Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children

Abstract

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.

Figure 1

Paradigm for evaluation of those with latent tuberculosis infection (LTBI) based on risk of infection, risk of progression to tuberculosis, and benefit of therapy. In developing a diagnostic approach for the evaluation of those with suspected LTBI, we recommend the clinician weigh the likelihood of infection, the likelihood of progression to tuberculosis if infected, and the benefit of therapy (Horsburgh and Rubin, Clinical practice: latent tuberculosis infection in the United States. N Engl J Med 2011; 364:1441–8). Recommendations were formulated for each of the 3 groups illustrated above. These groups are concordant with current recommendations for the interpretation of the tuberculin skin test (American Thoracic Society, Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep 2000; 49:1–51). Abbreviations: CXR, chest radiograph; HIV, human immunodeficiency virus; LTBI, latent tuberculosis infection; Mtb, Mycobacterium tuberculosis; RR, relative risk; TB, tuberculosis; TST, tuberculin skin test.

Figure 2

Summary of recommendations for testing for latent tuberculosis infection (LTBI). ¹Performing a second diagnostic test when the initial test is negative is a strategy to increase sensitivity. This may reduce specificity, but the panel decided that this is an acceptable trade-off in situations in which the consequences of missing LTBI (ie, not treating individuals who may benefit from therapy) exceed the consequences of inappropriate therapy (ie, hepatotoxicity). ²Performing a confirmatory test following an initial positive result is based upon both the evidence that false-positive results are common among individuals who are unlikely to be infected with Mycobacterium tuberculosis and the committee’s presumption that performing a second test on those patients whose initial test was positive will help identify initial false-positive results. Abbreviations: IGRA, interferon-γ release assay; LTBI, latent tuberculosis infection; TST, tuberculin skin test.