Tuberculosis after SOT • CID 2009:48 (15 June) • 1657
M A J O R A R T I C L E
Tuberculosis after Solid-Organ Transplant: Incidence,
Risk Factors, and Clinical Characteristics
in the RESITRA (Spanish Network of Infection
in Transplantation) Cohort
Julia ´n Torre-Cisneros,1Antonio Doblas,2Jose ´ Marı ´a Aguado,3Rafael San Juan,4Marino Blanes,8Miguel Montejo,9
Carlos Cervera,10Oscar Len,11Jordi Carratala,12Jose ´ Miguel Cisneros,14Germa ´n Bou,15Patricia Mun ˜oz,5
Antonio Ramos,6Merce Gurgui,13Nuria Borrell,16Jesus Fortu ´n,7Asuncio ´n Moreno,10and Joan Gavalda,11
for the Spanish Network for Research in Infectious Diseases
1Hospital Universitario Reina Sofia, Universidad de Co ´rdoba, and
Doce de Octubre, Universidad Complutense de Madrid,
Universidad Complutense de Madrid,
Universitario la Fe, Valencia,
de Vall d’Hebron,
Universitario Virgen del Rocı ´o, Sevilla,
2Hospital Universitario Reina Sofia, Co ´rdoba, Co ´rdoba,
4Hospital Universitario Doce de Octubre,
6Hospital Universitario Puerta de Hierro, and
9Hospital Universitario de Cruces, Universidad del Paı ´s Vasco, Bilbao,
12Hospital Universitario de Bellvitge Universidad de Barcelona, and
15Hospital Universitario Juan Canalejo, Corun ˜a, and
5Hospital Universitario Gregorio Maran ˜o ´n,
7Hospital Universitario Ramo ´n y Cajal, Madrid,
13Hospital Universitario San Pau, Barcelona,
16Hospital Universitario de Son Dureta, Mallorca, Spain
(See the editorial commentary by Kumar and Humar on pages 1666–8)
It is necessary to clarify the incidence of and risk factors for tuberculosis (TB) among solid-
organ transplant (SOT) recipients as well as changes in the chronology, clinical presentation, and prognosis of the
A total of 4388 SOT recipients were monitored prospectively at 16 transplant centers included in
the Spanish Network for Research in Infectious Diseases (REIPI). TB episodes were studied, and the incidence
rate was calculated. Certain variables were analyzed, by Cox regression analysis, as potential risk factors for TB.
Among the 4388 SOT recipients, 21 cases of TB were reported (0.48%). The median duration of
follow-up was 360 days (range, 0–720 days). The global incidence of TB was 512 cases per 105patients per year
(95% confidence interval [CI], 317–783), which was higher than that in the general population in Spain (18.9
cases per 105inhabitants per year; relative risk [RR], 26.6). The highest incidence (2072 cases per 105patients per
year; 95% CI, 565–5306) was observed among lung transplant recipients (RR, 73.3). Of the TB cases, 95% occurred
within the first year after transplant, and 76% were pulmonary forms. Crude mortality was 19.0%, and attributable
mortality was 9.5%. Multivariate analysis identified recipient age (RR, 1.05; 95% CI, 1.0–1.1) and receipt of a lung
transplant (RR, 5.6; 95%, 1.9–16.9) as independent risk factors.
TB incidence is increased among SOT recipients. The risk factors identified were age and receipt
of a lung transplant. TB-attributable mortality (9.5%) is still high.
The incidence of tuberculosis (TB) among solid-organ
transplant (SOT) recipients has not been well defined.
Previous studies have calculated the relative frequency
of TB rather than its incidence [1–7]. Furthermore,
Received 2 December 2008; accepted 2 February 2009; electronically published
15 May 2009.
Reprints or correspondence: Dr. Julia ´n Torre-Cisneros, Clinic Unit of Infectious
Diseases, Hospital Universitario Reina Sofı ´a, Avda. Mene ´ndez Pidal, s/n, 14004
Co ´rdoba, Spain (email@example.com).
Clinical Infectious Diseases2009;48:1657–65
? 2009 by the Infectious Diseases Society of America. All rights reserved.
most of the studies describing risk factors have been
retrospective, have included a small case series, and
have lacked control patients without TB [5, 8–11].
