title: Latent tuberculosis infection detection and active tuberculosis prevention in patients receiving anti-TNF therapy: an Italian nationwide survey.
abstract: OBJECTIVE
  Primary: to investigate Italian rheumatology practice regarding latent tubercular infection (LTBI) detection and tuberculosis (TB) prevention in patients requiring anti-tumor necrosis factor (anti-TNF) therapy. Secondary: to assess the overall number of TB cases over 10 years and their distribution by drug.
  
  
  METHODS
  An anonymous, 24 multiple-response questionnaire was completed by 393/449 (87.5%) rheumatologists prescribing anti-TNF therapy. Six questions provided setting information, and 18 the compliance with recommendations and the recorded TB cases.
  
  
  RESULTS
  The Italian recommendations were used by 323 (82%) and other sets by 60 (15%). TB specialists were always consulted by 81 (21%) and occasionally by 73 (19%). LTBI screening was made using chest radiograph (CR) by 5%, tuburculin skin test (TST) by 5.3%, CR + TST by 35.6%, interferon-gamma release assay (IGRA) by 7.4%, CR + IGRAs by 26% and CR + TST + IGRA by 20.6%. Isoniazid was initiated in the presence of positivity of TST by 97 (24.7%), TST + IGRA by 101 (25.7%) and IGRA by 195 (49.6%). Anti-TNF starting delay was 1 month in 63.1% of the cases, 3 months in 27.7%, concomitantly in 5.6%. Overall, 317 TB reactivation cases occurred in 39 353 patients, with an incidence rate of 80.5 cases/100 000/year (10 times higher than in the Italian general population). TB occurred during TB prophylaxis in 192 (60.6%). TB cases incidence rate divided by drug was: etanercept (ETN) 51 (16%), 28/100 000/year, adalimumab (ADA) 98 (31%), 89/100 000/year, infliximab (IFX) 137 (43.2%), 211/100 000/year, with a significantly lower frequency in the ETN group compared to ADA and IFX groups (χ(2)  = P < 0.001).
  
  
  CONCLUSIONS
  Italian rheumatologists are highly aware of anti-TNF-related TB risk with variable LTBI screening and TB prevention strategies. TB outcome was significantly lower in the ETN group.
authors.affiliation: Division of Rheumatology, Misericordia e Dolce Hospital, Prato, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Cantini
authors.affiliation: Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy.
authors.forename: Ennio
authors.initials: E
authors.lastname: Lubrano
authors.affiliation: Division of Rheumatology, Day Hospital Unit, Istituto Ortopedico G. Pini, Milano, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Marchesoni
authors.affiliation: 2nd Chair of Rheumatology, Department of Medical Sciences, University of Cagliari, Cagliari, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Mathieu
authors.affiliation: Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy.
authors.forename: Ignazio
authors.initials: I
authors.lastname: Olivieri
authors.affiliation: Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Salvarani
authors.affiliation: Rheumatology Research Unit, Department of Clinical and Experimental Medicine, University Federico II, Naples, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Scarpa
authors.affiliation: Department of Internal Medicine and Medical Specialties, Rheumatology Division - "La Sapienza", University of Rome, Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Spadaro
mesh_terms: D000068879:Adalimumab / Q000009:adverse effects; D018501:Antirheumatic Agents / Q000009:adverse effects*; D000995:Antitubercular Agents / Q000627:therapeutic use; D001688:Biological Products / Q000009:adverse effects*; D016009:Chi-Square Distribution; D000068800:Etanercept / Q000009:adverse effects; D019983:Guideline Adherence; D019538:Health Care Surveys; D006801:Humans; D016867:Immunocompromised Host; D015994:Incidence; D000069285:Infliximab / Q000009:adverse effects; D007558:Italy / Q000453:epidemiology; D055985:Latent Tuberculosis / Q000175:diagnosis / Q000453:epidemiology / Q000276:immunology*; D009894:Opportunistic Infections / Q000175:diagnosis / Q000453:epidemiology / Q000276:immunology* / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D011379:Prognosis; D012216:Rheumatic Diseases / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology; D000072140:Rheumatologists; D012307:Risk Factors; D013997:Time Factors; D014376:Tuberculosis / Q000175:diagnosis / Q000453:epidemiology / Q000276:immunology* / Q000517:prevention & control; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors* / Q000276:immunology
chemical_list: D018501:Antirheumatic Agents; D000995:Antitubercular Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept
keywords: anti-TNF; interferon-gamma release assays; latent tuberculosis infection; tuberculin skin test; tuberculosis