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TBTable of Contents

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CLINICAL PROTOCOLS

Tuberculosis Matrix......................................................................................................................1

Recommendations for Sputum Collection....................................................................................7

Managing Laboratory Data................................................................................................8

Classifying te Tuberculin S!in Test Reaction............................................................................."

Recommendations for #nfants$ Cildren$ % &dolescents............................................................1'

#ndications for T(o)Step Tuberculin S!in Tests *Tsts+...............................................................11

CASE MANAGEMENT

,uidelines % Recommendations for -sing lood &ssays..........................................................1/Recommendations for -se of #,R&s.........................................................................10

uanti23R45)T ,old Test *2T),+.......................................................................18

uanti23R45)T ,old #n)Tube Test *2T),#T+.......................................................1"

T)S64T.T Test *T)S64T+......................................................................................../'

Ris! factors for 6rogression of #nfection to &ctie T................................................................/1

Treatment &lgoritm for Culture 6ositie5egatie T...............................................................//

Directly 4bsered Terapy *D4T+...................................................................................09

Drug Regimens for T % Drug Resistant T

Drug Regimens for Culture)6ositie 6ulmonary T.................................................../9

Does of &ntiT drugs for &dults and Cildren............................................................/:

6yridoxine *;itamin :+ Supplementation................................................................../8

6otential Regimens for Management of Drug)Resistant 6ulmonary T.....................01

Management of Treatment #nterruptions....................................................................................0/

Ris! 2actors for MT #nfection *LT#+........................................................................................00

Directly 4bsered 6reentie Terapy *D46T+..............................................................0<

Treatment for Latent T #nfection....................................................................................09

Contact #nestigation.......................................................................................................08

References % =>4 T #ncidence Lin!...........................................................................9/

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TUBERCULOSIS MATRIX

Condition Assessment Education Follow-up

Classification 0

No TB Exposure

Not Infected

TB Risk Assessment with targeting testing

of persons in at-risk groups

Pesons at Inceased Ris! "o

M#co$acteium tu$eculosis In"ection

• Close contacts of a person known or

suspected to hae actie TB disease• !oreign-"orn persons# including children

who hae immigrated within the last $

%ears from areas where TB is prealent&&

• 'ersons who isits areas with a high TB

prealence# especiall% if isits are fre(uent

or prolonged

• Residents and emplo%ees of high-risk

congregate settings

• )ealth care workers *)C+s, who sere

high-risk clients

• edicall% undersered# low income

populations# homeless

• )igh-risk racial or ethnic minorit%

populations

• 'ersons who a"use drugs or alcohol

• Infants# children# and adolescents exposed

to adults at high-risk for latent TB

infection or actie TB disease

Complete TB Risk Assessment prior to

tu"erculin skin test *T.T, or "lood assa%for %co"acterium tu"erculosis *BAT,

for all classifications/ T.Ts are preferred

for children aged less than fie %ears/

Tu"erculin skin test *T.T,

with 'urified 'rotein eriatie *'',using the Mantou% met&od 'use

Tu$esol anti(en)

The T.T must "e gien and read "% a

nurse per 1entuck% Board of Nursing

Educate on signs and s%mptoms

of actie TB disease# risk factorsfor 2atent TB Infection *2TBI,#

and risk factors for rapid

progression from 2TBI to actie

TB disease

Two-step TST*

• If first step T.T is positie#

consider the person infected/

• If first step T.T is negatie#

gie the second step T.T

345 weeks later/

• If second step T.T is

positie# consider person

infected/

• If second step T.T is

negatie# consider person

uninfected/

BAT reported as positie#

consider person infected/

.ome groups ma% need annual TB Risk

Assessments/ .ome groups# e/g/ )C+sma% need annual T.Ts or BATs in

addition to annual TB Risk Assessments

All testing actiities should "e

accompanied "% a plan for follow-up

care/

'atients should return in 67489 hours fo

T.T reading# interpretation# and

recording "% nurse/

Anerg% .uspectso not rule out TB diagnosis "ased on

negatie skin test result: consider anerg%if immunosuppressed: also see other

diseases;conditions that can causesuppression of dela%ed-t%pe

h%persensitiit% *T), response/

+ela#ed t#pe &#pesensiti,it# '+T)

anti(en tests ae not ecommended "o

administation at L+s.

* .ee Core Curriculum on Tuberculosis *9033, for TB Classification .%stem/ &&.ee ta"les with international TB incidence and prealence rates in this reference for more information/

MMWR, Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, June 9, 2000

3/ Each 2) shall hae a designated emplo%ee responsi"le for Tu"erculosis *TB, serices in their count%/ This person must attend periodic TB updates or keep updated "% haing the latesteducational and scientific materials for the preention and control of TB from CC;AT.;A2A# the .outheastern National Tu"erculosis Center# and other National Tu"erculosis Centers/

9/ The physician or clinician knowledgea"le in the field of m%co"acterial diseases shall proide patient care/ The% shall agree to update themseles through professional meetings# consultationsand reiew of <ournal articles/ This must "e a component of an% 2) contract for TB clinician serices/

This current classification system of tuberculosis (TB) is based on the pathogenesis of TB. A person with a classification of 3 or 5 should be receiving drug treatment for TB, and should be

reported to the !".#

'age 9 of $9Core Clinical .erice =uide

.ection> TB.eptem"er 3# 9039

.ee procedure for T.T inthis reference/ Reiew

CC T.T ?ideo# 9005

.ee T.T Recommendations for Infants# Children#and Adolescents# p 33 in this reference

A two-step T.T is usuall%

recommended initiall% for>

An%one e/uied to hae

e(ula TB testing# regardless

of age

BATs are one-step in-itro tests

that assess for the present of

infection with M. tuberculosis.

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TUBERCULOSIS MATRIX 'Continued)

Condition Assessment Education Follow-up

Classification 0

*Continued,

No TB Exposure

Not Infected

=roups that s&ould "e TB Tested

*Continued,

Pesons at &i(&e is! "o de,elopin(

acti,e TB disease once in"ected

• 'ersons with )I? infection

• Infants and children aged less than fie *$,

%ears

• 'ersons recentl% infected with

Mcobacterium tuberculosis *within the

past two *9, %ears/

• Cigarette smokers and persons who a"use

drugs or alcohol

• 'ersons with a histor% of inade(uatel%

treated TB

• 'ersons with certain medical

conditions

Examples of groups that are not included inthe +R# @une 3# 9000# Targeted

Testing are>

!oster care parents# da% care workers#

firefighters# police# school emplo%ees#

school children# and food serice workers/

em"ers of these groups should receie

indiidual TB risk assessments# and targeted

tu"erculosis testing so that T.Ts or BATs

are administered to those at increased risk/

eelop a polic% that the 2) will

repeat T.Ts gien "% other health care

proiders not trained "% the 2) unless

their skill is known and trusted "% the

2)/

2)s NT need a similar polic% for

repeating BATs/

T.Ts administered "% 2)s can "e read

"% staff in other 2)s and do not usuall%

need to "e repeated/



'ersons with )I? infection

'ersons who are receiing immunosuppressie therap% such as tumornecrosis factor--alpha *TN!-, antagonists# s%stemic corticosteroids

e(uialent to D3$ mg of prednisone per da%# or immune suppressie

drug therap% following organ transplantation

.ilicosis

ia"etes mellitus

Chronic renal disease

Certain hematologic disorders *leukemias and l%mphomas,

Cancer of the head# neck# or lung

=astrectom% or <e<unoileal "%pass

'eople receiing immunosuppressie therap% for rheumatoid arthritisor Crohns disease

2ow "od% weight *BI F 3,

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Condition Assessment Teatment Education Follow-up

Classification 3

TB Exposure

*contact,# no eidenceof infection

Identi"# contacts within 0 wo!da#s of

suspect;case report# using prioritiGation andthe Concentric Circle Approach *p/ 66,/

Administer TST o daw $lood "o

BAMT and E%amine high-risk contacts

within 1 wo!da#s of identification *.ee

pages 57 and 6,

=ie T.T or draw "lood for BAT for

medium and low-risk contacts "ased on

findings from the Concentric Circle

Approach *.ee pages 66 and 6,

o the following>

3/ edical )istor%9/ T.T or BAT *unless there is

preiousl% documented positiereaction,

5/ Chest x-ra%# at t&e same time thosewho>

• )ae TB s%mptoms

• Are )I? infected or hae other

immunosuppressed conditions

• Are F 6 %ears of age

'osterior4Anterior *'A, chest

x-ra% is the standard iew used to detect

a"normalities

'A and lateral iew should "e done on

those F $ %ears of ageTargeted Testing, !age 2"

