Update to Pulmonary Tuberculosis Screening Recommendations

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Screening asymptomatic patients is only cost-effective in very high TB prevalence populations.
Screening asymptomatic patients is only cost-effective in very high TB prevalence populations.

In an update to the 2006 American College of Chest Physicians recommendations for cough from tuberculosis and other infections recently published in CHEST, a consensus panel recommended that individuals with cough who are at high risk for tuberculosis should be screened for pulmonary tuberculosis, regardless of cough duration.

To determine the optimal time to test patients with cough for pulmonary tuberculosis and other recommendations for infectious causes of cough, a systematic literature review was conducted by an international panel of experts using established Chest organization methods. Through the literature review, the panel attempted to address predefined key clinical questions related to cough, tuberculosis, and other infectious diseases. The quality of evidence was ranked using GRADE Evidence Profiles, and recommendations were voted on by the entire Cough Expert Panel.

Overall, the panel recommended that individuals in areas with high tuberculosis prevalence should be screened for pulmonary tuberculosis regardless of cough duration. This recommendation was made even though the authors acknowledged that most people with cough do not have pulmonary tuberculosis.

For people living with HIV, the presence of other diagnostic symptoms (ie, fever, night sweats, hemoptysis, and/or weight loss) increases the likelihood that the individual has pulmonary tuberculosis based on grade 2C evidence.

In ungraded consensus-based statements, the committee recommended both active case finding and passive case finding for patients with cough in high tuberculosis prevalence populations, as it may improve outcomes for patients with pulmonary tuberculosis and reduce transmission.

The investigators noted that other causes of cough, such as Mycobacterium avium complex lung disease, other nontuberculous mycobacteria, fungal diseases, and paragonimiasis, could not be distinguished from pulmonary tuberculosis or other lung diseases based on cough features. The studies on other infectious causes of cough were of poor quality and were not included in the systematic review.

The researchers concluded that, “screening of patients with cough for <2 weeks will increase the number of pulmonary tuberculosis cases identified earlier but will also increase the cost of investigations.”

Reference

Field SK, Escalante P, Fisher DA, Ireland B, Irwin RS; CHEST Expert Cough Panel. Cough due to tuberculosis and other chronic infections: CHEST guideline and expert panel report [published online November 28, 2017]. Chest. doi: 10.1016/j.chest.2017.11.018

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