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Efficacy of Control Measures in Preventing Nosocomial Transmission of Multidrug-Resistant Tuberculosis to Patients and Health Care Workers

Susan A. Maloney, MD, MHS; Michele L. Pearson, MD; Marcia T. Gordon, RN; Rachel Del Castillo, RN; John F. Boyle, PhD; and William R. Jarvis, MD
[+] Article, Author, and Disclosure Information

From the Centers for Disease Control and Prevention, Atlanta, Georgia; and the Cabrini Medical Center, New York, New York. Requests for Reprints: Michele L. Pearson, MD, Hospital Infections Program, Centers for Disease Control and Prevention, Mailstop A-07, 1600 Clifton Road NE, Atlanta, GA 30333. Disclaimer: Use of trade names and commercial sources is for identification purposes only and does not imply endorsement by the Public Health Service or by the U. S. Department of Health and Human Services. Acknowledgments: The authors thank the members of Infection Control, Employee Health, and the Mycobacteriology Laboratory at Cabrini Medical Center for their assistance in this investigation; Tim Hardnee for his assistance in the collection of tuberculin skin-testing data; and Linda Waller for her support in graphics arts production.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;122(2):90-95. doi:10.7326/0003-4819-122-2-199501150-00002
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Objective: To assess the efficacy of control measures in decreasing nosocomial transmission of multidrug-resistant tuberculosis.

Design: Retrospective cohort study.

Setting: A teaching hospital in New York City.

Population: 40 patients hospitalized with multidrug-resistant tuberculosis (case-patients) and health care workers receiving tuberculin skin testing.

Interventions: Centers for Disease Control and Prevention (CDC) 1990 guidelines for preventing transmission of tuberculosis, including 1) prompt isolation and treatment of patients with tuberculosis; 2) rapid diagnostic techniques for processing Mycobacterium tuberculosis specimens; 3) negative-pressure isolation rooms; and 4) molded surgical masks for health care workers.

Measurements: Proportion of case-patients with nosocomially acquired tuberculosis and rate of tuberculin skin test conversion among health care workers before and after implementation of control measures.

Results: The proportion of patients with multidrug-resistant strains of M. tuberculosis decreased after the interventions (10 of 70 [14%] compared with 30 of 95 [32%] patients before the intervention; relative risk [RR], 0.5; 95% CI, 0.2 to 0.9). Before onset of multidrug-resistant tuberculosis, case-patients in the intervention period were as likely to be hospitalized on high-risk wards containing patients with tuberculosis (4 of 10 compared with 17 of 30 patients; RR, 0.7; P = 0.5) but were less likely to be exposed to another case-patient with tuberculosis (1 of 10 compared with 20 of 30 patients; RR, 0.2; P =0.003). Tuberculin skin test conversion rates for health care workers assigned to wards housing patients with tuberculosis were lower in the intervention period than in the preintervention period (4 of 78 [5%] compared with 15 of 90 [17%] conversions; P = 0.02), decreasing to levels observed for workers assigned to other wards (4 of 78 [5%] compared with 9 of 228 [4%] conversions; P = 0.7).

Conclusions: Implementing control measures reduced nosocomial transmission of multidrug-resistant strains to patients and health care workers.


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Figure 1.
Distribution of patients with multidrug-resistant tuberculosis by date of first positive culture.

The numbers 1 to 4 with arrows indicate the dates of introduction of 1) improved patient isolation, expanded criteria for isolation of patients (June to July 1991), and molded surgical masks (July 1991); 2) improved laboratory services (15 July 1991); 3) acid-fast bacilli isolation rooms on wards with negative pressure systems (September 1991); and 4) negative-pressure chambers for aerosolized pentamidine administration and sputum induction (October 1991). The months are abbreviated using the first letter of the month.

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Figure 2.
Tuberculin skin test conversion rates in health care workers with and without direct patient contact.

Health care workers with direct patient contact included physicians, nurses, nurses' aides, respiratory therapists, and social workers. Health care workers without direct patient contact included administrative staff, clerks, dieticians, housekeeping personnel, engineers, and laboratory personnel. TST = tuberculin skin test.

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