If s%mptomatic# see sputum collection

recommendations in this reference and in

online forms/

Infants and Children F$ %ears of age# who

are high priorit% contacts and who hae anegatie T.T or negatie BAT# should

"e started on window period proph%laxis#with therap% administered "% irectl%

"sered 'reentie Therap% *'T,

until retested in 7-30 weeks/

If repeat T.T or BAT is positie#

continue medicines "% 'T *see

classification 9,

If repeat T.T or BAT is negatie# stop

medicine unless contact with infectious

case has not or cannot "e "roken/

Contacts with immunocompromising

conditions *e/g/ )I?-infected, that hae a

negatie T.T or negatie BAT should "e started on window proph%laxis therap%

"% 'T until retested in 7-30 weeks/ Ifthe repeat T.T or BAT remains

negatie# and an ealuation for actie TB

disease is negatie# a full course oftreatment for 2TBI should still "e

completed/

.ee edications to Treat 2TBI in this

reference

iscuss>

• )ow TB is transmitted

• 2TBI ersus actie TB

disease

• Importance and

significance of repeat skin test

in 7-30 weeks• Treatment of actie TB

disease or 2TBI

• Importance of taking

medicine on a regular "asis if

indicated

.teps for patient producing asputum specimen at home>

• Clean H thoroughl%

rinse mouth with water

• Breathe deepl% 5 times

*a tickling sensation at end of

"reath,

• After 5rd "reath# cough

hard H tr% to "ring up sputum

from deep in lungs

• Expectorate sputum

into a sterile containercollecting at least one

teaspoonful

• 'erform this in a

properl% entilated room#

"ooth# or outdoors

'roide patient information for an

informed consent/

If T.T or BAT is negatie# must retur

7430 weeks after contact has "een

"roken# for repeat T.T or BAT/

To aoid difficult% with test

interpretation in a contact inestigation#

the follow-up TB test method for a particular contact# whether T.T or

BAT# should prefera"l% "e the same

test method used for the first TB test/

se of the same test method for repeat

testing will minimiGe the num"er of

conersions that occur as a result of test

differences/

#elf$#tud Modules on Tuberculosis, Contact In%estigation for Tuberculosis, C&C Core Curriculum on Tuberculosis *9033, MMWR, Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, June 9, 2000

'age $ of $9Core Clinical .erice =uide


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TUBERCULOSIS MATRIX'Continued)


Classification 9

Infection wit&out

actie TB disease

• 'ositie T.T

*mm induration, or positie BAT

• Negatie

"acteriological

studies *if done,

• No clinical

"acteriological or

radiographiceidence of actie

TB disease/

Candidates for treatment of 2TBI

• .ee T.T reaction classification

or guidelines for BATs# this reference

• Cae"ul assessment to ule out

acti,e TB disease is necessa# $e"oe

teatment "o LTBI is stated

•Immediatel% get a chest x-ra% for

patients wit& s#mptoms AN a

positie T.T or positie BAT

• thers should "e gien a chest

x-ra% as soon as possi"le/ +hen TB

disease is ruled out# treat for 2TBI ifindicated/

• If chest x-ra% a"normal# o"tain

sputums# and consider as a suspect case

• etermine histor% of prior

treatment for 2TBI or actie TB disease

• etermine if there are an%

medical conditions that are

contraindications to treatment or would

increase risk of aderse reactions

• 'roide )I? counseling# testing#

and referral/ If )I? test is refused#

reoffer )I? testing monthl% while on

2TBI treatment/

Baseline hepatic measurements

recommended for>

• 'atients whose initial ealuation

suggests a lier disorder or regular use

of alcohol

• 'atient with )I? infection

• 'regnant women and those in

immediate post-partum period *5

months# especiall% Black and )ispanicwomen,

• 'atients with histor% of chronic

lier disease *e/g/# hepatitis B or hepatitis

C,

.ee 2TBI regimens in this reference

The following groups are considered to

"e high-risk indiiduals when it comes to

"eing adherent to taking their

medications/ If found to hae 2TBI#

these groups should "e placed on irectl%

"sered 'reentie Therap% *'T,>

• Children and

adolescents

• Contacts to a

case with actie TB disease

• )omeless

indiiduals

• 'ersons who

a"use su"stances

• 'ersons with a

histor% of treatment

non-adherence

• Immunocompro

mised patients#

especiall% )I?-infected

!or an% other persons# 'T should "eused if 2TBI treatment is ordered twice

weekl% *.ee pages 50 and 53,/ Call the

1entuck% TB 'rogram to discuss twice

weekl% treatment of 2TBI/

Esta"lish rapport with patient and

emphasiGe>

• Benefits of treatment

• Importance of

adherence to treatment

regimen

•'ossi"le aderse side

effects of medicine*s,

• +hen to stop

medication and call the local

health department *2),

• )I? testing with pre-

and post-test counseling

irectl% "sered 'reentie

Therap% *'T, for 2TBI is

recommended for an% at risk

adults who cannot or will not

relia"l% self-administer drugs

Baseline la"orator% testing

• Not routinel% indicated

uring the course of therap%>

At least monthl%# a 2) licensed

medical or nursing professional mustealuate for>

• Adherence to prescri"ed

regimen

• .igns;s%mptoms of actie TB

disease*.ee Classification 5# page $,

Chest x-ra% not recommended at thecompletion of routine 2TBI treatment

'age J of $9Core Clinical .erice =uide


ATTE2TIO2* edical proidersshould order dail% IN) for nine

months# administered "% 'T# to

treat 2TBI in children and adolescents#

unless medicall% contraindicated/

Call the 1K TB 'rogram to discuss

treatment of 2TBI in children and

adolescents/

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Centers for &isease Control and 're%ention, Core Curriculum on Tuberculosis ( 9033,

Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, MMWR, June 9, 2000



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Classification 5

TB disease3 clinicall#

acti,e

Tu"erculosis Case

efinition>

'ositie 2a" Test

Mcobacterium

tuberculosis culture

M. tuberculosis

complex demonstrated

in Nucleic Acid

Amplification *NAA,test or 'CR test

-or-

Clinical Case>

• 'ositie T.T or

positie BAT

• A"normal changing

chest x-ra% or

clinical eidence of

disease

•'laced on 9 or moreantitu"ercular

anti"iotic drugs

• Completed

diagnosticealuation

1entuck% endorses the

6 drug TB anti"iotic

therap% initiall%

.ee Contact Inestigation and the

Concentric Circle approach in this

reference

.hould "e seen "% local health department

*2), ph%sician as soon as possi"le if

2) is suppl%ing TB medications

Case anagement

• Assignment of responsi"ilit%

• .%stematic regular reiew

• 'lans to address "arriers to adherence

• 'roide )I? counseling# testing# and

referral/ If )I? test is refused# reoffer)I? testing monthl% while on treatment

for actie TB disease/

Adherence

• Non adherence is a ma<or pro"lem in

TB control

• se case management and directl%

o"sered therap% *T, to ensure

patients complete treatment/ If more

than 5 doses are missed# contact 1K

') TB staff/

• Initiall% order A.T# A2T# Biliru"in#

Alkaline phosphatase# serum creatinine#

and platelets for adults/ ?isual acuit%and color ision as "aseline if on EB#

(uestion ision status monthl%

• "tain "aseline weight and monitor

weights monthl%

etermine the 'atients clinical condition>

• Immediatel% if not hospitaliGed

• +ithin 5 da%s of notification if

hospitaliGed *"est to isit in hospital,

• Basic ph%sical exam done within 8 da%s

of notification

Basic 'rinciples of Treatment>

• 'roide safest# most effectie

therap% in s&otest time

• ultiple drugs to which the

organisms are suscepti"le

• 2e,e add single drug to failing

regimen• Ensure adherence to therap%

• T is the standard of care for all

cases of actie TB disease

anagement of )I? related actie TBdisease is complex: care should "e

proided "% a consultant expert in "oth)I? and TB

'regnant +omen

• month regimen - RI!# IN)# and

EB

• . is contraindicated

• In )I?-positie pregnant women#

consult an expert# *.NTC )otline

3-700-6TB-IN!, Notif% the .tate TB

'rogram a"out the prescri"ed regimen/

InfantsTreat as soon as tu"erculosis is suspected/

.ee regimens in this reference fortreatment of adults# children# and those

with extrapulmonar% tu"erculosis

Tu"erculosis caused "% rug Resistant

rganisms

Treatment should "e done "%# or in close

consultation# with an expert in the

management of these difficult situations

?itamin BJ 3049$mg for those with

certain conditions *e/g/ )I? infection,

Instruct patient a"out>

• Actie TB disease and how

it is spread

• Importance of taking

medications on a regular "asis

• edication side effects and

instructions to immediatel%report aderse reactions

• 'roper times and wa% to

collect;mail sputum specimens

• The taking of other

medications and the potentialrisks of drug interactions

• Importance of good nutrition

• To"acco cessation and

nicotine replacement therap%

Confinement and;or restriction of

actiities must "e addressed *TB

Control 2aw# 1R. 93$/$60,

1R. 93$/$53 states drug

suscepti"ilit% test on initial TB

isolates from patient with actie

TB disease must "e ordered "%

the ph%sician

Ensure that all initial positie TBcultures from independent la$s

hae drug suscepti"ilit% studiesordered "% priate ph%sicians

• onitor for Aderse Reactions

• .ee Recommendations for .putum

Collection

• Chest x-ra%s initiall#3 at 9 months aft

starting therap%# and at 0 to J0 da%s

after completion of therap%/ Clinical

cases also need chest x-ra% after9 months of multiple drug therap%

• All efforts to follow-up must "e

documented in the patients chart

• A home isit must "e done

• Consult with ') if the patients stat

changes while on treatment

#ee )entuc T+ Control La )R# 2-"

