Care of flexible bronchoscopes.

that RZ would be the most effective and the least expensive option for immigrants from Vietnam, Haiti, and the Philippines. 2 This issue may be even more cogent in Europe, given the massive migratory flows from low-income countries and considering that, unlike the United States, HIV-positive legal immigrants , who are at higher risk for active tuberculosis, are not expelled. The European framework for tuberculosis control and elimination, including the recommendation of using INH for LTB treatment in specific groups, has been recently published. 3 Nevertheless, in different European countries the origin of the immigrants' population may vary, and consequently the level of INH resistance too. For instance, in a multicenter study 4 in Italy, in 2000 primary INH resistance in immigrants was reported to be 9.4%. In a survey of patients referred to the General Hospital of Verona from January 2000 to June 2003, among 231 isolates of Mycobacterium tuberculosis, 28 of 41 of strains (68.3%) resistant to at least one antituberculosis drug were from immigrants (23.9% of cases in this category of patients). Overall resistance to INH was detected in 23 strains (9.9%); 60.8% of these were isolated in immigrants from the African continent (mainly Sene-gal, Ghana, Ivory Coast, and Nigeria) who were infected by INH-resistant strains in 22.2% of cases. These data highlight that in the area of Verona, the INH resistance rate among immigrants is much higher compared to the national level. Therefore, the use of INH as LTB treatment could be inadequate in nearly one of four African immigrants. We believe that it is essential to evaluate the origin of immigrants in a specific area while preparing national and local guidelines for LTB treatment because of the possibility of different resistance patterns. Considering the high level of INH resistance in some endemic areas, regimens including rifampin should be recommended. Nevertheless, following the recent withdrawal of the RZ regimen in the United States, new options for LTB treatment are urgently needed. In the meantime, based on a cost-effectiveness evaluation, we would suggest that in young immigrants from high tuberculosis prevalence countries with known high INH resistance, especially if at increased risk, such as HIV-positive subjects, RZ could be still considered in absence of any hepatopathy. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). References 1 Update: adverse event data and revised American Thoracic Society/CDC recommendations against …