SESSION TITLE: Respiratory Infections Posters II
SESSION TYPE: Original Investigation Poster
PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM
PURPOSE: Despite a declining incidence of tuberculosis (TB) in the USA, TB control programs face significant challenges. Delayed diagnosis and drug resistant TB are two examples. We report the results of a contact investigation of a patient with a delay in diagnosis of isoniazid (INH) resistant TB and estimate the costs to the public health system.
METHODS: The index case was an 82-year-old male with non-resolving pneumonia and 20 pound weight loss despite oral and intravenous antibiotics over a ten month period. Late in the course of his illness, multiple sputum and a bronchoalveolar lavage (BAL) fluid samples were acid-fast stain negative. The cultures of the specimens grew Mycobacterium tuberculosis that was later found to be INH resistant by DNA study. Despite standard therapy, the patient subsequently died of respiratory failure. Contact analysis was performed based on Tennessee state guidelines, a medical record review, an interview with the index patient, and a field investigation. Personnel at four health-care facilities and other individuals were included in the contact investigation. Total costs were estimated by the public health department.
RESULTS: A total of 434 contacts were identified. Thirty contacts had history of significant reactions to purified protein derivative (PPD) skin testing in the past but asymptomatic. Two step PPD skin testing was non-reactive in 371 of the contacts. A gamma interferon test was negative in 7 contacts. Ten contacts were lost to follow up and four died prior to the investigation. Eight were initial reactors (3 started treatments). Three contacts were recent convertors, requiring rifampin preventive therapy. One pregnant female was advised to defer PPD until after delivery. Six out of eight contacts completed rifampin therapy for LTBI. The cost of preventative therapy and testing was approximately $20,000. The cost calculation will be broken down for review. The man hours involved in the contact investigation are not included in this expense.
CONCLUSIONS: This investigation highlights the serious concern regarding delayed diagnosis of INH resistant TB and its impact on health care and costs to society. First, the delay in diagnosis likely resulted in the death of the index case. Second, the delay also resulted in 434 contacts resulting in significant cost expenditures.
CLINICAL IMPLICATIONS: We hope that our report will educate clinicians on the impact of a delayed diagnosis of TB can have on individual patients and on the public health system.
DISCLOSURE: The following authors have nothing to disclose: Saurabh Desai, Brijal Patel, Parthavkumar Patel, David Kirschke, Ryland Byrd, Thomas Roy, Jayantilal Mehta
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