Assessing the performance of overseas tuberculosis screening programs: a study among US-bound immigrants in Vietnam.

BACKGROUND: Tuberculosis cases in foreign-born persons account for more than 50% of all tuberculosis cases in the United States. The Institute of Medicine has recommended enhancing overseas screening as one measure to support tuberculosis elimination efforts. We assessed the ability of overseas tuberculosis screening (chest radiograph followed by 3 acid-fast bacilli sputum smears for persons with abnormal chest radiographs [suggestive of active tuberculosis]) to detect pulmonary tuberculosis disease among US-bound immigrants with abnormal chest radiographs. METHODS: During October 1998 to October 1999, 14 098 US immigrant visa applicants were screened overseas in Vietnam. Adult applicants with abnormal chest radiographs were enrolled to assess screening test characteristics among this group using mycobacterial culture as the gold standard for pulmonary tuberculosis disease diagnosis. Risk factors for pulmonary tuberculosis disease were also evaluated. RESULTS: Among 1179 adult applicants with abnormal chest radiographs, 82 (7.0%) had positive acid-fast bacilli smear results, and 183 (15.5%) had positive Mycobacterium tuberculosis culture results (pulmonary tuberculosis disease). The sensitivity, specificity, and positive and negative predictive values of serial acid-fast bacilli screening among this group were 34.4% (63/183), 98.1% (977/996), 76.8% (63/82), and 89.1% (977/1097), respectively. Risk factors for pulmonary tuberculosis disease included younger age (18-34 years), no history of tuberculosis or treatment, reported symptoms, and cavitation or consolidation on chest radiograph. CONCLUSIONS: The ability of current overseas screening to detect tuberculosis among immigrants with abnormal chest radiographs is low. Improved diagnostic methods, enhanced screening measures, and postmigration follow-up are essential to control tuberculosis among immigrants and support US and global tuberculosis elimination.

Microbiology of surgical site infections and associated antimicrobial use among Vietnamese orthopedic and neurosurgical patients.

OBJECTIVES: To determine the pathogens associated with surgical site infections (SSIs) and describe patterns of antimicrobial use and resistance in orthopedic and neurosurgical patients in a large university hospital in Vietnam. DESIGN: Prospective cohort study. SETTING: Cho Ray Hospital, Ho Chi Minh City, Vietnam. PATIENTS: All patients who had operations during a 5-week study period. RESULTS: Of 702 surgical patients, 80 (11.4%) developed an SSI. The incidence of SSI among orthopedic patients was 15.2% (48 of 315), and among neurosurgical patients it was 8.3% (32 of 387). Postoperative bacterial cultures of samples from the surgical sites were performed for 55 (68.8%) of the 80 patients with SSI; 68 wound swab specimens and 10 cerebrospinal fluid samples were cultured. Of these 78 cultures, 60 (76.9%) were positive for a pathogen, and 15 (25%) of those 60 cultures yielded multiple pathogens. The 3 most frequently isolated pathogens were Pseudomonas aeruginosa (29.5% of isolates), Staphylococcus aureus (11.5% of isolates), and Escherichia coli (10.3% of isolates). Ninety percent of S. aureus isolates were methicillin resistant, 91% of P. aeruginosa isolates were ceftazidime resistant, and 38% of E. coli isolates were cefotaxime resistant. All but 1 of the 702 patients received antimicrobial therapy after surgery, and the median duration of antimicrobial therapy was 11 days. Commonly used antimicrobials included aminopenicillins and second- and third-generation cephalosporins. Two or more agents were given to 634 (90%) of the patients, and most combination drug regimens (86%) included an aminoglycoside. CONCLUSIONS: Our data indicate that the incidence of SSI is high in our study population, that the main pathogens causing SSI are gram-negative bacteria and are often resistant to commonly used antimicrobials, that the use of broad-spectrum antimicrobials after surgery is widespread, and that implementation of interventions aimed at promoting appropriate and evidence-based use of antimicrobials are needed in Vietnam.