Skip to main content Accessibility help

Failure to Implement Respiratory Isolation: Why Does it Happen?

  • Kentaro Iwata (a1), Barbara A. Smith (a2), Eloisa Santos (a2), Bruce Polsky (a1) (a2) and Emilia M. Sordillo (a1) (a2) (a3)...



Respiratory isolation for 90% of individuals with acid-fast bacillus (AFB)-smear–positive tuberculosis (TB) is a recommended performance indicator in recent Infectious Diseases Society of America and Centers for Disease Control and Prevention guidelines. However, compliance with respiratory isolation reported from multiple centers in the United States and Europe falls short of that goal.


To identify missed clues in TB patients who are not appropriately isolated.


Retrospective survey.


A 900-bed voluntary hospital.


All patients with AFB-smear–positive TB admitted between January 1995 and December 1999 who were not appropriately isolated.


There were 173 TB cases admitted, including 106 with pulmonary TB. AFB smears were positive in 82 cases; 24 (29%) of these were not appropriately isolated. During the study period, the number of TB cases declined, but the proportion of appropriately isolated patients did not change. Most isolation failure cases were men (median age, 45.5 years); 21 of these patients were black, 2 were Hispanic white, and 1 was Asian, but none was non-Hispanic white. All isolation failure cases had at least one characteristic predictive of TB that could have been elicited at admission (eg, abnormal chest radiograph findings consistent with TB, fever, weight loss, a history of TB, a positive result on tuberculin skin test, hemoptysis, and human immunodeficiency virus infection).


Consistent with experiences at other hospitals, we found that the rate of isolation failure remained unchanged despite an overall decline in TB cases. In our experience, almost all isolation failures could be avoided by careful review of the history, physical examination, and chest radiograph for characteristics classically considered predictive of TB. (Infect Control Hosp Epidemiol 2002;23:595-599).


