Concomitant Pulmonary Tuberculosis in Hospitalized Healthcare-Associated Pneumonia in a Tuberculosis Endemic Area: A Multi-center Retrospective Study

Jia-Yih Feng,Chih-Yen Tu,Shih-Chi Ku,Chang-Wen Chen,Kuang-Yao Yang,Meng-Chih Lin,Wei-Juin Su,Chong-Jen Yu,Wen-Feng Fang,Yu-Chun Chen,Chieh-Liang Wu,Olivier Neyrolles

doi:10.1371/journal.pone.0036832

Abstract

BackgroundIn tuberculosis (TB) endemic areas, Mycobacterium tuberculosis is an important but easily misdiagnosed pathogen in community-acquired pneumonia (CAP). However, the occurrence of concomitant pulmonary tuberculosis (PTB) in hospitalized healthcare-associated pneumonia (HCAP) has never been investigated.Methods and FindingsSeven hundred and one hospitalized HCAP and 934 hospitalized CAP patients from six medical centers in Taiwan were included in this nationwide retrospective study. Concomitant PTB was defined as active PTB diagnosed within 60 days of admission due to HCAP or CAP. The predictors for concomitant PTB and the impact of PTB on the outcomes of pneumonia were investigated. Among the enrolled subjects, 21/701 (3%) of the HCAP patients and 25/934 (2.7%) of the CAP patients were documented to have concomitant PTB. In multivariate analysis, a history of previous anti-TB treatment (OR = 5.84, 95% CI: 2.29–20.37 in HCAP; OR = 3.33, 95% CI: 1.09–10.22 in CAP) and escalated pneumonia severity index (PSI) scores (OR = 1.014, 95% CI: 1.002–1.026, in HCAP; OR = 1.013, 95% CI: 1.001–1.026, in CAP) were independent predictors for concomitant PTB in both CAP and HCAP patients. Regarding treatment outcomes, HCAP patients with concomitant PTB were associated with more acute respiratory failure within 48 hours of admission (47.6% vs. 22.6%, p = 0.008), higher intensive care unit admission rate (61.9% vs. 35.7%, p = 0.014), longer hospitalization (39.6±34.1 vs. 23.7±27 days, p = 0.009), and higher in-hospital mortality (47.6% vs. 26.3%, p = 0.03) than those without concomitant PTB. Exposure to certain groups of antibiotics for the treatment of pneumonia was not associated with the occurrence of concomitant PTB.ConclusionsIn HCAP patients, the occurrence of concomitant PTB is comparable with that in CAP patients and associated with higher PSI scores, more acute respiratory failure, and higher in-hospital mortality.

Highlights

Tuberculosis (TB) is an important infectious disease associated with high mortality and morbidity
Patients characteristics During the study period, a total of 718 healthcare-associated pneumonia (HCAP) patients were identified from the six study hospitals
We found that the occurrence of concomitant pulmonary tuberculosis (PTB) in hospitalized HCAP patients was not rare and was comparable to those with community-acquired pneumonia (CAP)

Summary

Introduction

Tuberculosis (TB) is an important infectious disease associated with high mortality and morbidity. According to estimates of the World Health Organization (WHO), there were 9.4 million incident cases of TB, and 1.7 million people who died from TB worldwide in 2009 [1]. In Taiwan, the incidence and mortality of TB were 62 and 3.3 cases per 100,000 population, respectively, in 2008 [2]. Due to the non-specific symptoms and diverse radiographic presentations, it is not always easy to differentiate pulmonary tuberculosis (PTB) from bacterial pneumonia in a clinical setting [3]. In TB endemic areas, TB studies are frequently ordered in patients treated for community-acquired pneumonia (CAP). In tuberculosis (TB) endemic areas, Mycobacterium tuberculosis is an important but misdiagnosed pathogen in community-acquired pneumonia (CAP). The occurrence of concomitant pulmonary tuberculosis (PTB) in hospitalized healthcare-associated pneumonia (HCAP) has never been investigated

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