irectl% "sered Therap% *T,

• )ealth care worker watches patien

swallow each dose of medication

• T shall "e the 1entuck% standa

of care for all cases of actie TB

disease

• T must "e used with all

intermittent regimens

• T can lead to reductions in

relapse and ac(uired drug resistance• se T with other measures to

promote adherence

• Court ordered T ma% "e

necessar%

• .ee T in this reference

TB isolate from all specimens with a

positie TB culture shall "e sent to the

1entuck% epartment of 2a"orator%

.erices *2., for drug suscepti"ilit%and genot%ping tests/ 2) TB staff sh

contact hospital la"s# independent la"s# national reference la"s to coordinate

shipment of TB isolate to 2./'age 7 of $9

Core Clinical .erice =uide.ection> TB

.eptem"er 3# 9039

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Centers for &isease Control and 're%ention, Core Curriculum on Tuberculosis *9033,

'age of $9Core Clinical .erice =uide


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Classification 6 TB no longer clinicall% actie Teach patient signs and

s%mptoms of possi"le recurrence

of actie TB disease

Classification $ TB suspected/ iagnosis pending/ .houldnot hae this classification for more than

three *5, months

Results of a positie Nucleic Acid

Amplification *NAA, test# e/g/ =en-'ro"e#

on a sputum sample can help determineactie TB disease with Mcobacterium

tuberculosis *TB,

If NAA test on sputum is positie#treatment should "egin with a 6-drug

regimen until TB is ruled out

Teach patient signs ands%mptoms of possi"le recurrence

of actie TB disease/

As indicated




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Recommendations for Sputum Collection

Pupose Fe/uenc# 2um$e o" Specimens

Baseline for TB suspects Initial 5 samples that are collected 7 4 96 hours apart/

Recommend at least one sample collection "e

o"sered "% health care worker/

O$tain sputum samples BEFORE

initiatin( tu$eculosis t&eap#.

2AA testin( s&ould $e pe"omed on at least one espiato# specimen "om eac& patient wit&

si(ns and s#mptoms o" pulmona# TB "o w&om a dia(nosis o" TB is $ein( consideed $ut &as

not #et $een esta$lis&ed3 and "o w&om t&e test esult would alte case mana(ement o TB

contol acti,ities.4

onitoring for smea

conersion

*A!B .mear positie

Culture positie,($e%uest that state lab

do smears only)

E,e# 5 wee!s after 9 weeks of

therap% hae "een completed#

until 5 consecutie A!B smears

are negatie

After 9 months of uninterrupted

therap%

&ote' negati%e smears are

re/uired !er 902 )R 201200and 902 )R 2010-

3 sample 4 Recommend collection "e o"sered

"% health care worker

5 samples on consecutie da%s/ Recommend

collection "e o"sered "% health care worker

If still positie# treatment regimen must "e

re-ealuated

onitoring during

treatment for cultue

conersion

*A!B .mear negatie

Culture positie,

Mont&l# until 9 consecutie

specimens are negatie on culture

5 samples on consecutie da%s/ Recommend at

least one "e o"sered "% health care worker

• 'atients who hae positie cultures after

6 months of treatment should "e treated astreatment failures *+R# @une 90# 9005,

onitoring after culture

conersion to negatie

*or a clinical case,

Mont&l# until treatment is

completed/ 'atient ma% not "e

a"le to produce sputum at this

point

3 sample/ Recommend collection "e o"sered

"% health care worker

!re(uenc% of collections ma% "e increased if

there is a recurrence of s%mptoms or treatment

interruption/ 'atients with R-TB or )I?infection and TB ma% re(uire additional

sputum testing to monitor their clinical course

.end specimens to the state la" and instruct

priate hospitals and ph%sicians to use the state

la"

O$tain t&ee '0) consecuti,e sputum samples "o an# patient w&o &as e,idence o"

wosenin( clinical si(ns 6 s#mptoms o" acti,e TB disease 'i.e. new cou(&3 &emopt#sis3

"e,e3 sweats3 o wosenin( c&est %-a# "indin(s)44

Source: *MMWR 2009; 58(01):7-10 **SNTC Clinical Consultation – July 2010



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Managing Laboratory Data

• The LHD ill ensure that all culture !ositi"e !ul#onary an$ e%tra!ul#onary

Mycobacterium tuberculosis isolates &ro# outsi$e la'oratories are sent to the StateLa'oratory &or $ru( susce!ti'ility an$ (enoty!e testin()

• The LHD ill ensure that co!ies o& s!utu# !ositi"e T culture results+ !ositi"e T

culture results &ro# any other 'o$y site+ an$ !ositi"e Nucleic ,ci$ ,#!li&ication tests-e)() MTD !ositi"e results an$ .CR !ositi"e results/ &ro# outsi$e la'oratories ill 'esent to the State T .re"ention an$ Control .ro(ra#)

• t is the res!onsi'ility o& the LHD to ensure that $ru( susce!ti'ility testin( is !er&or#e$

on initial culture !ositi"e !ul#onary an$ e%tra!ul#onary T isolates) Sen$ a co!y o& thela'oratory re!ort a'out $ru( susce!ti'ility testin( to the State T .re"ention an$ Control

.ro(ra#) utsi$e la'oratories that re!ort culture !ositi"e !ul#onary an$ e%tra!ul#onaryT isolates #ay nee$ an a$$itional !hysician or$er to !er&or# $ru( susce!ti'ility testin()

• t is reco##en$e$ that all s!utu# sa#!les 'e sent to the State La' &or testin()



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CL,SS3N4 TH5 T65RC6LN S7N T5ST R5,CTN

$ or ore illimeters

30 or ore illimeters 3$ or ore illimeters

D $ mm is classified as positie in>

• )I?-positie persons

• Recent contacts of a case with actie TB

disease

• 'eople who hae preiousl% had actie TB

disease

• 'ersons with fi"rotic changes on chest

radiograph consistent with old healed TB

• 'atients with organ transplants and other

immunosuppressed patients *including

patients taking a prolonged course of oral or

intraenous corticosteroids or tumor necrosis

factor alpha *TN!-alpha, antagonists,

D 30 mm is classified as positie in>

• 'eople who hae come to the /./ within the

last $ %ears from areas of the world where TB

is common &

• In<ection drug users

• 'eople who lie or work in high-risk

congregate settings

• %co"acteriolog% la"orator% personnel

• Children %ounger than 6 %ears

• Infants# children# and adolescents exposed to

adults in high-risk categories&&

• 'ersons with clinical conditions that place

them at high-risk for TB *silicosis# dia"etes

mellitus# seere kidne% disease# certain t%pes ofcancer# and certain intestinal conditions,

D 3$ mm is classified as positie in>

• 'ersons with no known risk factors for TB

• Targeted skin testing programs should onl%

"e conducted among high-risk groups

A tu"erculin skin test conersion is defined as an increase of D 30 mm of induration within a 9-%ear period# regardless of age/

T# &iagnostic #tandards and Classification of Tuberculosis in dults and C3ildren. m. J. Res!ir. Care Med., 4500

Core Curriculum on Tu"erculosis: +hat the Clinician .hould 1now *9033,/

&.ee ta"les with international TB incidence and prealence rates in this reference for more information/

&&According to Red Book# 900# L30 mm induration is considered positie for children with increased exposure to adults who are

)I?-infected# homeless# users of illicit drugs# residents of nursing homes# incarcerated or migrant farm workers# p/ J70/



