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The steady decline in tuberculosis case rate reversed in the mid-1980s, and tuberculosis cases have increased dramatically since that time. Important factors contributing to this increase are the human immunodeficiency virus (HIV) epidemic and tuberculosis occurring in foreign-born persons. Tuberculosis outbreaks have occurred in HIV clinics and wards, prisons, homeless shelters, nursing homes, and health care facilities. Some of the outbreaks have involved strains of tuberculosis resistant to multiple antituberculosis drugs. Recent recommendations for initial therapy of tuberculosis include the use of four drugs and directly observed therapy in an effort to prevent the emergence of further drug resistance.

Short-course chemotherapy has made the treatment of TB easier and better than ever, but it works only when patients take the drugs regularly. Compliance is a must for therapy to be successful. Physicians treating patients with tuberculosis should be acutely aware of noncompliance, and every effort to ensure adequate treatment must be put forth. Directly supervised therapy is an excellent option when enough resources are available. Intermittent regimens markedly reduce the manpower required for observed therapy. New agents are being tested for in vitro activity against M. tuberculosis, and clinical studies of those found to be potentially effective are needed to formulate new regimens against the ever-increasing threat of multidrug-resistant TB.

Pulmonary tuberculosis (TB) and bacterial pneumonia are both characterized by fever, cough, and purulent sputum production. Although TB alone can cause these symptoms, the possibility of a concomitant bacterial pneumonia has led some clinicians to treat these patients empirically with antibacterial agents. Neither the benefit of such empiric antibiotic therapy nor transtracheal aspirate cultures from patients with pulmonary TB have yielded consistent results. Consequently, we performed a prospective study to obtain lower airway secretions via a bronchoscopic protected specimen brush (PSB) technique for quantitative aerobic and anaerobic cultures from untreated patients with extensive pulmonary TB (defined as cavitary disease or involvement of > or = 3 segments). We obtained bronchoscopic samples from 3 untreated men aged 21, 61, and 60 years with extensive pulmonary TB. There was no significant bacterial growth (aerobic or anaerobic) from the specimens obtained. These results, therefore, do not support the hypothesis that bacterial pneumonia is a common concomitant of extensive pulmonary TB.

The speed and accuracy of diagnosis of tuberculosis on general medical teaching services were retrospectively compared to that on a designated publicly funded tuberculosis service and to recent discouraging reports in the literature. The diagnosis was confirmed in all patients on the designated service and in 78.8% of patients not on the designated service within one week. No patient was discharged undiagnosed. Acid-fast smears done by the hospital laboratory showed a sensitivity of 82.5% and a specificity of 98.4%. Radiologic reports indicated the presence of tuberculosis or cavities in 85% of chest x-ray films in patients with pulmonary disease. These results may indicate that a publicly funded tuberculosis service, by providing emphasis on tuberculosis, allows more rapid and accurate diagnosis of tuberculosis in all patients. The impact of such training on future health care delivery should be recognized when decisions regarding allocation of public funds are made.