Tattevin P, Egmann G, Casalino E, Fleury L, Ruel M, Bouvet E
Clinique de réanimation des maladies infectieuses, hôpital Bichat-Claude-Bernard, Paris, France.
Rev Med Interne. 2000 Jun;21(6):533-41. doi: 10.1016/s0248-8663(00)89229-2.
As numerous nosocomial outbreaks of pulmonary tuberculosis have been reported during the last two decades, prompt identification and effective isolation of contagious patients should be made a priority in tuberculosis control policies. There is a need to develop a predictive model which would allow prompt recognition and isolation of smear-positive patients.
Various authors have attempted to improve the respiratory isolation policies for patients suspected of having pulmonary tuberculosis. A French multicenter prospective study of 211 patients suspected of having pulmonary tuberculosis established that: 1) the current respiratory isolation policy of suspected pulmonary tuberculosis needs improvement (sensitivity = 71.4%; i.e., 28.6% of smear-positive patients are admitted without isolation) and 2) better interpretation of clinical and radiological data available on patient admission could improve the adequacy of respiratory isolation. Univariate analysis showed that predictive factors of pulmonary tuberculosis were chest X-rays (P < 0.00001), symptoms (P = 0.0004), age (mean: 40.8 years for TB vs. 47.5 for non-TB, P = 0.04), HIV infection (10.6% vs. 28.7%, P = 0.01), immigrant (72% vs. 55%, P = 0.03) and BCG status (P = 0.025), while multivariate analysis demonstrated that chest X-ray pattern (P < 0.00001), HIV infection (P = 0.002) and symptoms (P = 0.009) were independent predictive factors.
From these data, a model was proposed and evaluated in the derivation cohort using the receiver operating characteristics (ROC) curve. We retrospectively studied the predictive model in two populations different from the one from which it was derived. The model would have improved sensitivity of the respiratory isolation policy from 71.4% (current respiratory isolation policy) to 82.4% and 91.1%, respectively. Prospective, multicenter studies are requested to establish the value of such a predictive model in improving the respiratory isolation policy for patients suspected of having pulmonary tuberculosis.
在过去二十年中，已有大量关于医院内肺结核暴发的报道，因此在结核病控制政策中，应优先对传染性患者进行及时识别和有效隔离。有必要开发一种预测模型，以便能迅速识别并隔离涂片阳性患者。
许多作者试图改进对疑似肺结核患者的呼吸道隔离政策。一项针对211例疑似肺结核患者的法国多中心前瞻性研究表明：1）当前对疑似肺结核的呼吸道隔离政策需要改进（敏感性 = 71.4%；即28.6%的涂片阳性患者在未隔离的情况下被收治）；2）更好地解读患者入院时的临床和放射学数据可提高呼吸道隔离的充分性。单因素分析显示，肺结核的预测因素包括胸部X光检查（P < 0.00001）、症状（P = 0.0004）、年龄（肺结核患者平均年龄40.8岁，非肺结核患者平均年龄47.5岁，P = 0.04）、HIV感染（10.6%对28.7%，P = 0.01）、移民身份（72%对55%，P = 0.03）和卡介苗接种状态（P = 0.025），而多因素分析表明，胸部X光影像（P < 0.00001）、HIV感染（P = 0.002）和症状（P = 0.009）是独立的预测因素。
基于这些数据，提出了一个模型，并在推导队列中使用受试者操作特征（ROC）曲线进行评估。我们对不同于模型推导人群的另外两个人群进行了回顾性研究。该模型可将呼吸道隔离政策的敏感性分别从71.4%（当前呼吸道隔离政策）提高到82.4%和91.1%。需要开展前瞻性多中心研究，以确定这种预测模型在改进疑似肺结核患者呼吸道隔离政策方面的价值。