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“TUBERCULIN SKIN TEST (TST) RECOMMENDATIONS

FOR INFANTS C!ILDR"N AND ADOL"SC"NTS#

Children for whom immediate T.T or I=RA is indicated

9

>• Contacts of people with confirmed or suspected contagious Mactie tu"erculosis Mdisease

*contact inestigation,

• Children with radiographic or clinical findings suggesting Mactie tu"erculosis disease

• Children immigrating from countries with endemic infection *e/g/# Asia# iddle East# Africa#

2atin America# countries of the former .oiet nion, including international adoptees

• Children with trael histories to countries with endemic infection and su"stantial contact with

indigenous persons from such countries5

Children who should hae annual T.T or I=RA>

• Children infected with )I? infection *T.T onl%,

• Incarcerated adolescents

C3ildren at increased ris of !rogression of LT+I to tuberculosis disease1 Children with other medical

conditions# including dia"etes mellitus# chronic renal failure# malnutrition# and congenital or ac(uired

immunodeficienc%s desere special consideration/ +ithout recent exposure# these people are not at

increased risk of ac(uiring tu"erculosis infection/ nderl%ing immune deficiencies associated with these

conditions theoreticall% would enhance the possi"ilit% for progression to seere disease/ Initial histories

of potential exposure to tu"erculosis should "e included for all of these patients/ If these histories or local

epidemiologic factors suggest a possi"ilit% of exposure# immediate and periodic T.T or I=RA should "e

considered/ An initial TST o I7RA s&ould $e pe"omed $e"oe initiation o" immunosuppessi,e

t&eap#3 includin( polon(ed steoid administation3 use o" tumo necosis "acto-alp&a

anta(onists3 o ot&e immunosuppessi,e t&eap# in an# c&ild e/uiin( t&ese teatments.8

A T.T can "e administered to indiiduals of an% age who are at increased risk for ac(uiring2TBI or actie TB disease# een to new"orn infants *.ee Congenital Tu"erculosis in 900 Red

Book# p/ JJ/,/

OOOOOOOOOOOOOOOOOOO

I=RA indicates interferon-gamma release assa%: )I? indicates human immunodeficienc% irus: 2TBI# latent tu"erculosis infection/

3 Bacille Calmette-=uPrin immuniGation is not a contraindication to a T.T/9 Beginning as earl% as 5 months of age/5 If the child is well# the T.T or I=RA should "e dela%ed for up to 30 weeks after return/

Reference> Red Book 900



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I2+ICATIO2S FOR T9O-STEP TUBERCULI2 S:I2 TESTS 'TSTs)

+R# ecem"er 50# 900$# p/ 9

MMWR 6uidelines for 're%enting t3e Transmission of Mcobacterium tuberculosis in 7ealt3$Care settings, 200", ! 29.

'age 3$ of $9Core Clinical .erice =uide


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GUIDELINES AND RECOMMENDATIONSFOR USING BLOOD ASSAYS FOR

Mycobacterium tuberculosis (BAMTs)

Before 9003# the tu"erculin skin test *T.T, was the onl% practical and commerciall% aaila"le

immunologic test for Mcobacterium tuberculosis infection approed in the nited .tates/Blood assa% for / tu"erculosis *BAT, is a general term to refer to recentl% deeloped in itro

diagnostic tests that assess for the presence of infection with M. tuberculosis/ This term

includes# "ut is not limited to# interferon-gamma *I!N- γ) release assa%s *I=RAs,/

.ince 9003# seeral I=RAs hae "een approed "% !A/ In the nited .tates# the currentl%

aaila"le tests are the Quanti!ERN-TB =old In-Tu"e test *Q!T-=IT, and the T-.'T.T+ test

*T-.pot,/ The following recommendations are from updated guidelines for using I=RAs in the@une 9$# 9030 +R> *Note that CC guidelines descri"e the use of I=RAs instead of the

more inclusie BAT/,

:E; POI2TS FOR USI27 BAMTs

• A BAT ma% "e used in place of *"ut not in addition to, a T.T in all situations in whichCC recommends tu"erculin skin testing as an aid in diagnosing M. tuberculosis

infection

• A BAT is preferred for testing persons from groups that historicall% hae low rates of

returning to hae T.Ts read/ !or example# use of a BAT might increase test

completion rates for homeless persons and drug-users/

• A BAT is preferred for testing persons who hae receied BC= *as a accine or for

cancer therap%,/

• A T.T is preferred for testing children aged less than $ %ears/

• Two-step testing is not re(uired for BAT.# "ecause I=RA testing does not "oost

su"se(uent test results/• Neither a BAT nor T.T can distinguish 2TBI from actie tu"erculosis/

• As with T.Ts# a negatie BAT result does not exclude 2TBI or actie TB disease

/

'age 3J of $9Core Clinical .erice =uide


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<Recommendations "o Use o" I7RAshttp>;;www/cdc/go;mmwr;'!;rr;rr$0$/pdf

7eneal Recommendations "o Use o" I7RAs

• T.Ts and I=RAs *Q!T-=# Q!T-=IT# and T-.pot, should "e used as aids in diagnosing

infection with M. tuberculosis/ These tests ma% "e used for sureillance purposes or to

identif% persons likel% to "enefit from treatment# including persons who are or will "e atincreased risk for M. tuberculosis infection *Box 3# "elow, or for progression to actie

tu"erculosis if infected *Box 9# "elow,/

• I=RAs should "e performed and interpreted according to esta"lished protocols using

!A-approed test formats/ The% should "e performed in compliance with Clinical

2a"orator% Improement Amendment *C2IA, standards/

• Both the standard (ualitatie test interpretation and the (uantitatie assa% measurements

should "e reported together with the criteria used for test interpretation/ This will permit

more refined assessment of results and promote understanding of the tests/

• Arrangement for I=RA testing should "e made prior to "lood collection to ensure that the

"lood specimen is collected in the proper tu"es# and that testing can "e performed within

the re(uired timeframe/

• 'rior to implementing I=RAs# each institution and tu"erculosis-control program should

ealuate the aaila"ilit%# oerall cost# and "enefits of I=RAs for their own setting/ Inaddition# programs should consider the characteristics of the population to "e tested/

• As with the T.T# I=RAs generall% should not "e used for testing persons who hae a low

risk for "oth infection and progression to actie tu"erculosis if infected *except for those

likel% to "e at increased risk in the future,/ .creening such persons dierts resourcesfrom higher priorit% actiities and increases the num"er of false-positie results/ Een

with a test specificit% approaching S# when the prealence of M. tuberculosis infection

is 3S# the ma<orit% of positie results will "e false posities/ If persons at low risk for "oth infection and progression are to "e tested# selection of the test with the greatest

specificit% will minimiGe false-positie results# reduce unnecessar% ealuation and

treatment# and minimiGe the potential for aderse eents from unnecessar% treatment/

Test Selection

• .election of the most suita"le test or com"ination of tests for detection of M. tuberculosis

infection should "e made on the "asis of the reasons and the context for testing# test

aaila"ilit%# and oerall cost effectieness of testing/ Results of studies examiningsensitiit%# specificit%# and agreement for I=RAs and T.T ar% with respect to which test

is "etter/ Although data on the accurac% of I=RAs and their a"ilit% to predict su"se(uent

actie tu"erculosis are limited# to date# no ma<or deficiencies hae "een reported in

studies inoling arious populations/ As use of these tests increases# greaterunderstanding of their alue and limitations will "e gained/

• An I=RA ma% "e used in place of *"ut not in addition to, a T.T in all situations in which

CC recommends tu"erculin skin testing as an aid in diagnosing M. tuberculosis infection# with preferences and special considerations noted "elow/ espite the

indication of a preference in these instances# use of the alternatie test *!A-approed

I=RA or T.T, is accepta"le medical and pu"lic health practice/



http://www.cdc.gov/mmwr/PDF/rr/rr5905.pdf

http://www.cdc.gov/mmwr/PDF/rr/rr5905.pdf

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su"se(uent disease risk has not "een demonstrated/ The criteria for interpreting changes

in an I=RA that identif% new infections remain uncertain/ CC encourages institutionsand programs in which I=RAs are used to pu"lish their experiences# particularl% in

regard to rates of conersion# reersion# and progression to actie tu"erculosis oer time/

