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Screening and prevention for latent tuberculosis in immunosuppressed patients at risk for tuberculosis: a systematic review of clinical practice guidelines
  1. Tasnim Hasan1,
  2. Eric Au2,
  3. Sharon Chen1,3,
  4. Allison Tong4,5,
  5. Germaine Wong2,5
  1. 1 Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
  2. 2 Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
  3. 3 School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
  4. 4 Centre for Kidney Research, The Children’s Hospital, Westmead, New South Wales, Australia
  5. 5 Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Tasnim Hasan; tasnim.hn{at}gmail.com

Abstract

Objective Immunosuppressed individuals are at a high risk of latent tuberculosis infection (LTBI) and clinical practice guidelines for the screening and management of LTBI in at-risk patients have been developed. We assessed the scope, quality and consistency of clinical practice guidelines on screening for LTBI and the prevention of tuberculosis infection (TB) in high-risk patient populations.

Design We conducted a systematic review of clinical practice guidelines. Methodological quality of these guidelines was assessed using the Appraisal of Guidelines for Research and Education (AGREE) II instrument. Textual synthesis was used to summarise and compare the recommendations.

Data sources Electronic databases (MEDLINE, EMBASE, PsycINFO) and guideline registries were searched from inception to December 2017.

Results Thirty-eight guidelines were included. Nineteen focused on patients receiving medical immunosuppression, seven on transplantation, three on patients with HIV and nine were generalised across all at risk populations. Most guidelines (n=32, 84%) used a systematic approach to identify and appraise the evidence. The methodological quality of the guidelines varied with the overall mean AGREE II scores ranging from 35% to 80%. Guidelines performed poorly in terms of editorial independence (average score 35%, range 0%–92%); however, most were robust in defining their scope and purpose (average score 80%, range 56%–100%). Guidelines recommended either or both the tuberculin skin test and the interferon gamma release assay for screening. Treatment of LTBI with isoniazid was consistently recommended.

Conclusion Clinical practice guidelines on LTBI vary in quality and scope. The recommendations for screening varied across guidelines, while recommendations for treatment were largely consistent. Improving the consistency and quality of guidelines may help to optimise the screening and management of LTBI for improved patient outcomes.

  • latent tuberculosis
  • immunosuppression
  • screening

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Footnotes

  • Contributors TH: database search, selection of guidelines; grading of guidelines, assessing quality, interpretation; preparation of manuscript and editing. EA: selection of guidelines; grading of guidelines, assessing quality, interpretation; preparation of manuscript and editing. SC, AT, GW: preparation of manuscript and editing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SC reports grants from MSD Australia, outside the submitted work.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available on request.

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