculosis during
the same time period. They report that 36% (18 cases) of the patients with
diabetes and tuberculosis had multidrug-resistant tuberculosis (MDR-TB)
compared to only 10% (10 cases) in the control group (p < 0.01). When the
controlled for homelessness, HIV status, and directly observed therapy, the
relative risk of MDR-TB was calculated to be 8.6 (confidence interval, 3.1
to 23.6) in the diabetic group compared to the control group. They sum up
noting that there was a significant association between diabetes and MDR-TB
and they point out diabetes continues to be a risk factor for tuberculosis;
it was associated with MDR-TB in their patients.
Info source: CDC HIV/STD/TB
Prevention News Update
.
Why
blame private medical practitoners?
In a letter to the editor
published in Chest. (2001;119:1288-1289; 2001; American College of Chest
Physicians) Ashish Bhalla refers to to the tendency among academicians to
blame private practitioners for everything that has gone wrong in the
treatment of tuberculosis citing studies implicating private practitioners
for wrong prescriptions that are blamed for emergence of
multidrug-resistant tuberculosis.Dr.Bhalla raises the question,who are
these private practitioners, and whom do they look to for correcting their
deficiencies? His answer is: their colleagues in the faculty positions at
medical institutes. He cites a study of knowledge, attitude, and practice
in 40 residents and faculty members from various departments prescribing
ATT in one medical institute in India, and says less than 50% knew what
directly observed short-course treatment was, less than 50% knew that the
World Health Organization (WHO) has classified tuberculosis patients into
broad categories; only 57% could answer that sputum-positive patients
belong to category I; 47.5% could correctly categorize tuberculosis
lymphadenitis to category III; less than 25% could correctly write the
exact drug schedule for category II patients; and only 50% could give the
correct dosage of antituberculosis drugs. Dr. Bhalla says the observation
that the knowledge regarding the treatment guidelines among the residents
and consultants is low points to the fact that reeducation of faculty
members regarding recent trends or guidelines is essential if we want this
knowledge to percolate to the periphery. The writer self-evaluation should
be encouraged so that one is aware of one's deficiencies and corrective
measures could be planned. Dr. Bhalla calls upon the WHO to also take up
the task of going to the basic level for imparting knowledge regarding
recent guidelines and suggests local initiative by faculty members in
educating their colleagues will go a long way in preventing such problems.
To help general practitioners to arrive at a decision on category
for their case we have an online module.You will be asked to fill up some
forms(site of lesion,sputum result etc)Then the treatment category and
treatment will be shown.
Click here for
running module
This module is being tested.If you encounter any
error
please send us details
Directly observed treatment for multidrug-resistant tuberculosis: an economic evaluation in the United States of America and South Africa
Int J Tuberc Lung Dis 2001 Dec;5(12):1137-42
Wilton P, Smith RD, Coast J, Millar M, Karcher A
Health Economics Group, School of Health Policy and Practice, University of East Anglia, Norwich, United Kingdom.
OBJECTIVE: To estimate the cost-effectiveness of directly observed treatment compared to conventional therapy in reducing the spread of multidrug-resistant tuberculosis, for an industrialised country (represented by the United States of America) and a developing country (South Africa). METHODS: Monte Carlo analysis using published data on probability, cost and health impact. RESULTS: In both countries, directly observed treatment is the dominant strategy, yielding cost savings and improved health outcomes. Cost savings for directly observed treatment relative to conventional therapy become more significant as more expensive second-line drugs are used in treatments. CONCLUSIONS: The cost-effectiveness of directly observed treatment relative to conventional therapy is demonstrated for both the USA and South Africa. Cost savings are more pronounced (especially for South Africa) as the likelihood of multidrug-resistant tuberculosis increases and more expensive second-line therapies are used. Given that health care resources are more severely constrained in developing countries, the data contained in this study are useful in guiding the design of policies for the effective management of multidrug-resistant tuberculosis in settings with limited resources.
New drugs for MDR-TB
Dr.Naismith of St Andrews University,Scotland are using microrganisms and structural biology to develop antibiotics to combat drug resistant bacteria such as Methicillin Resistant staphylococcus aureus (MRSA)They are studying the synthesis of carbohydrates as a way to create drugs to fight new,virulent forms of bacteria.They say that bacteria make carbohydrates molecules that are not found in humans,and that they have worked out how bacteria make two sugars particularly L-rhamnose and D-galactofuranose.The experimental research involves determines the full 3D structure of enzymes.In essence the enzyme protein is magnified one hundred million times.This allowed Dr.Naismith and his colleagues to see exactly how the protein works and,more importantly how the structure can be altered to stop it operating.While they are looking for drugs that could combat MRSA ,they are also focussing on MDR-TB
Info source: THE HINDU dated 21-dec-01
Design of regimens for treating tuberculosis in patients with HIV infection, with particular reference to sub-Saharan Africa.
Harries AD, Hargreaves NJ, Salaniponi FM
National Tuberculosis Control Programme, Ministry of Health, Lilongwe, Malawi. adharries@malawi.net
The highest burden of human immunodeficiency virus (HIV) related tuberculosis (TB) is in sub-Saharan Africa. HIV complicates several areas of TB control, one of which involves treatment and treatment outcome. Large patient numbers cause congestion on TB wards, there is increased morbidity, an increased risk of adverse drug reactions, an increased case fatality, and an increased recurrence of TB after treatment completion. TB Control Programmes have responded to these problems by taking actions such as abolishing thioacetazone and decentralising the initial phase of treatment to peripheral health centres and the community. Despite this response, there are three major on-going concerns which need to be addressed by research studies. There is a need to reduce case fatality rates focusing on 1) stronger treatment regimens, 2) adequacy of rifampicin levels when intermittent treatment regimens are used, and 3) adjunctive treatments. There is a need to reduce recurrent rates of TB by 1) determining the relative role of re-infection and reactivation as a cause of recurrence, 2) assessing the importance of duration and type of anti-TB treatment for the first episode of TB, and 3) determining the role of secondary isoniazid preventive therapy. There is a need to evaluate how best to decentralise treatment from the perspective of the health service and the patient. Research studies should be relevant to the needs and resources of TB control programmes, and should include pharmacokinetic studies, controlled clinical trials and operational research, including economic analysis and social science evaluation.
Int J Tuberc Lung Dis 2001 Dec;5(12):1143-7
To read the basics on TB and HIV click HIV in topmenu bar
Home
