An evaluation of the completeness of reporting of childhood tuberculosis.

The sensitivity of the Enhanced Tuberculosis Surveillance (ETS) scheme for monitoring tuberculosis in children is unknown. We used the British Paediatric Surveillance Unit (BPSU) reporting scheme to conduct a prospective observational study of tuberculosis in children aged <16 yrs in the UK. Reported cases were then matched with records from the ETS database. A total of 320 cases were reported to the BPSU between January and December 2004. We estimated that there were 557 paediatric cases in England, Wales and Northern Ireland in 2004: 222 (40%) cases reported to both BPSU and ETS, 98 (18%) reported to BPSU but not ETS and 237 (42%) reported to ETS but not BPSU. Children aged <5 yrs were significantly less likely to be reported to ETS compared with older children (p<0.01). There is substantial under-reporting of childhood tuberculosis, especially of children aged <5 yrs. ETS provides a representative picture of the demographics but may miss approximately 20% of cases. This should be taken into account when planning training and resource requirements for tuberculosis. Increased efforts are needed to ensure that all paediatric cases are reported to ETS.

Multidrug-resistant tuberculosis: this is the cost.

The costs of multidrug-resistant tuberculosis (MDR TB) reach far beyond the cost of the clinical treatment of the patient. The first impact of the discovery of MDR TB in a population is the need to recognize that all TB patients have the potential of being MDR. Public health measures to prevent the spread of MDR TB, or to control or reverse the problem where spread has already occurred, can be extremely expensive to implement. At the level of the individual patient, the second-line drugs used to treat MDR TB are more expensive, and the remaining first-line drugs will have to be used for a longer time than in drug-susceptible TB. Negative-pressure units add to the costs of treatment, as does the increased nursing intensity required. The cost to the wider economy includes lost productivity and lost tax revenue to the state as well as the cost of supporting the family if the patient is the breadwinner.

Multidrug-resistant tuberculosis in an HIV-positive man in the United Kingdom.

Multidrug-resistant Mycobacterium tuberculosis infection (MDR-TB) in those who are HIV positive has until now been largely a North American phenomenon. We report a fatal case in London.

Increasing incidence of tuberculosis in England and Wales: a study of the likely causes.

OBJECTIVE: To examine factors responsible for the recent increase in tuberculosis in England and Wales. DESIGN: Study of the incidence of tuberculosis (a) in the 403 local authority districts in England and Wales, ranked according to Jarman score, and (b) in one deprived inner city district, according to ethnic origin and other factors. SETTING: (a) England and Wales 1980-92, and (b) the London borough of Hackney 1986-93. MAIN OUTCOME MEASURE: Age and sex adjusted rate of tuberculosis. RESULTS: In England and Wales notifications of tuberculosis increased by 12% between 1988 and 1992. The increase was 35% in the poorest 10th of the population and 13% in the next two; and in the remaining 70% there was no increase. In Hackney the increase affected traditionally high risk and low risk ethnic groups to a similar extent. In the "low risk" white and West Indian communities the incidence increased by 58% from 1986-8 (78 cases) to 1991-3 (123), whereas in residents of Indian subcontinent origin the increase was 41% (from 51 cases to 72). Tuberculosis in recently arrived immigrants--refugees (11% of the Hackney population) and Africans (6%)--accounted for less than half of the overall increase, and the proportion of such residents was much higher than in most socioeconomically deprived districts. The local increase was not due to an increase in the proportion of cases notified, to HIV infection, nor to an increase in homeless people. CONCLUSIONS: The national rise in tuberculosis affects only the poorest areas. Within one such area all residents (white and established ethnic minorities) were affected to a similar extent. The evidence indicates a major role for socioeconomic factors in the increase in tuberculosis and only a minor role for recent immigration from endemic areas.

Tuberculosis in the United Kingdom and Republic of Ireland.

AIMS: To describe the clinical features, diagnosis and management of children with tuberculosis in the United Kingdom and Republic of Ireland. METHODS: Cases of culture-confirmed and clinically diagnosed tuberculosis were reported to the British Paediatric Surveillance Unit from December 2003 to January 2005. RESULTS: 385 eligible cases were reported. Pulmonary disease was present in 154 (40%) children. Just over half (197, 51%) of children presented clinically and most of the remainder (166, 43%) at contact tracing. A probable source case was identified for 73/197 (36%) of the children presenting clinically. The majority (253, 66%) of children had a microbiological and/or histological investigation, and culture results were available for 240 (62%), of whom 102 (26%) were culture positive. Drug resistance was reported in 15 (0.4%) cases. 44% (128/292) of non-white children did not receive the recommended quadruple drug therapy. Seven children died. Only 57% (217) of children were managed by a paediatric subspecialist in respiratory or infectious diseases or a general paediatrician with a special interest in one of these areas. Fewer than five cases were reported from 119/143 (83%) respondents and 72 of 96 (75%) centres. CONCLUSIONS: Many paediatricians and centres see few children with tuberculosis. This may affect adherence to national guidelines. Managed clinical networks for children with tuberculosis may improve management and should be the standard of care.