The incidence of TB among SOT recipients depends
on its incidence in the general population. Spain has a
high TB incidence (18.9 cases per 105inhabitants per
year), a high prevalence of latent TB infection (125%)
, and great transplant activity —that is, it has
the necessary conditions to allow a prospective cohort
study to include a sufficient number of cases for a re-
liable calculation of the incidence of TB and analysis
of its risk factors.
1658 • CID 2009:48 (15 June) • Torre-Cisneros
The main aim of the present research was to study TB in-
cidence and risk factors in a prospective cohort of SOT recip-
ients. Case analysis allowed us to detect changes in the chro-
nology, clinical presentation, and prognosis of the disease.
The RESITRA (Spanish Network of Infection in Transplan-
RESITRA is a research network formed by 16
transplant centers in which all SOTs performed are prospec-
tively included. Pretransplant, peritransplant, and follow-up
data (from 0, 7, 14, 30, 60, 90, 180, 270, 360, 540, and 720
days after transplant) aswellasinfectionsandrejectionepisodes
are prospectively recorded in an online database. Definitions
have been published on the RESITRA Web site . Data are
extracted through managerial and statistical databases gener-
ated from the SQL Server (Microsoft) database, after comple-
tion of a validating process managed by the coordinator at each
hospital. For the present study, we included all transplants in
the prospective RESITRA cohort from September 2003 to the
end of June 2006.
Tuberculin purified protein derivative (PPD) skin test.
A PPD test was conducted at those centers for which it was
included in their protocol. A positive PPD test result was de-
fined as induration of ?5 mm in diameter 48–72 h after the
administration of 2 IU of strain RT-23 (equivalent to 5 IU of
tuberculin PPD). When a patient was found to be positive by
the PPD test, it was recommended that he or she undergo
For TB diagnosis, definitions based on
World Health Organization criteria were used [15, 16]. A pa-
tient was considered to have TB when Mycobacterium tuber-
culosis was isolated by culture or when M. tuberculosis DNA
was isolated from a representative clinical sample, organ fluid,
or tissue by polymerase chain reaction. Patients for whom TB
was demonstrated histopathologically were also accepted. TB
was classified as pulmonary (involvement of pulmonary pa-
renchyma), extrapulmonary (involvement of other organs), or
disseminated (involvement of at least 2 noncontiguous organs).
Patients for whom TB was diagnosed on the basis of clinical
or radiological suspicion (for whom the corresponding phy-
sician prescribed a specific treatment) were not accepted. Def-
initions were normalized and predefined for the cohort .
The patient was considered to have been cured when symp-
toms disappeared (clinical cure) and when no M. tuberculosis
was identified in the same type of clinical sample in which it
had been identified previously (microbiological cure) after
completion of an adequate treatment regimen. Likewise, death
was considered to be related to TB when there was no clinical
and/or microbiological cure at the time of death.
Calculation of TB incidence.
RESITRA cohort was calculated by dividing the number of
patients with a diagnosis of TB by the time included in the
cohort or the number of days at risk, expressed as the number
of cases per 105patients per year. Time of exposure to risk for
each patient was estimated as the time from transplant to the
development of TB, patient death, or the end of follow-up. On
the basis of official incidence data from 2005 , incidence
in the general Spanish population was estimated to be 18.9
cases per 105inhabitants per year.
Immunosuppression and clinical management.
suppression and clinical management were done according to
the protocols of each center.
Variables analyzed as possible risk factors.
factors, we analyzed (1) pretransplant variables (recipient age,
diabetes mellitus, chronic obstructive pulmonary disease,
chronic renal failure, chronic hepatopathy, chronic hepatitis C
virus infection, previous SOT, recipient’s PPD test result, cy-
tomegalovirus serological mismatch [seropositive donor/sero-
negative recipient], and HLA matching); (2) type of trans-
planted organ; and (3) posttransplant variables (use of cy-
closporine, azathioprine, tacrolimus, sirolimus, muromonab-
CD3, basiliximab, daclizumab, and everolimus as well as re-
jection episodes). We could not analyze the value of signs of
residual TB lesions on pretransplant chest radiographs, because
this variable was not included in the RESITRA database.
The global incidence of TB, the inci-
dence of TB among SOT recipients, and the relative risk (RR)
of TB were calculated along with 95% confidence intervals
(CIs). A difference was considered to be statistically significant
if the incidence of TB in the general Spanish population was
found to be outside of the 95% CI of the incidence in the
Continuous variables were expressed either as means and
standard deviations (for variables with a normal distribution)
or as medians and ranges (mostly for variables with a skewed
distribution). Discrete variables were expressed as percentages.
