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Tuberculosis in hospitalized patients: clinical characteristics of patients receiving treatment within the first 24 h after admission* * Study carried out under the auspices of the Graduate Program in Pulmonology, Federal University of Rio Grande do Sul School of Medicine, and in the Department of Pulmonology, Porto Alegre Hospital de Clínicas, Porto Alegre, Brazil.

Abstracts

Objective:

To evaluate clinical characteristics and outcomes in patients hospitalized for tuberculosis, comparing those in whom tuberculosis treatment was started within the first 24 h after admission with those who did not.

Methods:

This was a retrospective cohort study involving new tuberculosis cases in patients aged ≥ 18 years who were hospitalized after seeking treatment in the emergency room.

Results:

We included 305 hospitalized patients, of whom 67 (22.0%) received tuberculosis treatment within the first 24 h after admission ( ≤24h group) and 238 (88.0%) did not (>24h group). Initiation of tuberculosis treatment within the first 24 h after admission was associated with being female (OR = 1.99; 95% CI: 1.06-3.74; p = 0.032) and with an AFB-positive spontaneous sputum smear (OR = 4.19; 95% CI: 1.94-9.00; p < 0.001). In the ≤24h and >24h groups, respectively, the ICU admission rate was 22.4% and 15.5% (p = 0.258); mechanical ventilation was used in 22.4% and 13.9% (p = 0.133); in-hospital mortality was 22.4% and 14.7% (p = 0.189); and a cure was achieved in 44.8% and 52.5% (p = 0.326).

Conclusions:

Although tuberculosis treatment was initiated promptly in a considerable proportion of the inpatients evaluated, the rates of in-hospital mortality, ICU admission, and mechanical ventilation use remained high. Strategies for the control of tuberculosis in primary care should consider that patients who seek medical attention at hospitals arrive too late and with advanced disease. It is therefore necessary to implement active surveillance measures in the community for earlier diagnosis and treatment.

Tuberculosis; Hospitalization; Time-to-treatment; Emergency medicine; Delayed diagnosis


Objetivo:

Comparar as características clínicas e os desfechos de pacientes hospitalizados por tuberculose que iniciaram tratamento nas primeiras 24 h de permanência hospitalar com as daqueles que iniciaram tratamento após 24 h.

Métodos:

Estudo de coorte retrospectivo de casos novos de tuberculose com idade ≥ 18 anos que necessitaram internação hospitalar após atendimento no setor de emergência.

Resultados:

Foram incluídos 305 pacientes hospitalizados, dos quais 67 (22,0%) iniciaram o tratamento nas primeiras 24 h (grupo ≤24h), e 238 (88,0%) o iniciaram após (grupo >24h). Ser do sexo feminino (OR = 1,99; IC95%: 1,06-3,74; p = 0,032) e ter pesquisa de BAAR positiva no escarro espontâneo (OR = 4,19; IC95%: 1,94-9,00; p < 0,001) se associaram com o tratamento nas primeiras 24 h. Na comparação dos grupos ≤24h e >24h, a taxa de internação em UTI foi de, respectivamente, 22,4% e 15,5% (p = 0,258), enquanto a ventilação mecânica foi utilizada em 22,4% e 13,9% (p = 0,133), a taxa de óbito hospitalar foi de 22,4% e 14,7% (p = 0,189), e a taxa de cura foi de 44,8% e 52,5% (p = 0,326).

Conclusões:

Embora o tratamento antituberculose tenha sido iniciado rapidamente em uma proporção considerável dos pacientes hospitalizados, as taxas de mortalidade hospitalar, internação em UTI e uso de ventilação mecânica permaneceram elevadas. Estratégias para o controle de tuberculose na atenção primária devem considerar que pacientes atendidos em hospitais chegam muito tardiamente e com doença avançada, sendo necessário implementar medidas de busca ativa na comunidade para o diagnóstico e o tratamento mais precoce.

