Physician attitudes regarding bacille Calmette-Guérin vaccination and treatment of latent tuberculosis infection.

OBJECTIVE: To investigate the attitudes of international medical graduates (IMGs) about treatment of latent tuberculosis infection (LTBI). DESIGN: Anonymous survey among physicians in training, all IMGs from TB endemic countries. Attitudes were assessed through hypothetical scenarios regarding the protective effect of BCG and LTBI treatment. RESULTS: Of 77 participants, 72.4% were male, the mean age was 31.4 years, and mean years post-graduation 8. Positive tuberculin skin tests (TSTs) were reported among 64.0%, and 89.6% had received BCG vaccine. Over a quarter of IMGs (27.4%) believed that BCG protects for many years. Only 59.2% believed that LTBI treatment was effective and 16% that the risks of treatment were greater than the benefits. Most would treat BCG-vaccinated patients with positive TST in various scenarios (63-94.7%), with less agreement about treating themselves (49.3%) or their family members (54.2%). For recent converters, more than 80% would recommend LTBI treatment. Over half felt that LTBI treatment should be mandatory for new immigrants with positive TST. CONCLUSIONS: IMGs are cautious about LTBI treatment except for recent converters. They are less likely to treat themselves and family members than others. Educational efforts should address discrepancies between these physicians' attitudes and current guidelines for treating LTBI in the US.

Pneumocystis carinii pneumonia as the first presentation of HIV infection in patients older than fifty.

A significant increase in the number of elderly patients first diagnosed with HIV infection at the time of presentation with an AIDS-related opportunistic infection has recently been reported. This suggests a significant delay in the diagnosis of HIV infection. Few data are available describing such cases and their outcome. We restrospectively reviewed records of all elderly patients (> 50 years of age) admitted to a New York City hospital over a 3-year period with confirmed Pneumocystis carinii pneumonia (PCP). The mean age was 57.9 +/- 6.6 years. In 80% (8 of 10 cases), the diagnosis of HIV infection was made at presentation with PCP. The mean CD4 count was 34.2 +/- 39.2/mm3 (1-117/mm3), indicating advanced AIDS. The clinical presentation of PCP was similar to that in younger patients. With prompt and appropriate therapy, a 70% survival rate for this hospitalization was achieved, similar to that reported in younger age groups. The diagnosis of HIV infection was not considered until presentation with PCP at an advanced stage of AIDS in 80% of these elderly patients, thus delaying institution of HIV treatment and counseling. Early consideration of HIV infection in the elderly is of importance because of the rising number of AIDS cases in this age group.