Corresponding author

St. Luke's-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025


Hide All
1.Pearson, ML, Jereb, JA, Frieden, TR, et alNosocomial transmission of multi-resistant Mycobacterium tuberculosis: a risk to patients and health care workers. Ann Intern Med 1992;117:191196.
2.Centers for Disease Control and Prevention. Outbreak of multidrug-resistant tuberculosis at a hospital: New York City, 1991. MMWR 1993;42:427434.
3.Center for Disease Control. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons: Florida and New York, 1988-1991. MMWR 1991;40:585591.
4.Edlin, BR, Tokars, JI, Grieco, MH, et alAn outbreak of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome. N Engl J Med 1992;326:15141521.
5.Coronado, VG, Beck-Sague, CM, Hutton, MD, et alTransmission of multidrug-resistant Mycobacterium tuberculosis among persons with human immunodeficiency virus infection in an urban hospital: epidemiologic and restriction fragment length polymorphism analysis. J Infect Dis 1993;168:10521055.
6.Busillo, CP, Lessnau, KD, Sanjana, V, et alMultidrug resistant Mycobacterium tuberculosis in patients with human immunodeficiency virus infection. Chest 1992;102:797801.
7.Center for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990;39(RR-17):129.
8.Center for Disease Control. Screening for tuberculosis and tuberculous infection in high-risk populations: recommendations of the Advisory Committee for Elimination of Tuberculosis. MMWR 1990; 39(RR-8):17.
9.Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. MMWR 1994;43(RR-13):1132.
10.Kenyon, TA, Ridzon, R, Luskin-Hawk, R, et alA nosocomial outbreak of multidrug-resistant tuberculosis. Ann Intern Med 1997;127:3236.
11.Nivin, B, Nicholas, P, Gayer, M, Frieden, TR, Fujiwara, PI. A continuing outbreak of multidrug-resistant tuberculosis, with transmission in a hospital nursery. Clin Infect Dis 1998;26:303307.
12.Horsburgh, CR Jr, Feldman, S, Ridzon, R. Practice guidelines for the treatment of tuberculosis. Clin Infect Dis 2000;31:633639.
13.Wisnivesky, JP, Kaplan, J, Henschke, C, McGinn, TG, Crystal, RG. Evaluation of clinical parameters to predict Mycobacterium tuberculosis in inpatients. Arch Intern Med 2000;160:24712476.
14.Knirsch, CA, Jain, NL, Pablos-Mendez, A, Friedman, C, Hripcsak, G. Respiratory isolation of tuberculosis patients using clinical guidelines and an automated clinical decision support system. Infect Control Hosp Epidemiol 1998;19:94100.
15.Tattevin, P, Casalino, E, Fleury, L, Egmann, G, Ruel, M, Bouvet, E. The validity of medical history, classic symptoms, and chest radiographs in predicting pulmonary tuberculosis: derivation of a pulmonary tuberculosis prediction model. Chest 1999;115:12481253.
16.White, AH, Khatib, R, Riederer, KM, Flood, M. Respiratory isolation in a teaching hospital with low-to-moderate rate of tuberculosis: compliance with Centers for Disease Control and Prevention guidelines for identifying patients who may have active tuberculosis. Am J Infect Control 1997; 25:467470.
17.Moran, GJ, McCabe, F, Morgan, MT, Talan, DA. Delayed recognition and infection control for tuberculosis patients in the emergency department. Ann Emerg Med 1995;26:290295.
18.Tokars, JI, McKinley, GF, Otten, J, et alUse and efficacy of TB infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis. Infect Control Hosp Epidemiol 2001;22:449455.
19.Blumberg, HM, Watkins, DL, Berschling, JD, et alPreventing the nosocomial transmission of tuberculosis. Ann Intern Med 1995;122:658663.
20.Bock, NN, McGowan, JE Jr, Ahn, J, Tapia, J, Blumberg, HM. Clinical predictors of tuberculosis as a guide for a respiratory isolation policy. Am J Respir Crit Care Med 1996;154:14681472.
21.Roy, MC, Fredrickson, M, Good, NL, Hunter, SA, Nettleman, MD. Correlation between frequency of tuberculosis and compliance with control strategies. Infect Control Hosp Epidemiol 1997;18:2831.
22.Pitchenik, AE, Rubinson, HA. Radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS. American Review of Respiratory Disease 1985;131:393396.
23.Selwyn, PA, Hartel, D, Lewis, VA, et alA prospective study of the risk of tuberculosis and intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989;320:545550.
24.Craft, DW, Jones, MC, Blanchet, CN, Hopfer, RL. Value of examining three acid-fast bacillus sputum smears for removal of patients suspected of having tuberculosis from the “Airborne Precautions” category. J Clin Microbiol 2000;38:42854287.
25.Nelson, SM, Deike, MA, Cartwright, CP. Value of examining multiple sputum specimens in the diagnosis of pulmonary tuberculosis. J Clin Microbiol 1998;36:467469.
26.Warren, JR, Battacharya, M, De Almeida, KN, Trakas, K, Peterson, LR. A minimum 5.0 ml of sputum improves the sensitivity of acid-fast smear for Mycobacterium tuberculosis. Am J Respir Crit Care Med 2000;161:15591562.
27.Di Perri, G, Cruciani, M, Danzi, MC, et alNosocomial epidemic of active tuberculosis among HIV-infected patients. Lancet 1989;2:15021504.
28.Fenelly, KP, Nardell, EA. The relative efficacy of respirators and room ventilation in preventing occupational tuberculosis. Infect Control Hosp Epidemiol 1998;19:754759.

Related content

Powered by UNSILO

Failure to Implement Respiratory Isolation: Why Does it Happen?

  • Kentaro Iwata (a1), Barbara A. Smith (a2), Eloisa Santos (a2), Bruce Polsky (a1) (a2) and Emilia M. Sordillo (a1) (a2) (a3)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.