These guidelines are not intended to impose a standard of care. They provide the basis for rational decisions in the diagnosis of tuberculosis in the context of the existing evidence. No guidelines can take into account all of the often compelling unique individual clinical circumstances.

Background Individuals infected with Mycobacterium tuberculosis (Mtb) may develop symptoms and signs of disease (tuberculosis disease) or may have no clinical evidence of disease (latent tuberculosis infection [LTBI]). Tuberculosis disease is a leading cause of infectious disease morbidity and mortality worldwide, yet many questions related to its diagnosis remain. Methods A task force supported by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America searched, selected, and synthesized relevant evidence. The evidence was then used as the basis for recommendations about the diagnosis of tuberculosis disease and LTBI in adults and children. The recommendations were formulated, written, and graded using the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results Twenty-three evidence-based recommendations about diagnostic testing for latent tuberculosis infection, pulmonary tuberculosis, and extrapulmonary tuberculosis are provided. Six of the recommendations are strong, whereas the remaining 17 are conditional. Conclusions These guidelines are not intended to impose a standard of care. They provide the basis for rational decisions in the diagnosis of tuberculosis in the context of the existing evidence. No guidelines can take into account all of the often compelling unique individual clinical circumstances.

The culture of M tuberculosis from gastric aspirates of children in the outpatient setting has a yield comparable to aspirates collected from hospitalized children. Collection of gastric aspirates in the outpatient setting will reduce both the cost and the inconvenience of the procedure. Although the yield from gastric aspirates is relatively low, important information including drug susceptibility patterns may be obtained. tuberculosis, gastric aspirate, children.

Implementation of a simple stewardship initiative with limited resources at a community nonfreestanding children's hospital effectively reduced antibiotic use without an overt negative impact on overall clinical outcomes. The results of this study suggest that nonfreestanding children's hospitals can achieve substantial reductions in antibiotic use despite limited resources.

Central nervous system tuberculosis (TB) was identifi ed in 20 cases of unexplained encephalitis referred to the California Encephalitis Project. Atypical features (encephalitic symptoms, rapid onset, age) and diagnostic challenges (insensitive cerebrospinal fl uid [CSF] TB PCR result, elevated CSF glucose levels in patients with diabetes, negative result for tuberculin skin test) complicated diagnosis.T uberculosis (TB) of the central nervous system (CNS) is classically described as meningitis. However, altered mental status, including encephalitis, is within the spectrum of clinical manifestations. Because early treatment can dramatically improve outcomes, consideration of TB as a potential pathogen in CNS infections, including encephalitis, is vital. The California Encephalitis Project (CEP), initiated in 1998 to study the causative agents, epidemiology, and clinical features of encephalitis, has identifi ed 20 cases of culture-confi rmed tuberculous encephalitis. In most instances, TB was not initially considered to be a likely cause. The StudyReferrals are received by the CEP statewide from clinicians seeking diagnostic testing for immunocompetent patients, including TB PCR testing when appropriate, who meet the CEP case defi nition of encephalitis (1). Mycobacterial testing was often also conducted by the referring hospital. Inclusion criteria for this report were a positive cerebrospinal fl uid (CSF) culture for Mycobacterium tuberculosis complex or a positive CSF TB PCR result. Clinical data were compiled from case history forms and other medical records when available. To evaluate differences among causes of encephalitis, TB patients were compared with CEP patients with cases of enterovirus and herpes simplex virus 1 (HSV-1) encephalitis. Demographic, clinical, and laboratory data were compared by using the Fisher exact test, χ 2 test, or Kruskal-Wallis test as appropriate (statistical signifi cance was set at α = 0.05).From June 1998 through October 2005, a total of 1,587 patients were enrolled in the CEP; 20 patients fulfi lled criteria as TB cases. Demographic and clinical information for the study population are detailed in the online Appendix Table (available from www.cdc.gov/EID/content/14/9/ 1473-appT.htm). Median age was 41 years (range 8 months to 77 years). The median time from symptom onset to fi rst lumbar puncture was 5 days (range 0-62 days). Seventeen patients (85%) had a second lumber puncture.In general, CSF values became more abnormal over time, with increasing leukocyte counts and protein levels and decreasing glucose levels (Appendix Table). Most patients had a CSF mononuclear cell predominance, although 4 patients (21%) had a neutrophil predominance. All patients had cranial neuroimaging, magnetic resonance imaging (18 of 20), and computed tomography (20 of 20) (Appendix Table; Table). Results of computed tomography scans were often normal (50%).Of patients in whom the results of a recent tuberculin skin test (TST) were known, 59% (10 of 17) had a negative result (Appendix Table). M...