1222 infection control & hospital epidemiology october 2015, vol. 36, no. 10 High-risk TB patient according to clinical algorithma or to healthcare provider suspicion


NAAT on 1–2 specimensb


AFB Smear (+)


Collect 3 sputums for AFB smear


(Collected at least 8 hours apart and at least 1


specimen collected in early morning or is induced)


NAAT (–)c


Alternative diagnosis confirmedd OR clinical suspicion for alternative diagnosise is higher than TB and dual diagnosis deemed unlikely


Yes No NAAT (+) NAAT (+) NAAT (–) NAAT (+)f


High-risk for TBg progression OR resident of congregate facilityh AND no ability to isolate OR severe illness consistent with TB OR clinical suspicion for TB remains high.


Yes No TB


treatment; Release from AIIR; Follow- up TB cultures


Start TB treatment No No TB


treatment; Release from AIIR; Follow-up evaluation when TB cultures finalized


Alternative diagnosis confirmedd OR clinical suspicion for alternative diagnosise is higher than TB and dual diagnosis deemed unlikely


No Yes


AFB Smear (–)


NAAT on 1–2 specimensb


AFB sputum smear results and the quality of the sputum specimen, and radiographic findings. cDetermine the type of NAAT used by the laboratory, and the occurrence of false-negative results for this type of NAAT due to presence of


NOTE. AIIR: airborne infection isolation room; AFB: acid-fast bacilli; NAAT: nucleic acid amplification test; TB: tuberculosis. aEither a clinical prediction rule that is published or based on local epidemiology of pulmonary TB. See Figure 1 for an example. bThe decision to test 1 or 2 sputum specimens with an NAAT will depend on the type of NAAT used (eg, Xpert® assay or laboratory- developed test) and on clinical factors such as suspicion for TB and confirmation of an alternative diagnosis, laboratory findings including


figure 2. Diagnostic evaluation of patients at high-risk for pulmonary tuberculosis in acute care facilities.


inhibitors. If inhibitors are detected, then an additional sputum specimen will need to be sent for an NAAT. dLaboratory confirmation of an alternative diagnosis (eg, nontuberculous mycobacteria detected from a respiratory specimen, or non-small


cell lung cancer confirmed based on pathology specimen from a lung biopsy). eAn example of an alternative diagnosis for which there may be higher suspicion than that for TB may be in a patient with post-obstructive


pneumonia with a right upper lobe infiltrate that radiographically appears to be due to lung cancer. fFor high-risk TB patients who have a sputum specimen that is AFB sputum smear-negative but NAAT positive, additional diagnostic


human immunodeficiency virus infection; use of TNF-α antagonist; or conversion of a tuberculin skin test or interferon-γ release assay. hResidents of congregate facilities include persons in homeless shelters, prisons, jails, drug rehabilitation or mental health facilities, and end- stage renal disease patients undergoing dialysis at a dialysis facility.


specimens (eg, sputum specimens) may be needed in order to obtain an isolate of Mycobacterium tuberculosis complex. gExamples of coexisting medical conditions and demographic factors that increase patient risk for progression to active TB disease include:


include 3 sputum specimens and at least 1NAAT. The decision to test more than 1 sputum specimen with an NAAT will depend not only on the type of NAAT used (eg, Xpert assay or laboratory-developed test) but also on clinical factors such as suspicion for TB and confirmation of an alternative diagnosis,


laboratory findings (including AFB sputum smear results


and the quality of the sputum specimen), and radiographic findings. The proposed combined strategy may optimize utilization of AIIRs and increase rapid detection and empiric treatment of infectious pulmonary TB patients.


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