Student’s unpaired t test was used to compare continuous
variables, the Mann-Whitney U test was used to compare con-
tinuous variables with a nonnormal distribution, and the x2or
Fisher’s exact test was used to compare proportions. All sta-
tistical tests were 2-tailed, and the threshold of statistical sig-
nificance was established at
P ! .05
RRs were calculated for variables with statistically significant
differences between patients with and those without TB. Cox
regression was applied individually to each variable to obtain
an RR in univariate analysis. Variables that were statistically
significant () in univariate analysis were introduced into
P ! .05
a multivariate model by means of forward stepwise logistic
regression, to identify independent risk factors for TB. In ad-
The incidence of TB in the
Tuberculosis after SOT • CID 2009:48 (15 June) • 1659
RESITRA (Spanish Network of Infection in Transplantation) cohort.
Characteristics of 4388 solid-organ transplant (SOT) recipients in the
Sex, % male/female
Pretransplant diabetes mellitus
Pretransplant chronic renal failure
Chronic HCV infection
Donor age, mean years ? SD
Recipient age, mean years ? SD
HLA matching (?2 of 6)
CMV serological mismatch (D+/R?)
Positive PPD test result
Duration of follow-up, median days (range)
46.8 ? 18
50.3 ? 13.8
CMV, cytomegalovirus; COPD, chronic obstructive pulmonary disease; D+/R?, seropositive donor/
seronegative recipient; HCV, hepatitis C virus; PPD, tuberculin purified protein derivative; SD, stan-
aData indicate whether the indicated drug was included in the immunosuppressive regimen.
bMuromonab-CD3 is an anti-CD3 monoclonal antibody.
Data are no. (%) of patients, unless otherwise indicated. ATG, antithymocyte globulin;
dition, clinically relevant factors with
ered to be potential confounders (on the basis of experience
and the existing literature) were forced into the multivariate
model, with the aim of investigating their effect. Patients were
censored at death or when they were lost to follow-up. SPSS
statistical software, version 13.0 (SPSS), was used to perform
that were consid-P ! .1
From September 2003 through June 2006, a total of 4388 SOT
recipients were prospectively included in the RESITRA cohort
(2052 kidney transplant recipients, 1507 liver transplant recip-
ients, 404 heart transplant recipients, 303 lung transplant re-
cipients, and 122 kidney-pancreas transplant recipients). The
median duration of follow-up was 360 days (range, 0–720
days). The general characteristics of the cohort are described
in table 1.
Latent TB infection.
In accordance with the protocols of
each center and before transplant, the PPD test was done for
1775 patients (40.5%), and the result was positive for 338
(19.0%). Pretransplant chemoprophylaxis with isoniazid was
performed for 147 (46.2%) of the 338 patients with a positive
PPD test result. Table 2 describes PPD test data by type of
TB frequency and incidence.
(0.48%) of the SOT recipients in the cohort (table 3). This
TB was diagnosed in 21
1660 • CID 2009:48 (15 June) • Torre-Cisneros
Network of Infection in Transplantation) cohort,asdeterminedbythetuberculinpurifiedprotein
derivative (PPD) skin test.
Analysis of latent Mycobacterium tuberculosis infection in the RESITRA (Spanish
aNumber of patients for whom a PPD test was performed per the total number of patients.
bNumber of patients with a positive PPD test result per the number of patients for whom a PPD test was
cNumber of patients who received prophylaxis per the number of patients with a positive PPD test result.
Network of Infection in Transplantation) cohort.
Frequency and incidence of tuberculosis (TB) in the RESITRA (Spanish
Recipients with TB,
proportion (%)Incidencea(95% CI)RR (95% CI)
aCases per 105transplant recipients per year.
CI, confidence interval; RR, relative risk.
frequency represented an incidence of 512 cases per 105patients
per year (95% CI, 317–783), which was statistically significantly
higher than that for the general Spanish population (18.9 cases
per 105inhabitants per year). TB incidence was statistically
higher among SOT recipients than in the general population
for all transplant types except the heart (255 cases per 105
patients per year; 95% CI, 6.5–1421)—for all other transplant
types, the general population’s incidence was within the 95%
CI for the RESITRA cohort. The greatest TB incidence was
observed for lung transplants (2072 cases per 105patients per
year; 95% CI, 565–5306), which was statistically higher than
that observed for kidney transplants (RR, 3.87; 95% CI, 1.14–
13.14). No statistically significant differences were observed be-
tween incidences for any of the other transplant types.
