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Influence of replacing tuberculin skin test with ex vivo interferon γ release assays on decision to administer prophylactic antituberculosis antibiotics before anti-TNF therapy
  1. Xavier Mariette1,
  2. Gabriel Baron2,
  3. Florence Tubach3,
  4. Frédéric Lioté4,
  5. Bernard Combe5,
  6. Corinne Miceli-Richard1,
  7. René-Marc Flipo6,
  8. Philippe Goupille7,
  9. Matthieu Allez8,
  10. Dominique Salmon9,
  11. Dominique Emilie,10,
  12. Guislaine Carcelain*,11,
  13. Philippe Ravaud*,2
  1. 1Rhumatologie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Sud 11, INSERM U1012, 78 rue du Général Leclerc, Le Kremlin Bicêtre, France
  2. 2Centre d’épidémiologie clinique, Groupe Hospitalier Cochin-Hotel Dieu, AP-HP, Université Paris Descartes, PRES Sorbonne Paris Cité, INSERM UMR-S 738, Paris, France
  3. 3Département d’Epidémiologie, Hôpital Bichat-Claude Bernard, Biostatistique et Recherche Clinique, Paris, France
  4. 4Rheumatology and INSERM UMR-S606, Paris Diderot University, Paris, France
  5. 5Rhumatologie, Hôpital Lapeyronie, Université Montpellier I, Montpellier, France
  6. 6Rhumatologie, Hôpital Roger Salengro, Université, Lille, France
  7. 7Rhumatologie, CHRU de Tours, Université François Rabelais, CIC INSERM-202, Tours, France
  8. 8Gastro-entérologie, Hôpital Saint-Louis, Paris, France
  9. 9Médecine interne et maladies infectieuses, Hôpital Cochin, Paris, France
  10. 10INSERM U996, Microbiologie-Immunologie Biologique, Hôpital Antoine Béclère, AP-HP, Université Paris-Sud 11, 32 rue des Carnets, Clamart, France
  11. 11Immunologie, Hôpital Pitié Salpétrière, Paris, France
  1. Correspondence to Xavier Mariette, Service de Rhumatologie, Hôpital de Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France; xavier.mariette{at}bct.aphp.fr

Abstract

Background The recommendations for detecting latent tuberculosis infection (LTBI) before antitumour necrosis factor (anti-TNF) therapy are based on the tuberculin skin test (TST), which lacks both specificity and sensitivity and can lead to unnecessary treatment with antibiotics. A study was undertaken to investigate the effect of replacing TST with interferon γ (IFNγ) release assays (IGRA) in screening for LTBI and deciding to begin prophylactic antituberculosis (TB) antibiotics before anti-TNF therapy in immune-mediated inflammatory diseases.

Methods In 15 tertiary care hospitals, consecutive patients with rheumatoid arthritis, spondylarthropathies or Crohn's disease were screened for LTBI before anti-TNF therapy with TST, QuantiFERON TB Gold in tube (QTF-Gold IT) and T-SPOT.TB at the same time. The potential diagnosis of LTBI and the effect on the decision to begin antibiotic prophylaxis were assessed.

Results Among 429 patients, 392 had results for the three tests. The results for TST, T-SPOT.TB and QTF Gold IT were positive for 35.2%, 15.1% and 9.9% of patients, respectively (p<0.0001). Antibiotics were required for 177 patients (45.2%) if positive TST results were included in the LTBI definition, 107 patients (27.3%) if TST results were replaced with results from one of the IGRA tests and 84 patients (21.4%) if TST results were replaced with QTF-Gold IT results (p<0.0001). The decision on the use of antibiotic prophylaxis was changed for 113 patients (28.8%, 95% CI 24.4% to 33.6%) if TST results were replaced with QTF-Gold IT results.

Conclusions Replacing TST with IGRA for determining LTBI allowed the proportion of patients with immune-mediated inflammatory diseases needing prophylactic anti-TB antibiotics before beginning anti-TNF agents to be reduced by half.

TrialRegNo: NCT00811343.

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Footnotes

  • Deceased. This paper is dedicated to his memory.

  • * GC and PR contributed equally to the study.

  • Funding This study was funded by the French Ministry of Health thanks to a STIC (Stratégies thérapeutiques Innovantes Couteuses) grant. The sponsor was the Département de la Recherche Clinique et du Développement of the Assistance Publique – Hôpitaux de Paris (STIC0717, P070310).

  • Ethics approval The study was authorised by the ethics committee of Paris Ile de France (CPP Ile de France II, N° 2008-07-04).

  • Competing interests None.

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

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