Situations in 9&ic& Testin( wit& Bot& an I7RA and a TST Ma# Be

Consideed

• Although routine testing with "oth a T.T and an I=RA is not generall% recommended#results from "oth tests might "e useful when the initial test *T.T or I=RA, is negatie in

the following situations> 3, when the risk for infection# the risk for progression# and the

risk for a poor outcome are increased *e/g/# when persons with )I? infection or childrenaged F$ %ears are at increased risk for M. tuberculosis infection, or 9, when clinical

suspicion exists for actie tu"erculosis *such as in persons with s%mptoms# signs# and;or

radiographic eidence suggestie of actie tu"erculosis, and confirmation of M.tuberculosis infection is desired/ In such patients with an initial test that is negatie#

taking a positie result from a second test as eidence of infection increases detection

sensitiit%/ )oweer# multiple negatie results from an% com"ination of these testscannot exclude M. tuberculosis infection/

• sing "oth a T.T and an I=RA also might "e useful when the initial test is positie in thefollowing situations> 3, when additional eidence of infection is re(uired to encourage

compliance *e/g/# in foreign-"orn health-care workers who "eliee their positie T.Tresult is attri"uta"le to BC=, or 9, in health% persons who hae a low risk for "oth

infection and progression/ In the first situation# a positie I=RA might prompt greater

acceptance of treatment for 2TBI as compared with a positie T.T alone/ In the lattersituation# re(uiring a positie result from the second test as eidence of infection

increases the likelihood that the test result reflects infection/ !or the second situation# an

alternatie is to assume# without additional testing# that the initial result is a false positieor that the risk for disease does not warrant additional ealuation or treatment# regardless

of test results/ .teps should "e taken to minimiGe unnecessar% and misleading testing of

persons at low risk/• Repeating an I=RA or performing a T.T might "e useful when the initial I=RA result is

indeterminate# "orderline# or inalid and a reason for testing persists/ A second test also

might "e useful when assa% measurements from the initial test are unusual# such as whenthe Nil alue is higher than t%pical for the population "eing tested *e/g/# I!N-U

concentration for Nil "% Q!T-= or Q!T-=IT L0/8 I;m2 for most of the /./

populations,# the Nil alue is apprecia"l% greater than the alue o"tained with M. tuberculosis antigen stimulation *e/g/ when I!N-U concentration for Nil "% Q!T-= is

0/5$ I;m2 greater than the concentration o"tained with either E.AT-J or C!'-30

stimulation# or when the num"er of spots for Nil "% T-.pot is four spots greater than thenum"er with either E.AT-J or C!'-30 stimulation,# or the itogen alue is lower than is

expected for the population "eing tested *e/g/# the itogen Response "% Q!T-= orQ!T-=IT is F0/$ I;m2# or the num"er of spots in the mitogen well "% T-.pot is F90,/

If an I=RA is to "e repeated# a new "lood sample should "e used/ In such situations#repeat testing with another "lood sample usuall% proides interpreta"le results/



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Medical Mana(ement A"te Testin(

• iagnoses of M. tuberculosis infection and decisions a"out medical or pu"lic health

management should not "e "ased on I=RA or T.T results alone# "ut should include

consideration of epidemiologic and medical histor% as well as other clinical information/

• 'ersons with a positie T.T or I=RA result should "e ealuated for the likelihood of

M tuberculosis infection# for risks for progression to actie tu"erculosis if infected# andfor s%mptoms and signs of actie tu"erculosis/ If risks# s%mptoms# or signs are present#

additional ealuation is indicated to determine if the person has 2TBI or actietu"erculosis/

• A diagnosis of 2TBI re(uires that actie tu"erculosis "e excluded "% medical ealuation#

which should include taking a medical histor% and a ph%sical examination to check forsuggestie s%mptoms and signs# a chest radiograph# and# when indicated# testing of

sputum or other clinical samples for the presence of M. tuberculosis/ Neither an I=RA

nor T.T can distinguish 2TBI from actie tu"erculosis/

• In persons who hae s%mptoms# signs# or radiographic eidence of actie tu"erculosis or

who are at increased risk for progression to actie tu"erculosis if infected# a positie

result with either an I=RA or T.T should "e taken as eidence of M. tuberculosis

infection/ )oweer# negatie I=RA or T.T results are not sufficient to exclude infection

in these persons# especiall% in those at increased risk for a poor outcome if diseasedeelops# and clinical <udgment dictates when and if further diagnostic ealuation and

treatment are indicated/

• In health% persons who hae a low likelihood "oth of M. tuberculosis infection and of

progression to actie tu"erculosis if infected# a single positie I=RA or T.T result should

not "e taken as relia"le eidence of M. tuberculosis infection/ Because of the low pro"a"ilit% of infection# a false-positie result is more likel%/ In such situations# the

likelihood of M. tuberculosis infection and of disease progression should "e reassessed#

and the initial test results should "e confirmed/ Repeat testing# with either the initial testor a different test# ma% "e considered on a case-"%-case "asis/ !or such persons# an

alternatie is to assume# without additional testing# that the initial result is a false

positie/

• In persons with discordant test results *i/e/# one positie and the other negatie,# decisions

a"out medical or pu"lic health management re(uire indiidualiGed <udgment in assessing

the (ualit% and magnitude of each test result *e/g/# siGe of induration and presence of

"listering for a T.T: and the TB Response# Nil# and itogen alues for an I=RA,# the pro"a"ilit% of infection# the risk for disease if infected# and the risk for a poor outcome if

disease occurs/

• Taking a positie result from either of two tests as eidence of infection is reasona"le

when 3, clinical suspicion exists for actie tu"erculosis *e/g/# in persons with s%mptoms#

signs# and;or radiographic eidence of actie tu"erculosis, or 9, the risks for infection# progression# and a poor outcome are increased *e/g/# when persons with )I? infection or

children aged F$ %ears are at increased risk for M. tuberculosis infection,/

• !or health% persons who hae a low risk for "oth infection and progression# discounting

an isolated positie result as a false positie is reasona"le/ This will increase detectionspecificit% and decrease unnecessar% treatment/

• !or persons who hae receied BC= and who are not at increased risk for a poor

outcome if infected *Box 9# "elow,# T.T reactions of F3$ mm in siGe ma% reasona"l% "e

discounted as false posities when an I=RA is clearl% negatie/



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TABLE =. Intepetation citeia "o t&e

>uantiFERO2-TB 7old Test '>FT-7)

Intepetation 2il4 TB Response?Mito(en

Response@

'ositie W An% D0/5$ I;ml and D$0S of Nil An%

Negatie&& 0/8 F0/5$ I;ml D0/$

IndeterminateXX 0/8 F0/5$ I;ml F0/$

L0/8 F$0S of Nil An%

Souce* Based on Cellestis 2imited/ Quanti!ERN-TB =old M'ackage insert/ Aaila"le athttp>;;www/cellestis/com;IR;Compan%;.how'age/aspxYC'IZ3968

& The interferon gamma *I!N-U, concentration in plasma from "lood incu"ated with saline/

X The higher I!N-U concentration in plasma from "lood stimulated with a cocktail of peptides representing

earl% secretor% antigenic target-J *E.AT-J, or a cocktail of peptides representing culture filtrate protein 30*C!'-30, minus Nil/

[ The I!N-U concentration in plasma from "lood stimulated with mitogen minus Nil/

W Interpretation indicating that Mcobacterium tuberculosis infection is likel%/

&& Interpretation indicating that M. tuberculosis infection is not likel%/

XX Interpretation indicating an uncertain likelihood of M. tuberculosis infection/



http://www.cellestis.com/IRM/Company/ShowPage.aspx?CPID=1247

http://www.cellestis.com/IRM/Company/ShowPage.aspx?CPID=1247

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TABLE 5. Intepetation citeia "o t&e

>uantiFERO2-TB 7old In-Tu$e Test '>FT-7IT)

Intepetation 2il4 TB Response?Mito(en

Response@

'ositie W 7/0 D0/5$ I;ml and D9$S of Nil An%

Negatie&& 7/0 F0/5$ I;ml or F9$S of Nil D0/$

IndeterminateXX 7/0 F0/5$ I;ml or F9$S of Nil F0/$

L7/0 An% An%

Souce* Based on Cellestis 2imited/ Quanti!ERN-TB =old In-Tu"e M'ackage insert/ Aaila"le at

http>;;www/cellestis/com;IR;content;pdf;Quanti!eronS90.S90?er=--@an9030S90NS90TRI./pdf /

& The interferon gamma *I!N-U, concentration in plasma from "lood incu"ated without antigen/

X The I!N-U concentration in plasma from "lood stimulated with a single cocktail of peptides representing

earl% secretor% antigenic target-J *E.AT-J,# culture filtrate protein-30 *C!'-30,# and part of TB 8/8 minus

Nil/

[ The I!N-U concentration in plasma from "lood stimulated with mitogen minus Nil/


