TBSure: an ESGMYC survey of pediatric TB management practices in high-income countries.

Introduction: Tuberculosis (TB) remains a leading cause of pediatric morbidity and mortality worldwide, with diagnostic and therapeutic challenges continuing to affect outcomes, including in high-income settings. The TBSure study investigated current practices in pediatric TB diagnosis and management across multiple countries, aiming to identify variations, strengths, and gaps in real-world care and to inform evidence-based recommendations. Methods: We conducted a cross-sectional, structured survey distributed to healthcare professionals involved in pediatric TB care through a professional network. The questionnaire assessed diagnostic approaches, specimen selection, use of microbiological and molecular tests, treatment regimens for active and latent TB, monitoring practices, and adherence to international (WHO 2022, ERS/ECDC 2017 and IJTLD 2023) guidelines. Descriptive analyses were performed to summarize practices and identify variability across settings. Results: A total of 60 participants from 17 countries responded, predominantly from Europe. In children unable to expectorate, early-morning gastric aspirates were used by 47% of respondents, induced sputum or gastric aspirate depending on age by 29%, and induced sputum alone by 18%. Smear microscopy and culture were systematically performed by 86 and 63% of respondents, respectively. Rapid molecular testing was routinely performed by 80%. Culture was systematically requested following negative nucleic acid amplification test results in 88% of cases. Molecular drug-resistance testing on initial samples was commonly requested, most frequently for rifampicin resistance alone (47%) or combined rifampicin and isoniazid resistance (41%). Treatment practices for presumed drug-susceptible tuberculosis were uniform across respondents, with universal use of the standard 6-month regimen. However, implementation of the 4-month regimen for non-severe disease was inconsistent, being reported by only 47% of respondents. Fluoroquinolones were used as first-line therapy in cases of suspected isoniazid resistance by 49% of respondents and in tuberculous meningitis by 33%. Baseline blood testing (92%), toxicity monitoring (67%), HIV testing (86%), and post-discharge directly observed therapy (83%) were widely implemented. Conclusion: Pediatric TB practices are generally aligned with guidelines, with widespread use of rapid molecular testing and standardized treatment regimens, but substantial heterogeneity persists for diagnostic approaches and isolation measures. Strengthening implementation of evolving international recommendations may improve early diagnosis, treatment consistency, and outcomes for children affected by tuberculosis.