The role of oxygen saving devices in patients with chronic hypoxemia.

There is good evidence in favor of the use of oxygen savers in patients with portable oxygen, but not for their use in conjunction with fixed oxygen installations in the home. Individual assessment of efficacy is vital. With the use of savers, the true total cost of therapy seems unlikely to fall and might even rise.

Resource implications of patients with multidrug resistant tuberculosis.

BACKGROUND: Multidrug resistant tuberculosis (MDR TB) requires a complex drug regimen and lengthy multidisciplinary care. The financial cost of successful management of each case is potentially large. METHODS: The costs of managing nine HIV negative patients with pulmonary MDR TB were compared with 18 age group and ethnicity matched controls with fully sensitive disease. Calculations included: cost of outpatient visits and inpatient stays including negative pressure isolation; costs of drug provision and toxicity monitoring; costs of additional procedures and multidisciplinary referrals. RESULTS: The mean cost of managing a case of pulmonary MDR TB was in excess of 60,000 pounds sterling and for sensitive disease it was 6040 pounds sterling. CONCLUSIONS: Clinicians and healthcare commissioning authorities may both be underestimating the costs of managing MDR TB, and accordingly the consequences for units dealing with such cases may be serious. Funding of care for MDR TB in the UK requires strategic decisions at regional or governmental level.

Microbiology of pyogenic liver abscess.

Sixteen patients with pyogenic liver abscesses were studied over 10 years to discover the causative organisms of the condition. Pus was subjected to Gram-negative smear or gas-liquid chromatography to detect volatile acids characteristic of anaerobes and then cultured. All isolates were identified by conventional methods and tested for sensitivity to appropriate antimicrobial agents. Bacteria were grown from the liver abscesses in all 16 patients. Streptococcus milleri Lancefield group F was the commonest organism isolated from the pyogenic liver abscesses, being found in 13 patients. If Strep milleri is isolated care should be taken not to mistake it for an anaerobe, and finding the organism in the blood should alert the clinician to the possible presence of a liver abscesses.

Respiratory disease in pregnancy.

Respiratory disease is common in pregnancy, and becoming more so: asthma, pneumonia and tuberculosis are all increasing in frequency. This review discusses these conditions and their relationship to pregnancy, as well as considering briefly some rarer diseases.

Fever during treatment of infective endocarditis.

In 83 episodes of culture-positive infective endocarditis (IE) of a native valve, fever persisted or recurred in 42 (50%) despite appropriate bactericidal antibiotics. The commonest cause of fever was extensive infection of the valve ring and adjacent structures, even when the infecting organisms were viridans streptococci; urgent surgery was required. Less frequent causes were systemic and pulmonary emboli and drug hypersensitivity. Infected intravenous access sites were seldom responsible. In no case was fever due to antibiotic resistance of the infecting organism. In patients with a definite microbiological diagnosis who have been given appropriate antibiotics, the temptation to alter antibiotic therapy because of persistent or recurrent fever should be resisted unless there are features of drug hypersensitivity. When fever persists or recurs during treatment of IE, the opinions of a cardiologist and cardiac surgeon should be obtained as soon as possible; delay in valve replacement may prove fatal in patients with extensive infection.

Prosthetic valve endocarditis.

During 1965 to 1982, 32 episodes of infective endocarditis on prosthetic valves in 30 patients were treated at this hospital. In early endocarditis (presenting within four months of operation) staphylococci were the organisms most commonly responsible. Early endocarditis appears to be declining in incidence and is largely preventable; sternal sepsis was the main predisposing factor, requiring urgent and effective treatment. Streptococci were the most common organisms in late onset disease, but as with natural valve endocarditis a wide range or organisms was responsible. All but one of the patients with early onset disease were treated conservatively, but mortality was high; prompt surgical replacement of infected prostheses is probably indicated in such patients. Medical management was effective in most patients with late onset disease, and for them early surgical intervention may not be justified.