&& Interpretation indicating that M. tuberculosis infection is not likel%/

XX Interpretation indicating an uncertain likelihood of M. tuberculosis infection/



http://www.cellestis.com/IRM/content/pdf/QuantiFeron%20US%20VerG--Jan2010%20NO%20TRIMS.pdf

http://www.cellestis.com/IRM/content/pdf/QuantiFeron%20US%20VerG--Jan2010%20NO%20TRIMS.pdf

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TABLE 0. Intepetation citeia "o t&e T-SPOT.TB Test 'T-SPOT)

Intepetation 2il4 TB Response? Mito(en@

'ositie W 30 spots D7 spots An%

Borderline&& 30 spots $# J# or 8 spots An%

NegatieXX 30 spots 6 spots

Indeterminate&& L30 spots An% An%

30 spots F$ spots F90 spots

Souce* Based on xford Immunotec 2imited/ T-.'T/T+ M'ackage insert/ Aaila"le athttp>;;www/oxfordimmunotec/com;.pageInsert /

& The num"er of spots resulting from incu"ation of 'BCs in culture media without antigens/

X The greater num"er of spots resulting from stimulation of peripheral "lood mononuclear cells *'BCs, with

two separate cocktails of peptides representing earl% secretor% antigenic target-J *E.AT-J, orculture filtrate protein-30 *C!'-30, minus Nil/

[ The num"er of spots resulting from stimulation of 'BCs with mitogen without ad<ustment for the num"er

of spots resulting from incu"ation of 'BCs without antigens/


&& Interpretation indicating an uncertain likelihood of M. tuberculosis infection/

XX Interpretation indicating that M. tuberculosis infection is not likel%/

Centers for isease Control and 'reention/ Updated 7uidelines "o Usin( Inte"eon 7amma

Release Assa#s to +etect y cob act eri um tu ber cu lo sis In"ection --- United States3 5=.

+R 9030:$*No/ RR-$,>3-9$



http://www.oxfordimmunotec.com/USpageInsert

http://www.oxfordimmunotec.com/USpageInsert

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BOX 5. Ris! "actos "o po(ession o" in"ection to acti,e tu$eculosis

'ersons at increased risk& for progression of infection to actie tu"erculosis include

• persons with human immunodeficienc% irus *)I?, infection:X

• infants and children aged F$ %ears:X

• persons who are receiing immunosuppressie therap% such as tumor necrosisfactor--alpha *TN!-, antagonists# s%stemic corticosteroids e(uialent to

D3$ mg of prednisone per da%# or immune suppressie drug therap% followingorgan transplantation:X

• persons who were recentl% infected with M. tuberculosis *within the past 9 %ears,:

• persons with a histor% of untreated or inade(uatel% treated actie tu"erculosis#

including persons with fi"rotic changes on chest radiograph consistent with prior

actie tu"erculosis:

• persons with silicosis# dia"etes mellitus# chronic renal failure# leukemia#

l%mphoma# or cancer of the head# neck# or lung:

•

persons who hae had a gastrectom% or <e<unoileal "%pass:• persons who weigh F0S of their ideal "od% weight:

• cigarette smokers and persons who a"use drugs or alcohol: and

• populations defined locall% as haing an increased incidence of actie

tu"erculosis# possi"l% including medicall% undersered or low-income

populations

Souce* Based on CC/ Targeted tu"erculin testing and treatment of latent tu"erculosis infection/

+R 9000:6*No/ RR-J,/

& 'ersons with these characteristics hae an increased risk for progression of infection to actie

tu"erculosis compared with persons without these characteristics/

X Indicates persons at increased risk for a poor outcome *e/g/# meningitis# disseminated disease# or death, if

actie tu"erculosis occurs/



http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm





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Teatment Al(oit&m "o Cultue-Positi,e Tu$eculosis

Centers for &isease Control and 're%ention. Treatment of Tuberculosis, merican T3oracic #ociet, C&C,

and Infectious &iseases #ociet of merica. MMWR 2008"2(o. RR$--:1 .

Teatment Al(oit&m "o Acti,e3 Cultue-ne(ati,e

Pulmona# Tu$eculosis and Inacti,e Tu$eculosis



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+IRECTL; OBSERE+ TERAP; '+OT)

T is a method of ensuring patients adherence to therap%/ T means that a health care

professional or other responsi"le person# not related to the patient# watches the patient swallow

each dose of TB medication/ 2) staff must recogniGe T as the 1entuck% standard of care/All actie TB disease# whether pulmonar% or extrapulmonar%# should "e treated "% T/ The

T method should "e cone%ed with confidence to patients/ Alwa%s respect the patients

confidentialit%/

The Centers for isease Control and 'reention *CC, and the American Thoracic .ociet%

*AT., recommends that all TB patients "e considered for T "ecause of the difficult% in predicting who will adhere to the treatment regimen/

The following persons must "e placed on T>

• All patients with TB that is resistant to either isoniaGid *IN), or rifampin *RI!,

• All patients receiing intermittent therap%

• 'ersons with )I? related tu"erculosis

The following patients are considered at high risk for non-adherence and should receie T>• 'ersons who a"use su"stances

• 'ersons with mental# emotional# or certain ph%sical impairments that interfere with their

a"ilit% to self-administer medications

• Children and adolescents

• 'ersons with a histor% of treatment non-adherence

.ometimes 2) staff ma% designate another person to watch the patient take the TB medicines/

T should not "e delegated to a famil% mem"er/ thers such as school or emplo%ee health

nurses or clerg% ma% proide T/ 1entuck%s TB Control 'rogram does not consider it asT if a famil% o"seres the patient taking the medication/

Be aware of techni(ues a patient ma% use to aoid swallowing the medication such as hiding the pills in the mouth# spitting the pills into the fluid used to take them with# or omiting the pills

after leaing the treatment site/

T reduces the fre(uenc% of treatment failures# of ac(uiring drug resistance# and in sufferingrelapse of the disease/ ost treatment regimens for TB can "e gien intermittentl% if T is

used/ Intermittent T reduces the total num"er of doses a patient must take and the num"er of

encounters with health department personnel/ If the patient cannot go to a treatment center# 2)staff can arrange another site that is safe# conenient# and agreea"le to "oth patient and staff/

Besides "eing cost effectie# T has man% other "enefits/ T is a patient-focused sericethat also proides the health care worker with a "etter understanding of the patients needs# thus

placing the worker in position to assist with needed health or social serices# and making the

appropriate referrals/ T proides an effectie opportunit% for education# not onl% of the

patient "ut also of the patients support s%stem/ T is also adantageous to the communit% "ecause a patient on T "ecomes noninfectious much more (uickl%/ This reduces the time that

a patient is a"le to spread the disease in the communit%/



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+RU7 RE7IME2S FOR CULTURE-POSITIE PULMO2AR;

TUBERCULOSIS CAUSE+ B; +RU7-SUSCEPTIBLE OR7A2ISMS $, *une +, +3, p. 3

Centers for &isease Control and 're%ention. Treatment of Tuberculosis, merican T3oracic #ociet, C&C, and Infectious &iseases #ociet of merica.

MMWR 2008"2(o. RR$--:1 .



7/27/2019 QFT-GIT


Centers for &isease Control and 're%ention. Treatment of Tuberculosis, merican T3oracic #ociet, C&C,and Infectious &iseases #ociet of merica. MMWR 2008"2(o. RR$--:1 4.



+OSES4 OF A2TITUBERCULOSIS +RU7S FOR A+ULTS A2+

C-IL+RE2

MMWR, June 20, 200, !. 4

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+OSES4 OF A2TITUBERCULOSIS +RU7S FOR A+ULTS A2+ CIL+RE2†

'Continued)

$, *une +, +3, p. 5


MMWR 2008"2(o. RR$--:1 ".