Although the incidence of TB among SOT recipients with a
positive PPD test result (864 cases per 105patients per year;
95% CI, 178–2526) was higher than the incidence among those
with a negative result (190 cases per 105patients per year; 95%
CI, 39–554), the difference was not statistically significant (RR
4.21; 95% CI, 0.84–20.41).
Description of TB cases.
The distribution of the 21 cases
of TB was as follows: 8 cases among 1507 liver transplant re-
cipients (0.53%), 7 among 2052 kidney transplant recipients
(0.34%), 4 among 303 lung transplant recipients (1.32%), 1
among 404 heart transplant recipients (0.25%), and 1 among
122 kidney-pancreas transplant recipients (0.82%) (table 4).
The median age of these patients was 59 years (range, 37–75
For 15 (71.4%) of these 21 patients, no PPD test was per-
formed, and none of them received prophylaxis with isoniazid.
The PPD test result was positive for 3 (50.0%) of the 6 patients
for whom it was performed. Only 1 of these 3 patients received
TB appeared a median of 183 days after transplant (range,
28–499 days). Of the 21 cases, 20 (95.2%) appeared within the
first posttransplant year. Most frequently, TB appeared after the
third month (14 instances [66.7%]); in 7 instances (33.3%),
TB appeared within the first 3 months.
Pulmonary TB was observed in 16 patients (76.2%; 2 cases
had laryngeal involvement), extrapulmonary TB was observed
in 3 patients (14.3%; 1 case of meningitis, 1 case of spondylitis,
and 1 case of genitourinary tract TB), and disseminated TB
was observed in 2 patients (9.5%). TB involved the pulmonary
graft in all lung transplant recipients. No differences were ob-
served in the time of appearance between pulmonary TB and
extrapulmonary or disseminated TB.
Cases of tuberculosis among 4388 solid-organ transplant recipients in the RESITRA (Spanish Network of Infection in Transplantation) cohort.
Patient no. (age in years, sex)
PPD test result
Patient 1 (65, male)
Dead (509) Nonrelated
Patient 2 (63, male)
Progression Dead (152) Related
Patient 3 (38, male)
Patient 4 (43, male)
Patient 5 (59, male)
Patient 6 (60, male)
Patient 7 (67, female)
Patient 8 (70, female)
Patient 9 (75, male)
Hypertensive nephropathy ND
Progression Dead (236) Related
Patient 10 (46, male)
Patient 11 (52, male)
Patient 12 (53, female)
Patient 13 (53, male)
Patient 14 (56, male)
Hypertensive nephropathy Negative
Patient 15 (62, male)
Hypertensive nephropathy ND
Patient 16 (63, male)
Dead (105) Nonrelated
Patient 17 (53, male)
Patient 18 (59, male)
Patient 19 (60, male)
Patient 20 (37, male)
Kidney-pancreas Diabetic nephropathy
Patient 21 (53, male)
C, ciprofloxacin; COPD, chronic obstructive pulmonary disease; E, ethambutol; H, isoniazid; M, moxifloxacin; ND, not done; R, rifamycin (rifampicin or rifabutin); PPD, tuberculin purified protein
derivative; Z, pyrazinamide.
aTime of TB onset, given as the number of days after transplant.
1662 • CID 2009:48 (15 June) • Torre-Cisneros
4388 solid-organ transplant (SOT) recipients in the RESITRA (Spanish Network of
Infection in Transplantation) cohort.
Univariate and multivariate analysis of risk factors for tuberculosis among
RR (95% CI)P RR (95% CI)P
Pretransplant diabetes mellitus
Pretransplant chronic renal failure
Chronic HCV infection
PPD test result
CMV serological mismatch (D+/
HLA matching (?2 of 6)
1.05 (1.0–1.1) .021
logistic regression models (see Results). ATG, antithymocyte globulin; CI, confidence interval; CMV,
cytomegalovirus; D+/R?, seropositive donor/seronegative recipient; COPD, chronic obstructive pul-
monary disease; HCV, hepatitis C virus; PPD, tuberculin purified protein derivative; RR, relative risk.
aMuromonab-CD3 is an anti-CD3 monoclonal antibody.
