Tuberculosis (TB) Part 3

Other Problems to be Considered:

Blast mycosis
Cat scratch disease

• It is critical that hopitalized patients with suspected or documented TB be placed in appropriate isolation. This includes a private room with negative pressure and adequate air exchanges. Persons entering the room must wear masks or respirators capable of filtering droplet nuclei.

• Patients should remain in isolation until sputum becomes smear-negative; however, patients ordinarily should not be kept in the hospital for the sole purpose of providing isolation, Special arrangements are necessary for patients who live with children, individuals infected with HIV, patients returning to a closed-group setting (eg, nursing home, correctional facilities, residential facility, homeless shelter).

Further Outpatient Care:

• Patients diagnosed with active TB should have sputum examined for M tuberculosis weekly until sputum conversion is documented. Monitoring for toxicity includes baseline and periodic liver enzymes, complete blood count, and serum creatinine.

• In addition, patients on pyrazinamide should have baseline or periodic serum uric acid determinations, and patients on long-term ethambutol therapy should have baseline or periodic visual acuity and red-green color perception testing. The latter can be performed with a standard test such as Inhihara test for color blindness.

Deterrence/Prevention:

• Patients with a clinically significant result on tuberculin skin testing (see other tests) should be given a course of therapy once active infection and disease is ruled out. Guidelines published by the CDC in 2000 now refer to this as treatment of latent TB. The recommended regimens are listed below:

o INH daily for 9 months
o INH twice weekly for 9 months (given as DOT)
o INH daily for 6 months (should not be used in patients with fibrotic lesions on chest radiograph, patients with HIV, or children)
o INH twice weekly for 6 months (given as DOT, should not be used in patients with fibrotic lesions on chest radiograph, patients with HIV, or children)
o Rifampin daily for 4 months
o Rifampin plus pyrazinamide daily for 2 months

• Children should be given INH for 9 months. In addition, children younger than 5 years who have closed contact to an active case of TB should be started on INH even of skin testing is negative; preventive therapy can be stopped if repeat skin testing is negative 3 months after last contact with a culture positive source case.
•
Patient exposed to MDR-TB may be given ethambutol plus pyrazinamide for 6 – 12 months or pyrazinamide plus levofloxacin for 6 – 12 months; the index isolate should be susceptible to all drugs used.

• Recommended regimens in patients with HIV infection include pyrazinamide plus rifampin daily for 2 months, rifampin alone daily for 4 months, or 9 months of INH (daily or twice weekly). Patients on antiretroviral therapy may need rifabutin in place of rifampin.

Patients should remain in isolation until sputum becomes smear-negative; however, patients ordinarily should not be kept in the hospital for the sole purpose of providing isolation, Special arrangements are necessary for patients who live with children, individuals infected with HIV, patients returning to a closed-group setting (eg, nursing home, correctional facilities, residential facility, homeless shelter).

Dr. D.S. Merchant Resident Medicine
Gold Medalist (Anatomy & Histology)
Visit: http://www.lipidholdings.com

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