Tuberculose; Hospitalização; Tempo para o tratamento; Medicina de emergência; Diagnóstico tardio


Introduction

Tuberculosis remains a major public health problem worldwide. It is estimated that one third of the world population is infected with Mycobacterium tuberculosis. In 2011, 9 million new tuberculosis cases were estimated to have occurred worldwide, with 1.4 million deaths. Brazil ranks 22nd among the 22 countries with the highest reported incidence of tuberculosis, with 42 cases/100,000 population in 2011.( 11. World Health Organization. Global Tuberculosis Control 2010. Geneva: World Health Organization; 2012. )

Disease control in the community depends on early diagnosis and treatment. Although tuberculosis control programs recommend that the diagnosis of tuberculosis be made at primary health care clinics, most patients are diagnosed in hospitals.( 22. dos Santos MA, Albuquerque MF, Ximenes RA, Lucena-Silva NL, Braga C, Campelo AR, et al. Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil. BMC Public Health. 2005;5:25. http://dx.doi.org/10.1186/1471-2458-5-25
http://dx.doi.org/10.1186/1471-2458-5-25...
, 33. Sreeramareddy CT, Panduru KV, Menten J, Van den Ende J. Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature. BMC Infect Dis. 2009;9:91. http://dx.doi.org/10.1186/1471-2334-9-91
http://dx.doi.org/10.1186/1471-2334-9-91...
) In Porto Alegre, Brazil, 39% of all tuberculosis patients have been diagnosed in hospitals.( 44. Prefeitura Municipal de Porto Alegre [homepage on the Internet]. Porto Alegre: a Prefeitura [cited 2014 Jan 8]. Boletim epidemiológico no. 45 de maio de 2011. [Adobe Acrobat document, 8p.]. Available from: http://lproweb.procempa.com.br/pmpa/prefpoa/cgvs/usu_doc/10018-boletim_epidemiologico_setembro_2011_45[1].pdf
http://lproweb.procempa.com.br/pmpa/pref...
)

A previous study conducted in a university hospital in Porto Alegre( 55. Rossato Silva D, Müller AM, Dalcin Pde T. Factors associated with delayed diagnosis of tuberculosis in hospitalized patients in a high TB and HIV burden setting: a cross-sectional study. BMC Infect Dis. 2012;12:57. http://dx.doi.org/10.1186/1471-2334-12-57
http://dx.doi.org/10.1186/1471-2334-12-5...
) showed that the median time elapsed between hospital admission and diagnosis of tuberculosis was 6 days, the major factors associated with delayed diagnosis being extrapulmonary disease and negative sputum smears. The emergency room has always been the gateway for such patients.

In this context, it is important to analyze the characteristics of patients diagnosed with tuberculosis and receiving tuberculosis treatment within the first 24 h after hospital admission. We hypothesize that such patients do not need hospitalization, and that strategies for the screening and management of tuberculosis in the primary care setting can be developed on the basis of the present study, contributing to reducing the rates of emergency room treatment and the burden of hospitalization for tuberculosis.

The objective of the present study was to analyze clinical characteristics and major outcomes in patients who were hospitalized for tuberculosis and who started tuberculosis treatment within the first 24 h after admission.

Methods

This was a retrospective cohort study of patients who were diagnosed with and hospitalized for tuberculosis after seeking treatment in the emergency room of the Hospital de Clínicas de Porto Alegre (HCPA, Porto Alegre Hospital de Clínicas), located in the city of Porto Alegre, Brazil.

The study was approved by the local research ethics committee. The authors signed a data use agreement, protecting the confidentiality of patient information.

The study population consisted of new tuberculosis patients who were diagnosed after seeking treatment in the HCPA emergency room. We included patients who were 18 years of age or older and who were identified as new cases of tuberculosis on the basis of consensus criteria.( 66. Conde MB, Melo FA, Marques AM, Cardoso NC, Pinheiro VG, Dalcin Pde T, et al. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol. 2009;35(10):1018-48. ) The diagnosis of pulmonary tuberculosis was based on the criteria established by the Third Brazilian Thoracic Association Guidelines on Tuberculosis( 66. Conde MB, Melo FA, Marques AM, Cardoso NC, Pinheiro VG, Dalcin Pde T, et al. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol. 2009;35(10):1018-48. ): a) positive Ziehl-Neelsen staining for AFB (two positive sputum smears); b) positive Ziehl-Neelsen staining for AFB (one positive sputum smear and one positive sputum culture for M. tuberculosis); c) positive Ziehl-Neelsen staining for AFB and radiological findings consistent with pulmonary tuberculosis; d) a single positive sputum culture for M. tuberculosis; or e) epidemiological, clinical, and radiological findings consistent with pulmonary tuberculosis, together with a favorable response to treatment with antituberculosis drugs. The diagnosis of extrapulmonary tuberculosis was based on clinical examination findings and ancillary test results (depending on the site of disease). The exclusion criteria were as follows: reported tuberculosis cases in which the diagnosis was subsequently changed; and cases of patients who had started treatment before hospitalization.