Boldface type indicates potential risk factors that were consistently retained in the various
Treatment included isoniazid for all patients with TB. The
most widely followed regimen was isoniazid, rifampicin or ri-
fabutin, and pyrazinamide and/or ethambutol (for 2 months),
followed by isoniazid and rifampicin or rifabutin (17 patients
[81%]). For 3 patients, another drug was added for the first 2
months (ethambutol for 2 patients and moxifloxacin for 1).
For 4 patients (19.0%), a rifamycin was not included in the
therapeutic regimen; these patients were treated with isoniazid,
pyrazinamide, and ethambutol for 2 months, followed by iso-
niazid and either ethambutol or pyrazinamide. Ciprofloxacin
was added for the first 2 months for 1 patient. The database
did not enable us to analyze interactions between TB treatment
and immunosuppressive drugs. Multidrug-resistant TBwasnot
Crude mortality was 19.0% (4 cases); however, death was
attributable to TB for only 2 patients (9.5%), 1 liver transplant
recipient with meningitis (who was treated with 3 drugs, in-
cluding rifampicin) and 1 kidney transplant recipient with dis-
seminated TB (who was treated with 4 drugs, none of which
TB risk factors.
To study TB risk factors,wefirstperformed
a univariate analysis comparing patients who had TB with the
remainder of the patients in the cohort (table 5). Because of
the paucity of events inthestudycohort,wecouldnotconstruct
a multivariate logistic regression model that included only the
major potential risk factors; instead, we performed an explor-
atory analysis of the major statistically significant variables ob-
tained in univariateanalysis,adjustingeachvariableforallother
Tuberculosis after SOT • CID 2009:48 (15 June) • 1663
variables by constructing different logistic regression models
that included a maximum of 2 variables. The potential risk
factors that were consistently retained in the various models
were recipient age (RR, 1.05; 95% CI, 1.0–1.1;
lung transplant (RR, 5.6; 95% CI, 1.9–16.9;
) andP p .021
P p .002 ).
Studies of TB after SOT usually report frequencies instead of
incidences , and the frequencies reported have been quite
variable (1.2%–15%) . Our study reports a TB frequency of
0.48%. A retrospective study conducted by GESITRA (Spanish
Transplantation Infection Study Group) in the 1990s observed
a frequency of 0.8% . Other studies conducted in Spain have
shown higher frequencies among both kidney  and lung
[19, 20] transplant recipients. Our data reflect a slight decrease
in the frequency of TB among SOT recipients. The obtained
TB incidence (512 cases per 105patients per year) was much
higher than that observed in the general Spanish population
(18.9 cases per 105inhabitants per year; RR, 26.6), among re-
cipients of allogeneic transplant of hematopoietic stem cells
(135.6 cases per 105transplant recipients per year) , and
among candidates for transplant (80 cases per 105candidates
per year) in our environment . Therefore, patients under-
going SOT should be considered at high risk for the devel-
opment of TB, although differences in incidence have been
shown among different types of organ transplants. For organ
transplants with a low incidence of TB, a greater sample size
is required for differences to appear, as was demonstrated in
the present study for heart transplant recipients.
TB incidence was particularly high among lung transplant
recipients. Receipt of a pulmonary graft instead of another
organ increases the risk of developing TB up to 5.6-fold. In
our series, a lung transplant recipient had a 73.3-fold higher
risk of developing TB than did a person from the general Span-
ish population. This problem was already known—Bravo et al.
 reported a frequency of 6.4% among lung transplant re-
cipients, and in our previous study  prevalence was 1.15%,
similar to that observed here (1.32%). Risk factors that have
been previously described in the literature are previous expo-
sure to M. tuberculosis (positive PPD test result and/or signs
of residual TB lesions on pretransplant chest radiographs), pre-
transplant clinical condition (dialysis, diabetes, cirrhosis, and
hepatitis C virus infection), and the intensity of immunosup-
pression (use of antilymphocyte antibodies, type of basal im-
munosuppression, and intensification of immunosuppressive
treatment as a result of rejection) [1, 5, 8, 10, 22, 23]. The
demonstration that receipt of a pulmonary graft constitutes a
risk factor for TB would be novel.