7/27/2019 QFT-GIT


P;RI+OXI2E 'ITAMI2 BG) SUPPLEME2TATIO2

+URI27 TREATME2T OF LTBI OR ACTIE TB +ISEASE

Pe,ention o" Peip&eal 2euopat&# and Cental 2e,ous S#mptom E""ects o" I2

Indications "o p#ido%ine w&en I2 is odeed to teat LTBI o acti,e TB disease*

Adults> '%ridoxine supplementation can "e ordered for an% adult "eing treated

with IN)# unless there is a medical contraindication/ '%ridoxine *itamin BJ,supplementation is particularl% recommended when IN) is used for treatment of

2TBI or actie TB disease in some adults with medical conditions were peripheral

neuropath% is common# such as3#9#5

>

• Nutritional deficiencies

• ia"etes

• )I? infection

•

Chronic renal failure• Alcoholism

• 'ersons with seiGure disorders

• 'regnant women

• Breastfeeding women

In"ants3 c&ilden3 and adolescents3#9#5#6#$#J

* Routine administration of p%ridoxine

is not recommended for most children and adolescents taking IN)6/ '%ridoxine is

recommended when IN) is used for treatment of 2TBI or actie TB disease in

some infants# children# and adolescents at increased risk for peripheral neuritis orother IN) aderse effects# such as>

• Breastfed infants# particularl% those who are exclusiel% "reastfed

• Children and adolescents on meat- and milk-deficient diets

• Children and adolescents with nutritional deficiencies

• Children who experience paresthesias while taking isoniaGid

• )I? infection# particularl% s%mptomatic )I?-infected indiiduals

• 'regnant adolescents

• Breastfeeding adolescents



7/27/2019 QFT-GIT


+ose o" p#ido%ine w&en I2 is odeed to teat LTBI o acti,e TB disease*

Adults*

• CC guidelines 4 9$ mg;da%3

• +isconsin TB 'rogram guidelines 4 30 to $0 mg;da%9

• The )arriet 2ane )and"ook $ 4 9$ to 300 mg;da%

In"ants3 c&ilden3 and adolescents*

• The )arriet 2ane )and"ook $> Child 4 3-9 mg;kg;da%/ '%ridoxine

in<ecta"le can "e compounded with simple s%rup to make an oral solution

containing 3 mg;m2J/

• 30 mg;da% to 9$ mg;da%3

Pe,ention o" 2euoto%ic E""ects o" C#closeine 'A Second-line TB du() in Adults*'%ridoxine ma% help preent and treat neurotoxic side effects of c%closerine in the treatment of

actie TB disease and is usuall% gien in a dosage of 300--900 mg;da%/3

Recommended +ail# Allowances and Recommended Ma%imum +ail# Inta!e8*

]The dail% recommended dietar% allowances *RAs, of itamin BJ are> Infants 0-J months# 0/3 mg:

Infants 8-39 months# 0/5 mg: Children 3-5 %ears# 0/$ mg: Children 6-7 %ears# 0/J mg: Children -35%ears# 3 mg: ales 36-$0 %ears# 3/5 mg: ales oer $0 %ears# 3/8 mg: !emales 36-37 %ears# 3/9 mg:

!emales 3-$0 %ears# 3/5 mg: !emales oer $0 %ears# 3/$ mg: 'regnant women# 3/ mg: and "reast-

feeding women# 9 mg/ .ome researchers think the RA for women 3-$0 %ears should "e increased to

3/$-3/8 mg per da%/ The recommended maximum dail% intake is> Children 3-5 %ears# 50 mg: Children

6-7 %ears# 60 mg: Children -35 %ears# J0 mg: Adults# pregnant and "reast-feeding women# 36-37 %ears#

70 mg: and Adults# pregnant and "reast-feeding women# oer 37 %ears# 300 mg/V OOOOOOOOOOOOOOOOOOOOOOOOOOOO

3 Centers for isease Control and 'reention/ Treatment of Tu"erculosis/ +R 9005:$9 *No/ RR-33,#

http>;;www/cdc/go;+R;'!;rr;rr$933/pdf 9 Centers for isease Control and 'reention/ Targeted Tu"erculin Testing and Treatment of 2atent Tu"erculosis

Infection/ +R9000:6*No/ RR-J,# http>;;www/cdc/go;+R;'!;rr;rr60J/pdf 5 +isconsin TB 'rogram/ ]!re(uentl% Asked Questions a"out '%ridoxine *?itamin B-J,#V

http>;;www/dhs/wisconsin/go;t";resources;guidelines;p%ridoxineOfa(/pdf 6 American Academ% of 'ediatrics/ 900 Red Book> Report of the Committee on Infectious isease/ Elk =roe

?illage# I2> American Academ% of 'ediatrics# p/ J78/$

Ro"ertson @# .hilkofski# N# editors/ The )arriet 2ane )and"ook> A anual for 'ediatric )ouse fficers# 38th

Edition# Elseier os"%# 900$ p/ 6/

J Nationwide Childrens )ospital# Colum"us )/ '%ridoxine )%drochloride ral .olution#

http>;;www/nationwidechildrens/org;ocument;=et;85J9# accessed No 07# 9030/8 National Institutes of )ealth/ edline 'lus> '%ridoxine *?itamin BJ,#

http>;;www/nlm/nih/go;medlineplus;druginfo;natural;56/html# accessed No 07# 9030/



http://www.cdc.gov/MMWR/PDF/rr/rr5211.pdf




http://www.dhs.wisconsin.gov/tb/resources/guidelines/pyridoxine_faq.pdf

http://www.nationwidechildrens.org/Document/Get/79362


http://www.nlm.nih.gov/medlineplus/druginfo/natural/934.html




http://www.dhs.wisconsin.gov/tb/resources/guidelines/pyridoxine_faq.pdf



7/27/2019 QFT-GIT


+OSA7E CART4

Weightin

!"n#s

Weightin

Ki$!g%&'s

D!s&ge&t

'g*g

D!s&ge&t +,

'g*g

D!s&ge&t +

'g*g

D!s&ge&t -,

'g*g

D!s&ge&t -

'g*g

D!s&ge&t .,

'g*g

5 2.3 11.3 22.7 34.0 45.4 56.7 68.0

10 4.5 22.7 45.4 68.0 90.7 113.4 136.1

15 6.8 34.0 68.0 102.1 136.1 170.1 204.1

20 9.1 45.4 90.7 136.1 181.4 226.8 272.225 11.3 57 113 170 227 283 340

30 13.6 68 136 204 272 340 408

35 15.9 79 159 238 318 397 476

40 18.1 91 181 272 363 454 544

45 20.4 102 204 306 408 510 612

50 22.7 113 227 340 454 567 680

55 24.9 125 249 374 499 624 748

60 27.2 136 272 408 544 680 816

65 29.5 147 295 442 590 737 885

70 31.8 159 318 476 635 794 953

75 34.0 170 340 510 680 850 1021

80 36.3 181 363 544 726 907 1089

85 38.6 193 386 578 771 964 1157

90 40.8 204 408 612 816 1021 122595 43.1 215 431 646 862 1077 1293

100 45.4 227 454 680 907 1134 1361

105 47.6 238 476 714 953 1191 1429

110 49.9 249 499 748 998 1247 1497

115 52.2 261 522 782 1043 1304 1565

120 54.4 272 544 816 1089 1361 1633

125 56.7 283 567 850 1134 1417 1701

130 59.0 295 590 885 1179 1474 1769

135 61.2 306 612 919 1225 1531 1837

140 63.5 318 635 953 1270 1588 1905

145 65.8 329 658 987 1315 1644 1973

150 68.0 340 680 1021 1361 1701 2041

155 70.3 352 703 1055 1406 1758 2109

160 72.6 363 726 1089 1451 1814 2177165 74.8 374 748 1123 1497 1871 2245

170 77.1 386 771 1157 1542 1928 2313

175 79.4 397 794 1191 1588 1984 2381

180 81.6 408 816 1225 1633 2041 2449

185 83.9 420 839 1259 1678 2098 2517

190 86.2 431 862 1293 1724 2155 2585

195 88.5 442 885 1327 1769 2211 2654

200 90.7 454 907 1361 1814 2268 2722

205 93.0 465 930 1395 1860 2325 2790

210 95.3 476 953 1429 1905 2381 2858

215 97.5 488 975 1463 1950 2438 2926

220 99.8 499 998 1497 1996 2495 2994

225 102.1 510 1021 1531 2041 2551 3062

230 104.3 522 1043 1565 2087 2608 3130

235 106.6 533 1066 1599 2132 2665 3198

240 108.9 544 1089 1633 2177 2722 3266

245 111.1 556 1111 1667 2223 2778 3334

250 113.4 567 1134 1701 2268 2835 3402

*Dosage calculated may have to be adjusted i o!de! ot to e"ceed the ma"imum dose #o! ay d!ug beig used. $able !ecalculated i %ovembe! 2010 &ith cove!sio #acto! o# '1 (oud ) 0.45359237 ilog!ams.+



7/27/2019 QFT-GIT


POTE2TIAL RE7IME2S FOR TE MA2A7EME2T OF PATIE2TS 9IT

+RU7-RESISTA2T PULMO2AR; TUBERCULOSIS $, *une +, +3, p. -


MMWR 2008"2(o. RR$--:1 9.

CO2SULT TB EXPERTS AT S2TC '-DTB-I2FO) a"out treatment recommendations for drug-resistant tu"erculosis.