The patients were retrospectively identified on the basis of data obtained from individual tuberculosis report forms in the Sistema de Informação de Agravos de Notificação (SINAN, Brazilian Case Registry Database), and patient charts were reviewed. At our hospital, computerized physician order entry of antituberculosis drugs automatically generates the SINAN report form; therefore, we were able to identify all of the patients who started treatment.

Patient charts were reviewed by the investigators, who completed a standardized questionnaire including the following items: demographic data (age, gender, race, and level of education); comorbidities; smoking status; alcohol use; injection drug use; use of immunosuppressive drugs; history of tuberculosis; clinical form of tuberculosis; symptoms at admission; diagnostic methods; treatment regimen used; HIV infection; time from admission to initiation of treatment; length of hospital stay; ICU admission; need for and duration of mechanical ventilation; outcome of hospitalization (discharge or death); and outcome after discharge (cure, treatment nonadherence, or death). Post-discharge data were obtained by reviewing patient charts, by searching the SINAN database, or by telephoning the outpatient clinics where patients were being followed.

Data were entered into a Microsoft Excel(r) 2010 spreadsheet, after which they were processed and analyzed with the Statistical Package for the Social Sciences, version 18.0 (SPSS Inc., Chicago, IL, USA).

The study variables were analyzed descriptively. Quantitative data were presented as mean ± SD or as median (interquartile range). Qualitative data were expressed as number of cases and proportion.

For statistical analysis, patients were divided into two groups: the ≤24h group, comprising those who received tuberculosis treatment within the first 24 h after hospital admission and the >24h group, comprising those who did not.

For continuous variables, we used the independent sample t-test or the Mann-Whitney U test. For qualitative variables, we used the chi-square test (Yates' correction or Fisher's exact test being used when necessary).

The non-collinear variables that reached significance (p < 0.01) in the univariate analysis were included in a stepwise forward conditional binary logistic regression model (adjusted for gender and age) for each outcome.

All statistical tests were two-tailed, and the level of significance was set at 5%.

Results

Between January of 2008 and January of 2011, 305 patients diagnosed with tuberculosis were included in the study.

Table 1 shows the characteristics of the patients studied and a comparison between the ≤24h and >24h groups. The mean age was 42.0 ± 17.2 years, and most (64.6%) of the patients were male and White (75.4%). Of the 305 tuberculosis patients, 110 (36.1%) had pulmonary tuberculosis, 143 (46.9%) had extrapulmonary tuberculosis, and 52 (17.0%) had concomitant pulmonary and extrapulmonary disease. A total of 191 patients (62.6%) were HIV-positive. The mean length of hospital stay was 27.7 ± 21.8 days. None of the patients were discharged within the first 24 h after hospital admission, 6 (2%) were discharged 24-48 h after admission, and 9 (3%) were discharged 24-72 h after admission. The mean time elapsed between admission and initiation of treatment was 8.8 ± 10.8 days. Tuberculosis treatment was initiated on the same day as diagnosis. Therefore, the mean length of hospital stay after diagnosis and initiation of treatment was 18.9 ± 19.1 days. Although there was no difference between HIV-positive and HIV-negative patients regarding the length of hospital stay (p = 0.921), the hospital stay was longer in patients with one or more comorbidities than in those without comorbidities (29.3 ± 23.1 days vs. 23.2 ± 16.9 days; p = 0.030).

Table 1
- Patient characteristics and comparison between the group of patients who received tuberculosis treatment within the first 24 h after hospital admission and that of those who did not.a

A total of 67 patients (22.0%) received tuberculosis treatment within the first 24 h after hospital admission. The proportion of males was higher in the >24h group than in the ≤24h group (68.5% vs. 50.7%; p = 0.011). The proportion of patients with pulmonary tuberculosis alone was higher in the ≤24h group than in the >24h group (61.2% vs. 29.0%; p < 0.001), whereas the proportion of patients with extrapulmonary tuberculosis alone was higher in the >24h group than in the ≤24h group (54.2% vs. 20.9%; p < 0.001). Cough was more common in the ≤24h group than in the >24h group (64.2% vs. 37.4%; p < 0.001), as were night sweats (35.8% vs. 21.0%; p = 0.019). The proportion of patients with AFB-positive spontaneous sputum smears was significantly higher in the ≤24h group than in the >24h group (53.7% vs. 14.7%; p < 0.001). The proportion of patients with routine chest X-rays showing cavitary disease was significantly higher in the ≤24h group than in the >24h group (22.4% vs. 7.6%; p = 0.001), whereas the proportion of patients with normal chest X-rays was significantly higher in the >24h group than in the ≤24h group (16.4% vs. 4.5%; p = 0.015). The total length of hospital stay was shorter in the ≤24h group than in the >24h group (19.6 ± 22.6 days vs. 29.9 ± 21.1; p = 0.001). There were no differences between the two groups of patients regarding the following outcomes: ICU admission; mechanical ventilation use; in-hospital mortality; one-year mortality; and cure rate (p > 0.05 for all).

