The validity of medical history, classic symptoms, and chest radiographs in predicting pulmonary tuberculosis: derivation of a pulmonary tuberculosis prediction model.
OBJECTIVE
To improve the respiratory isolation policy for patients with suspected pulmonary tuberculosis (TB).


METHODS
Prospective, descriptive, French multicenter study.


METHODS
Emergence of nosocomial outbreaks of TB.


METHODS
All consecutive patients admitted with suspicion of pulmonary TB.


RESULTS
Medical history, social factors, symptoms, and chest radiograph (CXR) pattern (symptoms and CXR both scored as typical of pulmonary TB, compatible, negative, or atypical) were obtained on admission. Serial morning sputa were collected. Of the 211 patients, 47 (22.3%) had culture-proven pulmonary TB, including 31 (14.7%) with a positive smear. Mean age was 46.2 years; 52 patients were HIV positive (24.6%). The sensitivity of the respiratory isolation policy was 71.4%, specificity was 51.7%, negative predictive value (NPV) was 88.2%, and positive predictive value (PPV) was 26.3%. On univariate analysis, predictive factors of culture-proven pulmonary TB were CXR (p < 0.00001), symptoms (p = 0.0004), age (mean, 40.8 years for TB patients vs 47.5 years for non-TB patients; p = 0.04), absence of HIV infection (89.4% vs 71.3%; p = 0.01), immigrant status (72% vs 55%; p = 0.03), and bacillus Calmette-Guérin status (p = 0.025). On multivariate analysis, CXR pattern (p < 0.00001), HIV infection (p = 0.002), and symptoms (p = 0.009) remained independently predictive. Based on these data, a model was proposed using a receiver operating characteristics curve. In the derivation cohort, the sensitivity and NPV of the model in detecting smear-positive pulmonary TB would have been 100%. The specificity and PPV would have been 48.4% and 25%, respectively. The model performed less well when evaluated on two retrospective groups, but its sensitivity remained above that of the current respiratory isolation policy (91.1% and 82.4% for the retrospective groups vs 71.1% for the current policy).


CONCLUSIONS
Improved interpretation of clinical and radiologic data available on patient admission could improve adequacy of respiratory isolation. A prediction model is proposed.
Tattevin
P
P
Clinique de Réanimation des Maladies Infectieuses, Hôpital Bichat-Claude Bernard, Paris, France.
Casalino
E
E
Fleury
L
L
Egmann
G
G
Ruel
M
M
Bouvet
E
E
D001500:BCG Vaccine; D003428:Cross Infection / Q000517:prevention & control; D004641:Emigration and Immigration; D005260:Female; D005602:France; D006679:HIV Seropositivity / Q000150:complications; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010356:Patient Isolation; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D013902:Radiography, Thoracic; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000517:prevention & control
D001500:BCG Vaccine