Subscribe for unlimited access to DynaMed content, CME/CE & MOC credit, and email alerts on content you follow.

Already subscribed? Sign in now

CME

Latent Tuberculosis Infection (LTBI)

General Information

Description

  • LTBI is defined as infection with Mycobacterium tuberculosis in the absence of clinical disease and is detected by the presence of an immune response to M. tuberculosis antigens 1,2,3

Also called

  • LTB
  • latent tuberculosis

References

General references used

  1. Chee CBE, Reves R, Zhang Y, Belknap R. Latent tuberculosis infection: Opportunities and challenges. Respirology. 2018 Oct;23(10):893-900
  2. World Health Organization guideline on programmatic management of latent TB infection WHO 2018 PDF
  3. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017 Jan 15;64(2):e1-e33full-text

Recommendation grading systems used

  • Centers for Disease Control and Prevention/National Institutes of Health/HIV Medicine Association of Infectious Diseases Society of America (CDC/NIH/IDSA) grading system for recommendations
    • strength of recommendation
      • A - strong recommendation for the statement
      • B - moderate recommendation for the statement
      • C - optional recommendation
    • quality of evidence for recommendation
      • I - 1 or more randomized trials with clinical outcomes and/or validated laboratory endpoints
      • II - 1 or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes
      • III - expert opinion
    • Reference - CDC/NIH/IDSA guideline on prevention and treatment of opportunistic infections in HIV-infected adults and adolescents (AIDSinfo 2018 May 29PDF)
  • American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America (ATS/CDC/IDSA) 2016 grading system
    • strength of recommendation
      • Strong - most individuals should receive the intervention
      • Conditional or Weak - be prepared to help individuals make a decision that is consistent with their own values/decision aids and shared decision making
    • quality of evidence
      • High - randomized trials or very high-quality observational studies
      • Moderate - randomized trials with a methodologic downgrade or high-quality observational studies
      • Low - observational studies or randomized trials with 2 methodologic downgrades
      • Very low -
        • case series or case reports
        • observational studies with a methodologic downgrade
        • randomized trials with three methodologic downgrades
    • Reference - ATS/IDSA/CDC clinical practice guideline on diagnosis of tuberculosis in adults and children (27932390Clin Infect Dis 2017 Jan 15;64(2):e1)
  • American Thoracic Society/Centers for Disease Control and Prevention (ATS/CDC) rating system
  • American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America (ATS/CDC/IDSA) 2005 rating system
  • World Health Organization (WHO) 2018 recommendation grading system
    • strength of recommendations
      • Strong - confident that desirable effects of adherence to recommendation outweigh undesirable effects
      • Conditional - less certain about balance between benefits and harms or disadvantages of implementing a recommendation
    • certainty of evidence
      • High - very confident that true effect lies close to that of estimate of effect
      • Moderate - true effect is likely to be close to estimate of effect, but possibility that it is substantially different
      • Low - true effect may be substantially different from estimate of effect
      • Very low - true effect likely to be substantially different from estimate of effect
    • Reference - WHO guideline on programmatic management of latent TB infection (WHO 2018 PDF)
  • World Health Organization (WHO) recommendations classification
    • strength of recommendation
      • Strong - desirable effects of adherence to recommendation clearly outweigh undesirable effect, based on high-quality evidence
      • Conditional - desirable effects of adherence to recommendation probably outweigh undesirable effects, but trade-offs are uncertain, recommended course of action can be adjusted on basis of feasibility and acceptability
      • Weak - insufficient evidence and based on field application and expert opinion
    • quality of evidence
      • High - further research is very unlikely to change confidence in the estimate of effect
      • Moderate - further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate
      • Low - further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate
      • Very low - any estimate of effect is very uncertain
    • Reference - WHO guideline on treatment of tuberculosis (fourth edition) (WHO 2010 PDF)
  • World Health Organization (WHO) recommendations classification
    • strength of recommendation
      • Strong - panel is confident that desirable effects of adherence to recommendation outweigh undesirable effects either in favor of or against an intervention
      • Conditional - panel concluded desirable effects of adherence to recommendation probably outweigh undesirable effects, but panel not confident about trade-offs
    • quality of evidence
      • High - further research is very unlikely to change confidence in the estimate of effect
      • Moderate - further research is likely to have an important impact on confidence in the effect
      • Low - further research is very likely to have an impact on the estimate of effect and is likely to change the estimate
      • Very low - any estimate of effect is very uncertain
    • Reference - WHO guideline on management of latent tuberculosis infection (WHO 2015 PDF)
  • Pediatric Tuberculosis Control Group (PTCG) grading system for recommendations
    • strength of recommendation
      • Grade A - preferred
      • Grade B - acceptable alternative
      • Grade C - offer when preferred or alternative regimens cannot be given and should not generally be given
      • Grade D - should never be offered
    • quality of evidence supporting the recommendation
      • Level I - at least 1 randomized trial with clinical endpoints
      • Level II - data from clinical trials that are not randomized or were conducted in other populations
      • Level III - expert opinion
    • Reference - PTCG targeted tuberculin skin testing and treatment of latent tuberculosis infection in children and adolescents (Pediatrics 2004 Oct;114(Suppl 4):1175full-text)
  • American College of Rheumatology (ACR) levels of evidence
    • Level A - data derived from multiple randomized controlled trials or meta-analyses
    • Level B - data derived from single randomized trial or nonrandomized studies
    • Level C - data derived from consensus opinion of experts, case studies, or standards of care
    • Level C* - medical literature (potentially including randomized trials, observational studies, or case series) might have addressed general topic but did not address specific clinical situations or scenarios reviewed by task force panel creating recommendations
    • References
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade Definitions

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed Team-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
  • All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
  • DynaMed content includes Practice-Changing Updates, with support from our partners, McMaster University and F1000.

Special acknowledgements

On behalf of the American College of Physicians
  • Barbara Turner, MD, MSEd, MACP, ACP Deputy Editor, Clinical Decision Resource, as part of the ACP-EBSCO Health collaboration, managed the ACP peer review of the Overview and Recommendations section and related clinical content in this topic.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114028, Latent Tuberculosis Infection (LTBI); [updated 2018 Dec 04, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114028. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

top

Subscribe for unlimited access to DynaMed content.
Already subscribed? Sign in