This reality should result in practical consequences for lung
transplantation. TB should be considered early in the differ-
ential diagnosis of pulmonary infiltrates. For candidates with
pulmonary infiltrates, the results of PPD testing and pretran-
splant chest radiography have limited value, because TB can
appear through the reactivation of latent infection in the graft
(especially for bipulmonary transplant recipients). It would be
necessary to validate the profitability of new techniques—such
as the quantification of interferon-g release in response to M.
tuberculosis antigens (QuantiFERON-TB Gold test; Cellestis)—
for the detection of latent infection in donors [24, 25]. Itshould
also be emphasized that, of the 3 lung transplant recipients in
the present study who developed TB, 2 had negative PPD test
results beforethe transplant,andTBappearedinthepulmonary
Here, recipient age was found to be a risk factor for TB, as
has been observed in at least one other study . The prev-
alence of latent TB infection has progressively decreased in
Spain since the 1960s, likely as a result of an increase in Spain’s
sociohealth level [26, 27]; this may explain why the risk of TB
reactivation is higher in older SOT recipients, given that it
mirrors the situation in the general population.
Current recommendations of chemoprophylaxis are based
on a history of contact with M. tuberculosis (PPD test positivity,
wrongly treated TB, or coresidence with a person with active
TB) and/or the presence of signs of residual injuries on the
recipient’s chest radiograph . These indications should be
kept. The variables included in the RESITRA database hindered
us in assessing whether the presence of signs of residual TB
lesions on pretransplant chest radiographs constitutes a risk
factor. The same problem has been faced by previous studies
of risk factors . The result of the pretransplant PPD test
was positive for 19.0% of patients in the present study, a figure
similar to that reported in our previous series (20%). Only 3
(0.9%) of 338 patients with a positive PPD test result developed
TB, and one of them was a bipulmonary transplant recipient
with graft TB whose PPD test result had limited value. PPD
test positivity and isoniazid prophylaxis were not found to be
risk factors for TB in the present study, but we cannot rule out
the possibility that this finding was due to a lack of statistical
power. The PPD test, despite being widely recommended, was
conducted for only 40.6% of patients, whereas it had been
performed for 59% of patients during the period 1980–1994.
The PPD test was not performed for 15 (71.4%) of the 21
patients with a diagnosis of TB in the present study. Moreover,
prophylaxis was prescribed for less than half of the patients
with a positive PPD test result. It is necessary to insist on the
advisability of performing the PPD test and administering pro-
phylaxis when indicated. Because we cannot identify other risk
factors (e.g., type of transplant and age), classic prevention
strategies maintain all of their currency.
We did not find that the chronology of TB among SOT
recipients is changing. Although in the present study 95% of
cases were diagnosedwithinthefirstyearaftertransplantduring
1664 • CID 2009:48 (15 June) • Torre-Cisneros
the period 2003–2006, compared with 61% during the period
1980–1994 in the preliminary study , patient follow-up in
the present study was far greater, thus favoring the inclusion
of late forms of TB. Neither did we observe a change in the
form in which the infection appeared—pulmonary forms pre-
dominated in both studies. Even though we ascertained a re-
duction in crude mortality (19.0% vs. 31%) and related mor-
tality (9.5% vs. 20%) between the studies, the current TB
mortality figure remains very high.
The use of rifampicin in the transplant context continues to
els. Rifabutin has excellent efficacy with less cytochrome P450
induction, and it is an attractive alternative in the transplant
population. Of the patients in our series, 81% were treated with
a rifamycin. Some series have demonstrated that these drugs
may be safe with rigorous control of immunosuppressor levels
, as has been acknowledged by European guidelines ,
even though in certain cases they have increased the frequency
of rejection and mortality . In the present study, we did
not observe higher crude mortality among patients who re-
ceived a rifamycin (17.6% vs. 25%).
In short, we found the incidence of TB to be higher among
SOT recipients than among the general population, in partic-
ular among lung transplant recipients andolderSOTrecipients.
Nevertheless, our study of risk factors for TB has important
limitations. We could not assess the value of signs of residual
TB lesions on pretransplant chest radiographs, and a PPD test
was not performed in many cases—although positivity was not
related to a higher risk of TB among those for whom a PPD
test was performed. Most patients with a positive PPD test
result were treated with a rifamycin, and use of this class of
drugs was not associated with higher mortality.
We thank the Andalusian Society of Infectious Diseases (Manuel Milla)
for performing statistical analyses.
Spanish Ministry for Health and Consumption,
(grant G03/075), and Spanish Network for Research in Infectious Diseases
Potential conflicts of interest.
All authors: no conflicts.
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