Regional survey of tuberculosis risk assessment in rheumatology outpatients commencing anti-TNF-α treatment in relation to British Thoracic Society guidelines

Abstract

-The aim of this study was to analyse tuberculosis (TB) risk assessment for rheumatology patients commencing anti-tumour necrosis factor-␣ ␣ (anti-TNF-␣ ␣) therapy using the British Thoracic Society (BTS) guidelines. Data were obtained retrospectively on 856 outpatients regionally receiving anti-TNF-␣ ␣. Prior to commencing treatment, patients had the following assessments documented: respiratory examination, 47.4%; chest X-ray, 84.5%; TB history, 92.9%; and advice about TB risk, 45.8%. Of the 856 patients, 94.3% were on immunosuppressives but 27% had a tuberculin test; 12.6% had у у1 high-risk factors for TB. In total, 3.4% were referred to a TB specialist and of these, 24.1% had no risk factors for TB. Of patients with у у1 risk factor, 76.9% were not referred. Only 4/28 patients at high risk for TB due to ethnicity or birthplace received chemoprophylaxis. Marked inter-unit variation was demonstrated and it was evident that patients require improved screening for TB. Greater awareness is necessary of patients with risk factors, particularly ethnicity, to facilitate more appropriate targeting of chemoprophylaxis. Multi-centre audit is a valuable clinical governance tool.

Latent tuberculosis infection detection and active tuberculosis prevention in patients receiving anti‐TNF therapy: an Italian nationwide survey

“…LTBI screening was made using chest radiograph (CR) alone by 5%, TST alone by 5.3%, CR + TST by 35.6%, IGRAs alone by 7.4%, CR + IGRAs by 26% and CR + TST + IGRAs by 20.6%. In presence of a clinical history and CR suspicious for previous TB infection, 31.5% of the rheumatologists started TB prophylaxis, and respectively, 31.3% and 7% did not perform any further investigations if IGRAs or TST were negative, and 30% did further examinations to detect active TB foci independently on IGRA results. Isoniazid (INH) 9-month course for TB prevention was employed by 324/393 (82.5%) rheumatologists, INH + rifampin for 4 months by 19/393 (4.8%), rifampin alone by 6/393 (1.5%), and other strategies after consultation with the local infectious disease specialist by 44 (11.2%).…”

“…However, when examining the strategies to detect LTBI, adherence to recommendations was rather variable, with 70/393 (17.8%) rheumatologists adopting only one procedure among CR, TST or IGRAs, and almost 40% (20.6% always and 18.6% sometimes) consulting the local TB experts regardless the risk stratification indicated by the recommendations. Similarly, in a recent survey from the UK, a broad failure to meet the British Society for Rheumatology guidelines for prescribing anti‐TNF and the British Thoracic Society for assessing TB risk and management was observed, including the appropriateness of performing TST and the identification of high‐risk patients with 86/108 (79.6%) with one or more risk factors for TB not referred to a TB specialist. The low compliance with the recommendations for LTBI detection and TB prevention has been also confirmed by data from the Spanish National Registry BIOBADASER, showing that the screening procedures were correctly followed only in 2655 (51%) out of 5198 patients, with a seven times higher risk of developing TB in the group with unattended recommendations.…”

“…Indeed, over the last 5 years tuberculin-purified protein derivative was not regularly dispensed to hospitals and almost 30% of laboratories were unable to perform IGRAs for several reasons, including difficulties to prompt the technique and the adjunctive economic burden despite the demonstration of cost-effectiveness of IGRA use. 32 The low compliance of Italian rheumatologists with all the recommendations for anti-TNF use was also responsible for the scattered behavior in presence of patients with clinical history and chest radiographs suspicious for previous TB infection: 31.5% of clinicians started TB preventive therapy independently on TST and IGRA results, 30% performed further investigations to detect active TB foci whatever the result of IGRA or TST, and respectively 31.3% and 7.1% did not further investigate if IGRA or TST were negative. The same broad range of strategies for starting TB prophylaxis in patients with negative CR was adopted by Italian rheumatologists, while in keeping with the recommendations, most of them (82.5%) employed INH for TB prevention.…”

Latent tuberculosis treatment results in patients that taken Tnf-alpha blockers at Ankara Numune Training and Research Hospital Chest Diseases Clinic for last 8 years (2006-2013)

“…TNF-α aktivitesinin engellenmesi, granülomatöz inflamasyonu baskılar (9). Bu durumda anti-TNF-α ilaçlar bu mekanizmayı bozarak tüberküloz başta olmak üzere, fırsatçı infeksiyonların gelişme riskini artırmaktadırlar (8,10).…”

Eight years’ experience of regional audit: an assessment of its value as a clinical governance tool

“…Each involved approximately 2,000 patients across 10 to 13 units (Table 1). [9][10][11][12][13][14] The authors previously conducted a qualitative study with a small sample of healthcare professionals to evaluate this innovative regional audit programme. Findings from this work suggest that regional audit has specific strengths in the clinical governance armamentarium.…”