Table 2 shows the binary logistic regression analysis of the characteristics associated with initiation of tuberculosis treatment within the first 24 h after hospital admission. Initiation of tuberculosis treatment within the first 24 h after admission was independently associated with being female (OR = 1.99; 95% CI: 1.06-3.74; p = 0.032) and with an AFB-positive spontaneous sputum smear (OR = 4.19; 95% CI: 1.94-9.00; p < 0.001).

Table 2
- Binary logistic regression for characteristics associated with tuberculosis treatment initiation within the first 24 h after hospital admission.

Discussion

This retrospective cohort study evaluated new cases of tuberculosis treated in the emergency room of a university hospital and requiring hospitalization. Of the sample as a whole, 22.0% were diagnosed with tuberculosis and started treatment within the first 24 h after hospital admission. Diagnosis of tuberculosis and initiation of tuberculosis treatment within the first 24 h after admission were associated with being female and with an AFB-positive spontaneous sputum smear. However, there were no differences between the ≤24h group and the >24h group regarding the following outcomes: ICU admission; mechanical ventilation use; in-hospital mortality; one-year mortality; and cure rate. In addition, for the sample as a whole, the mean hospital stay was long (27.7 days), and 97% of the patients required hospitalization for more than 3 days. The fact that the mean length of hospital stay after diagnosis and initiation of treatment was 18.9 days underscores the severity of the clinical situation resulting from tuberculosis or comorbidities.

In the present study, an AFB-positive sputum smear was significantly associated with diagnosis within the first 24 h after hospital admission. Various studies have shown that a negative sputum smear is associated with delayed diagnosis.( 77. Farah MG, Rygh JH, Steen TW, Selmer R, Heldal E, Bjune G. Patient and health care system delays in the start of tuberculosis treatment in Norway. BMC Infect Dis. 2006;6:33. http://dx.doi.org/10.1186/1471-2334-6-33
http://dx.doi.org/10.1186/1471-2334-6-33...

8. Lin CY, Lin WR, Chen TC, Lu PL, Huang PM, Tsai ZR, et al. Why is in-hospital diagnosis of pulmonary tuberculosis delayed in southern Taiwan? J Formos Med Assoc. 2010;(4):269-77. http://dx.doi.org/10.1016/S0929-6646(10)60052-6
http://dx.doi.org/10.1016/S0929-6646(10)...

9. Lorent N, Mugwaneza P, Mugabekazi J, Gasana M, Van Bastelaere S, Clerinx J, et al. Risk factors for delay in the diagnosis and treatment of tuberculosis at a referral hospital in Rwanda. Int J Tuberc Lung Dis. 2008;12(4):392-6.

10. Sherman LF, Fujiwara PI, Cook SV, Bazerman LB, Frieden TR. Patient and health care system delays in the diagnosis and treatment of tuberculosis. Int J Tuberc Lung Dis. 1999;3(12):1088-95.

11. Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health. 2008;8:15. http://dx.doi.org/10.1186/1471-2458-8-15
http://dx.doi.org/10.1186/1471-2458-8-15...
- 1212. Whitehorn J, Ayles H, Godfrey-Faussett P. Extra-pulmonary and smear-negative forms of tuberculosis are associated with treatment delay and hospitalisation. Int J Tuberc Lung Dis. 2010;14(6):741-4. ) A cross-sectional study of adults with newly diagnosed tuberculosis showed that hospitalization and delayed treatment were more likely to occur in smear-negative patients.( 1212. Whitehorn J, Ayles H, Godfrey-Faussett P. Extra-pulmonary and smear-negative forms of tuberculosis are associated with treatment delay and hospitalisation. Int J Tuberc Lung Dis. 2010;14(6):741-4. ) In a referral hospital in Rwanda, a negative sputum smear was considered a risk factor for further health care system delay.( 99. Lorent N, Mugwaneza P, Mugabekazi J, Gasana M, Van Bastelaere S, Clerinx J, et al. Risk factors for delay in the diagnosis and treatment of tuberculosis at a referral hospital in Rwanda. Int J Tuberc Lung Dis. 2008;12(4):392-6. ) Previous studies have shown that, in addition to delayed diagnosis, indicators of atypical manifestations (such as negative sputum smears) were associated with increased mortality.( 1313. Naalsund A, Heldal E, Johansen B, Kongerud J, Boe J. Deaths from pulmonary tuberculosis in a low-incidence country. J Intern Med. 1994;236(2):137-42. http://dx.doi.org/10.1111/j.1365-2796.1994.tb01275.x
http://dx.doi.org/10.1111/j.1365-2796.19...
, 1414. Penner C, Roberts D, Kunimoto D, Manfreda J, Long R. Tuberculosis as a primary cause of respiratory failure requiring mechanical ventilation. Am J Respir Crit Care Med. 1995;151(3 Pt 1):867-72. http://dx.doi.org/10.1164/ajrccm/151.3_Pt_1.867
http://dx.doi.org/10.1164/ajrccm/151.3_P...
)

Being female was associated with a diagnosis of tuberculosis within the first 24 h after hospital admission. In a cross-sectional study conducted in Ethiopia,( 1515. Wondimu T, Michael KW, Kassahun W, Getachew S. Delay in initiating tuberculosis treatment and factors associated among pulmonary tuberculosis patients in East Wollega, Western Ethiopia. Ethiop J Health Develop 2007;21(2):148-56. http://dx.doi.org/10.4314/ejhd.v21i2.10043
http://dx.doi.org/10.4314/ejhd.v21i2.100...
) it was demonstrated that female patients took longer to seek medical attention than did male patients, although there was less delay in diagnosis in female patients after their entry into the health care system, a finding that is consistent with ours. Other studies have shown that being female is a risk factor for a delay in seeking medical attention (patient delay).( 1616. Lawn SD, Afful B, Acheampong JW. Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. Int J Tuberc Lung Dis. 1998;2(8):635-40.

17. Lienhardt C, Rowley J, Manneh K, Lahai G, Needham D, Milligan P, et al. Factors affecting time delay to treatment in a tuberculosis control programme in a sub-Saharan African country: the experience of The Gambia. Int J Tuberc Lung Dis. 2001;5(3):233-9.

18. Ngamvithayapong J, Yanai H, Winkvist A, Diwan V. Health seeking behaviour and diagnosis for pulmonary tuberculosis in an HIV-epidemic mountainous area of Thailand. Int J Tuberc Lung Dis. 2001;5(11):1013-20.

19. Pronyk RM, Makhubele MB, Hargreaves JR, Tollman SM, Hausler HP. Assessing health seeking behaviour among tuberculosis patients in rural South Africa. Int J Tuberc Lung Dis. 2001;5(7):619-27.

20. Rajeswari R, Chandrasekaran V, Suhadev M, Sivasubramaniam S, Sudha G, Renu G. Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India. Int J Tuberc Lung Dis. 2002;6(9):789-95.
- 2121. Xu X, Liu JH, Cao SY, Zhao Y, Dong XX, Liang Y, et al. Delays in care seeking, diagnosis and treatment among pulmonary tuberculosis patients in Shenzhen, China. Int J Tuberc Lung Dis. 2013;17(5):615-20. http://dx.doi.org/10.5588/ijtld.12.0231
http://dx.doi.org/10.5588/ijtld.12.0231...
) Therefore, in the present study, female patient delay in seeking medical attention was possibly associated with a more severe and more advanced disease presentation, which raised diagnostic suspicion in the emergency room.

