Greenaway Christina, Menzies Dick, Fanning Anne, Grewal Raj, Yuan Lilian, FitzGerald J Mark
McGill University, Montreal, Quebec, Canada.
Am J Respir Crit Care Med. 2002 Apr 1;165(7):927-33. doi: 10.1164/ajrccm.165.7.2107040.
Delayed diagnosis of active pulmonary tuberculosis (TB) among hospitalized patients is common and believed to contribute significantly to nosocomial transmission. This study was conducted to define the occurrence, associated patient risk factors, and outcomes among patients and exposed workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17 acute-care hospitals in four Canadian cities, initiation of appropriate treatment was delayed 1 week or more in 127 (30%). This was associated with atypical clinical and demographic patient characteristics, and after adjustment for these characteristics, with admission to hospitals with low TB admission rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR: 2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In hospitals with low TB admission rates, initially missed diagnosis, smear-positive patients undergoing bronchoscopy, late intensive care unit admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more common than in hospitals with high TB admissions (> 10/ 10,000); a similar trend was seen in hospitals with intermediate TB admissions. Even after adjustment for workers' characteristics and ventilation in patients' rooms tuberculin conversions were disproportionately high in hospitals with low and intermediate TB admission rates and significantly higher in hospitals with overall TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied, as the rate of TB admissions decreased, the likelihood of poor outcomes and risk of transmission of TB infection per hospitalized patient with TB increased. Institutional risk of TB transmission was poorly correlated with number of patients with TB and better correlated with indicators of patient care such as delayed diagnosis and treatment and overall TB-related patient mortality.
住院患者中活动性肺结核（TB）的延迟诊断很常见，且被认为是医院内传播的重要原因。本研究旨在确定活动性肺结核延迟诊断在患者及接触者中的发生率、相关患者风险因素及后果。在加拿大四个城市的17家急症医院中，于1992年6月至1995年6月期间新诊断出患有活动性肺结核的429例患者中，127例（30%）开始适当治疗的时间延迟了1周或更长时间。这与患者非典型的临床和人口统计学特征相关，在对这些特征进行调整后，还与入住结核病入院率低（每10000例入院中有0.2 - 3.3例）或中等（3.4 - 9.9/10000）的医院有关，以及与潜在可预防的（晚期）重症监护病房入院（比值比[OR]：16.8；95%置信区间[CI]：2.0,144）和死亡（OR：3.3；CI：1.7,6.5）有关。在结核病入院率低的医院中，最初漏诊、接受支气管镜检查的涂片阳性患者、晚期重症监护病房入院（OR：2.3；CI：0.1,56）和死亡（OR：3.8；CI：1.2,12.1）比结核病入院率高（>10/10000）的医院更常见；在结核病入院率中等的医院中也观察到类似趋势。即使在对工作人员特征和患者病房通风情况进行调整后，结核病入院率低和中等的医院中结核菌素转化率仍然过高，而在总体结核病死亡率高于10%的医院中显著更高（OR：2.5；CI：1.6,3.7）。在所研究的医院中，随着结核病入院率的降低，每例住院结核病患者出现不良后果的可能性和结核感染传播风险增加。结核病传播的机构风险与结核病患者数量相关性较差，而与患者护理指标（如诊断和治疗延迟以及总体结核病相关患者死亡率）相关性更好。
