Screening and prevention for latent tuberculosis in immunosuppressed patients at risk for tuberculosis: a systematic review of clinical practice guidelines

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.

Keywords: immunosuppression; latent tuberculosis; screening.

Figure 1

Database search strategy The medical databases EMBASE, PsychINFO and Medline were searched for articles relevant to tuberculosis in an immunosuppressed setting, using the search strategy described in online supplementary appendix 1. A total of 9467 articles were found and compiled into the EndNote software (Clarivate Analytics 2017, V.X7), of which 1130 articles were duplicate articles. From the remaining articles, 6121 articles were excluded by abstract review, primarily because they were irrelevant. A further 2056 articles were removed during a second review of titles and abstracts. A total of 160 articles were reviewed in full of which 122 were excluded as they did not fulfil guideline or relevance criteria. A total of 38 articles were included in our final review.