Although it is recommended that the diagnosis of tuberculosis be made at primary health care clinics, a significant proportion of the population is diagnosed in public hospitals.( 1010. Sherman LF, Fujiwara PI, Cook SV, Bazerman LB, Frieden TR. Patient and health care system delays in the diagnosis and treatment of tuberculosis. Int J Tuberc Lung Dis. 1999;3(12):1088-95. , 2222. Zerbini E, Chirico MC, Salvadores B, Amigot B, Estrada S, Algorry G. Delay in tuberculosis diagnosis and treatment in four provinces of Argentina. Int J Tuberc Lung Dis. 2008;12(1):63-8. ) In 2007 in Porto Alegre, 38.98% of all tuberculosis cases were reported by hospitals.( 2323. Prefeitura Municipal de Porto Alegre [homepage on the Internet]. Porto Alegre: a Prefeitura [cited 2014 Jan 8]. Boletim epidemiológico no. 36 de fevereiro de 2008. [Adobe Acrobat document, 8p.]. Available from: http://lproweb.procempa.com.br/pmpa/prefpoa/sms/usu_doc/boletim_36_fevereiro_2008.pdf
http://lproweb.procempa.com.br/pmpa/pref...
) The fact that tuberculosis is often diagnosed in hospitals is generally believed to be due to a lack of resources in primary care or the need for tests that are more specific in order to establish a diagnosis. In fact, studies have shown that delayed diagnosis is closely related to poor access to health care (which is due to the fact that health care facilities are far from where patients live), difficulties in performing tests, and the prescription of drugs other than antituberculosis drugs.( 22. dos Santos MA, Albuquerque MF, Ximenes RA, Lucena-Silva NL, Braga C, Campelo AR, et al. Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil. BMC Public Health. 2005;5:25. http://dx.doi.org/10.1186/1471-2458-5-25
http://dx.doi.org/10.1186/1471-2458-5-25...
, 1111. Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health. 2008;8:15. http://dx.doi.org/10.1186/1471-2458-8-15
http://dx.doi.org/10.1186/1471-2458-8-15...
) However, in our study, 22% of all patients were diagnosed with tuberculosis and started tuberculosis treatment within the first 24 h after hospital admission, and positive sputum smears were associated with treatment initiation within the first 24 h after admission. This means that the diagnosis of tuberculosis was quickly established, often on the basis of sputum smear microscopy, which is a simple test that is available at primary health care clinics. Another possible explanation for this finding is the inability of primary health care professionals to recognize tuberculosis symptoms, which delays the diagnostic process. A previous study showed that cough, expectoration, and hemoptysis were less common in females than in males,( 2424. Long NH, Diwan VK, Winkvist A. Difference in symptoms suggesting pulmonary tuberculosis among men and women. J Clin Epidemiol. 2002;55(2):115-20. http://dx.doi.org/10.1016/S0895-4356(01)00455-3
http://dx.doi.org/10.1016/S0895-4356(01)...
) leading physicians to suspect less of tuberculosis in the former. In addition, as discussed above, being female is usually associated with a delay in seeking medical attention, which might be due to the fact that females have to balance work and home duties or to the stigma attached to the disease; even after their entry into the health care system, difficulties in collecting sputum samples constitute an obstacle to early diagnosis in the primary care setting.( 2525. Allebeck P. Delay in tuberculosis care: one link in a long chain of social inequities. Eur J Public Health. 2007;17(5):409. http://dx.doi.org/10.1093/eurpub/ckm046
http://dx.doi.org/10.1093/eurpub/ckm046...

26. Boeree MJ, Harries AD, Godschalk P, Demast Q, Upindi B, Mwale A, et al. Gender differences in relation to sputum submission and smear-positive pulmonary tuberculosis in Malawi. Int J Tuberc Lung Dis. 2000;4(9):882-4.

27. Gosoniu GD, Ganapathy S, Kemp J, Auer C, Somma D, Karim F, et al. Gender and socio-cultural determinants of delay to diagnosis of TB in Bangladesh, India and Malawi. Int J Tuberc Lung Dis. 2008;12(7):848-55.

28. Hudelson P. Gender differentials in tuberculosis: the role of socio-economic and cultural factors. Tuber Lung Dis. 1996;77(5):391-400. http://dx.doi.org/10.1016/S0962-8479(96)90110-0
http://dx.doi.org/10.1016/S0962-8479(96)...
- 2929. Karim F, Islam MA, Chowdhury AM, Johansson E, Diwan VK. Gender differences in delays in diagnosis and treatment of tuberculosis. Health Policy Plan. 2007;22(5):329-34. http://dx.doi.org/10.1093/heapol/czm026
http://dx.doi.org/10.1093/heapol/czm026...
)

The major limitation of the present study is its retrospective design; the accuracy of data collection is lower in retrospective studies than in prospective studies. Another limitation is that this was a single-center study. Nevertheless, it is important to investigate the factors associated with delayed diagnosis, because it has an impact on tuberculosis transmission. Therefore, it is crucial that the sources of delay in diagnosis be evaluated under tuberculosis control programs at hospitals.

