title: Preventing nosocomial transmission of pulmonary tuberculosis: when may isolation be discontinued for patients with suspected tuberculosis?
abstract: OBJECTIVE
  The Centers for Disease Control and Prevention and the American Thoracic Society recommend obtaining cultures of at least three sputum specimens for acid-fast bacilli (AFB) from patients in whom tuberculosis (TB) is suspected. On the basis of this, most hospitals isolate patients with suspected TB for 3 days or more until three smear (not culture) results are negative. Our objective was to evaluate the predictive value and sensitivity of these smears.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  Four urban medical centers.
  
  
  METHODS
  The posttest probability of TB given sequential negative AFB smears from 274 patients isolated for suspected TB and the sensitivity of sequential AFB smears from 209 patients with positive results on culture for pulmonary TB were measured.
  
  
  RESULTS
  The posttest probabilities of having TB given one, two, and three negative AFB smears were low: 1.1% (3 of 265; 95% confidence interval [CI95], 0.23% to 3.27%), 0.4% (1 of 262; CI95 0% to 2.1%), and 0% (0 of 260; CI95, 0% to 1.4%), respectively. Among the 209 patients with positive results on culture for pulmonary TB, 169 (81%) had an expectorated sputum specimen sent, of which 91 (54%) were positive for AFB. Forty (24%) of the 169 patients had a second expectorated sputum specimen sent after the results of the first specimen were negative; only 6 (15%) of these had positive AFB smears. None of the 10 patients in whom the first two expectorated sputum samples yielded an AFB smear without an organism had a third AFB smear that was positive.
  
  
  CONCLUSIONS
  Unless there is high clinical suspicion of pulmonary TB in a specific patient, the use of three AFB smears on expectorated sputa is a rational approach to discontinuing isolation for patients with suspected TB.
authors.affiliation: University of Maryland School of Medicine and the VA Maryland Health Care System, Baltimore, 21201, USA.
authors.forename: Anwer H
authors.initials: AH
authors.lastname: Siddiqui
authors.forename: Trish M
authors.initials: TM
authors.lastname: Perl
authors.forename: Martha
authors.initials: M
authors.lastname: Conlon
authors.forename: Nancy
authors.initials: N
authors.lastname: Donegan
authors.forename: Mary-Claire
authors.initials: MC
authors.lastname: Roghmann
mesh_terms: D015142:Baltimore / Q000453:epidemiology; D002487:Centers for Disease Control and Prevention, U.S.; D003428:Cross Infection / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D003470:Culture Media; D004219:District of Columbia / Q000453:epidemiology; D006786:Hospitals, Urban / Q000592:standards; D006801:Humans; D017053:Infection Control / Q000592:standards*; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D010351:Patient Discharge; D010356:Patient Isolation / Q000592:standards*; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D014481:United States
chemical_list: D003470:Culture Media