Implementation efficiency of a diagnostic algorithm in sputum smear-negative presumptive tuberculosis patients.

BACKGROUND: For the diagnosis of smear-negative pulmonary tuberculosis (PTB), India’s Revised National Tuberculosis Control Programme (RNTCP) recommends a course of broad-spectrum antibiotics after negative smear on initial sputum examination, followed by repeat sputum examination and chest X-ray (CXR). OBJECTIVES: 1) To ascertain the proportion of presumptive PTB patients smear-negative on initial sputum examination who completed the diagnostic algorithm, and 2) to investigate barriers to the completion of the algorithm. METHODS: In Karnataka State, India, 256 study participants were interviewed in 2012 to ascertain the number of days antibiotics had been prescribed and consumed, the number of re-visits to health centre(s), whether repeat sputum examinations had been performed, whether or not CXR had been performed andwhen, and whether PTB had been diagnosed. In-depth interviews were conducted with 19 medical officers. RESULTS: The diagnostic algorithm was completed in 13 (5.1%) of 256 participants; three were diagnosed with PTB without completing the algorithm. Most medical officers were unaware of the algorithm, had trained 5–10 years previously, prescribed antibiotics for ,10 days and advised CXR without repeat sputum examination, irrespective of the number of days of antibiotic treatment. Other main reasons for noncompletion of algorithm were patients not returning to the health centres and a proportion switching to the private sector. CONCLUSION: Refresher training courses, raising patient awareness and active follow-up of patients to complete the algorithm are suggested.