In conclusion, although a diagnosis of tuberculosis was established and tuberculosis treatment was initiated within the first 24 h after hospital admission in 22.0% of the new cases of tuberculosis treated in our emergency room and requiring hospitalization, the rates of in-hospital mortality, ICU admission, and mechanical ventilation use remained high. Diagnosis of tuberculosis and initiation of tuberculosis treatment within the first 24 h after admission were associated with being female and with an AFB-positive spontaneous sputum smear. Strategies for the control of tuberculosis in primary care should consider that patients who seek medical attention at hospitals arrive too late and with advanced disease. It is therefore necessary to implement active surveillance measures in the community for earlier diagnosis and treatment.

References

  • 1
    World Health Organization. Global Tuberculosis Control 2010. Geneva: World Health Organization; 2012.
  • 2
    dos Santos MA, Albuquerque MF, Ximenes RA, Lucena-Silva NL, Braga C, Campelo AR, et al. Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil. BMC Public Health. 2005;5:25. http://dx.doi.org/10.1186/1471-2458-5-25
    » http://dx.doi.org/10.1186/1471-2458-5-25
  • 3
    Sreeramareddy CT, Panduru KV, Menten J, Van den Ende J. Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature. BMC Infect Dis. 2009;9:91. http://dx.doi.org/10.1186/1471-2334-9-91
    » http://dx.doi.org/10.1186/1471-2334-9-91
  • 4
    Prefeitura Municipal de Porto Alegre [homepage on the Internet]. Porto Alegre: a Prefeitura [cited 2014 Jan 8]. Boletim epidemiológico no. 45 de maio de 2011. [Adobe Acrobat document, 8p.]. Available from: http://lproweb.procempa.com.br/pmpa/prefpoa/cgvs/usu_doc/10018-boletim_epidemiologico_setembro_2011_45[1].pdf
    » http://lproweb.procempa.com.br/pmpa/prefpoa/cgvs/usu_doc/10018-boletim_epidemiologico_setembro_2011_45[1].pdf
  • 5
    Rossato Silva D, Müller AM, Dalcin Pde T. Factors associated with delayed diagnosis of tuberculosis in hospitalized patients in a high TB and HIV burden setting: a cross-sectional study. BMC Infect Dis. 2012;12:57. http://dx.doi.org/10.1186/1471-2334-12-57
    » http://dx.doi.org/10.1186/1471-2334-12-57
  • 6
    Conde MB, Melo FA, Marques AM, Cardoso NC, Pinheiro VG, Dalcin Pde T, et al. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol. 2009;35(10):1018-48.
  • 7
    Farah MG, Rygh JH, Steen TW, Selmer R, Heldal E, Bjune G. Patient and health care system delays in the start of tuberculosis treatment in Norway. BMC Infect Dis. 2006;6:33. http://dx.doi.org/10.1186/1471-2334-6-33
    » http://dx.doi.org/10.1186/1471-2334-6-33
  • 8
    Lin CY, Lin WR, Chen TC, Lu PL, Huang PM, Tsai ZR, et al. Why is in-hospital diagnosis of pulmonary tuberculosis delayed in southern Taiwan? J Formos Med Assoc. 2010;(4):269-77. http://dx.doi.org/10.1016/S0929-6646(10)60052-6
    » http://dx.doi.org/10.1016/S0929-6646(10)60052-6
  • 9
    Lorent N, Mugwaneza P, Mugabekazi J, Gasana M, Van Bastelaere S, Clerinx J, et al. Risk factors for delay in the diagnosis and treatment of tuberculosis at a referral hospital in Rwanda. Int J Tuberc Lung Dis. 2008;12(4):392-6.
  • 10
    Sherman LF, Fujiwara PI, Cook SV, Bazerman LB, Frieden TR. Patient and health care system delays in the diagnosis and treatment of tuberculosis. Int J Tuberc Lung Dis. 1999;3(12):1088-95.
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  • *
    Study carried out under the auspices of the Graduate Program in Pulmonology, Federal University of Rio Grande do Sul School of Medicine, and in the Department of Pulmonology, Porto Alegre Hospital de Clínicas, Porto Alegre, Brazil.

Publication Dates

  • Publication in this collection
    May-Jun 2014

History

  • Received
    08 Jan 2014
  • Accepted
    26 Mar 2014
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