7/27/2019 QFT-GIT


MA2A7EME2T OF TREATME2T I2TERRUPTIO2S $, *une +, +3 /0


MMWR 2008"2(o. RR$--:1 ".



7/27/2019 QFT-GIT


BOX =. Ris! "actos "o ycobacterium tuberculosis in"ection

'ersons at increased risk& for M. tuberculosis infection

• close contacts of persons known or suspected to hae actie tu"erculosis:

• foreign-"orn persons from areas that hae a high incidence of actie tu"erculosis

*e/g/# Africa# Asia# Eastern Europe# 2atin America# and Russia,:• persons who isit areas with a high prealence of actie tu"erculosis# especiall% if

isits are fre(uent or prolonged:

• residents and emplo%ees of congregate settings whose clients are at increased risk

for actie tu"erculosis *e/g/# correctional facilities# long-term care facilities# andhomeless shelters,:

• health-care workers who sere clients who are at increased risk for actie

tu"erculosis Mdisease:

• populations defined locall% as haing an increased incidence of latent

M. tuberculosis infection or actie tu"erculosis# possi"l% including medicall%

undersered# low-income populations# or persons who a"use drugs or alcohol: and

• infants# children# and adolescents exposed to adults who are at increased risk for

latent M. tuberculosis infection or actie tu"erculosis/

Souce* Based on CC/ Targeted tu"erculin testing and treatment of latent tu"erculosis infection/ +R

9000:6*No/ RR-J,/

& 'ersons with these characteristics hae an increased risk for M. tuberculosis infection compared with

persons without these characteristics/







7/27/2019 QFT-GIT


+IRECTL; OBSERE+ PREE2TIE TERAP; '+OPT)

FOR LATE2T TB I2FECTIO2

A ma<or step in controlling TB in a communit% is to make sure that a patient who is "eing treated

for latent TB infection *2TBI, completes a course of treatment/ 'T is the onl% wa% to ensurethat these patients are adherent to the medication/ As 1entuck% is experiencing a decline in the

num"er of TB cases# it is time to put a stronger focus on treating latent TB infection/

The TB Control 'rogram is adocating that the 2)s proide 'T to some higher risk

patients# as well as to children/ Children can "e the most difficult clients when it comes to taking

their medication/ B% proiding 'T# the health department not onl% preents future cases ofTB "ut also proides a alua"le serice to families/

em"ers of the groups "elow are considered to "e high-risk indiiduals when it comes to "eingadherent to taking their medications/ If found to hae latent TB infection# mem"ers of these

groups should "e placed on 'T>

• Children and adolescents

• Contacts to a case with actie TB disease• )omeless indiiduals

• 'ersons who a"use su"stances

• 'ersons with a histor% of treatment non-adherence

• Immunocompromised patients# especiall% )I?-infected



7/27/2019 QFT-GIT


ME+ICATIO2S TO TREAT LATE2T TUBERCULOSIS I2FECTIO2* +OSES3 TOXICITIES3 A2+

MO2ITORI27 RE>UIREME2TS MMWR, June 9, 2000, !!. 2<, 29

Oral dose (mg/kg (ma!"m#m dose

$a"l% T&"'e &eekl%$r#g Ad#lts C)"ldren Ad#lts C)"ldren Ad*erse rea't"ons Mon"tor"ng Comments

#sonia?id 9*0'' mg+

1'@/'*0'' mg+

19*"'' mg+

/'@<'*"'' mg+

Ras>epatic en?yme

ele7ation>epatitis6eriperal neuropaty

Mild central ner7oussystem effects

Drug interactionsresulting in increasedpenytoin *Dilantin+ orDisulfiram *&ntabuse+le7els

Clinical monitoring montlyLi7er function testsA at baseline in

selected casesB and repeatmeasurements if

aseline results are abnormal

6atient is pregnant$ in teimmediate postpartumperiod$ or at ig ris! forad7erse reactions

6atient as symptoms ofad7erse reactions

>epatitis ris! increases (it age andalcool consumption

6yridoxine *7itamin :$ 1'@/9 mgd+migt pre7ent periperalneuropaty and central ner7ous

system effects

Rifampin 1'*:'' mg+

1'@/'*:'' mg+

1'*:'' mg+

Ras>epatitis2e7erTrombocytopenia2lu)li!e symptoms4range)colored body

fluids *secretions$urine$ tears+

Clinical monitoring at (ee!s /$ <$and 8 (en pyra?inamide gi7en

Complete blood count$ platelets$and li7er function testsA atbaseline in selected casesBand repeat measurements if

aseline results are abnormal6atient as symptoms ofad7erse reactions

Rifampin is contraindicated or souldbe used (it caution in umanimmunodeficiency 7irus *>#;+)infected patients ta!ing proteaseinibitors *6#s+ or nonnucleosidere7erse transcriptase inibitors*55RT#s+

Decreases le7els of many drugs *e.g.$metadone$ coumadin deri7ati7es$glucocorticoids$ ormonalcontracepti7es$ estrogens$ oralypoglycemic agents$ digitalis$anticon7ulsants$ dapsone$

!etocona?ole$ and cyclosporin+Migt permanently discolor soft

contact lenses

Rifabutin 9*0'' mg+E

9*0'' mg+E

Ras>epatitis2e7erTrombocytopenia4range)colored body

fluids *secretions$urine$ tears+

=it increased le7els ofrifabutin

Se7ere artralgias-7eitisLeu!openia

Clinical monitoring at =ee!s /$ <$and 8 (en pyra?inamide gi7en

Complete blood count$ platelets$and li7er function testsA atbaseline in selected casesBand repeat measurements if

aseline results are abnormal6atient as symptoms of

ad7erse reactions-se adFusted daily dose of

rifabutin and monitor fordecreased antiretro7iral acti7ityand for rifabutin toxicity ifrifabutin ta!en concurrently(it 6#s or 55RT#sE

Rifabutin is contraindicated for>#;)infected patients ta!ing ard)gelsaGuina7ir or dela7irdineH caution isalso ad7ised if rifabutin isadministered (it soft)gel saGuina7ir

Reduces le7els of many drugs *e.g.$6#s$ 55TR#s$ metadone$ dapsone$!etocona?ole$ coumadin deri7ati7es$ormonal contracepti7e$ digitalis$sulfonylureas$ dia?epam$ I)bloc!ers$anticon7ulsants$ and teopylline+

Migt permanently discolor contactlenses

6yra?inamide 19@/'

*/.' g+

9'

*<.' g+

,astrointestinal upset

>epatitisRas &rtralgias,out *rare+

Clinical monitoring at =ee!s /$ <$

and 8Li7er function testsA at baseline inselected casesB and repeatmeasurements if

aseline results are abnormal6atient as symptoms of

ad7erse reactions

Treat yperuricemia only if patient as

symptomsMigt ma!e glucose control moredifficult in persons (it diabetes

Sould be a7oided in pregnancy butcan be gi7en after first trimester

J&ll intermittent dosing sould be administered by directly obser7ed terapy.A &ST or &LT and serum bi lirubin.B >#; infection$ istory of li7er disease$ alcoolism$ and pregnancy.E #f nelfina7ir$ indina7ir$ amprena7ir$ or ritona7ir is administered (it rifabutin$ blood concentrations of tese protease inibitors decrease. Tus$ te

dose of rifabutin is reduced from 0'' mg to 19' mgd (en efa7iren? is administered (it rifabutin$ blood concentrations of rifabutin decrease.Tus$ (en rifabutin is used concurrently (it efa7iren?$ te daily dose of rifabutin sould be increased from 0'' mg to <9' mg or :'' mg.6armaco!inetic studies suggest tat rifabutin migt be gi7en at usual doses (it ne7irapine. #t is not currently !no(n (eter dose adFustment ofrifabutin is reGuired (en used concurrently (it soft)gel saGuina7ir. 2or patients recei7ing multiple 6#s or a 6# in combination (it an 55RT#$ druginteractions (it rifabutin are li!ely more complexH in suc situations$ te use of rifabutin is not recommended until additional data are a7ailable.

uanti23R45K Test & blood test for latent tuberculosis infection *LT#+ as been recently licensed. Te entuc!y Tuberculosis Control 6rogram does not recommend

tis test for general use pending results of ongoing studies of te sensiti7ity and specifici ty of te test in 7arious sub)populations. &t tis time$ teentuc!y State Laboratory is not conducting te test.



uanti23R45K)T ,old #n)Tube and T)S64TK.TBTese t(o blood assays for Mycobacterium tuberculosis *&MT+ ae been licensed by te 2D&. Te entuc!y Tuberculosis 6rogram does notrecommend eiter of tese tests for general use pending results of ongoing studies of te sensitiity and specificity of tese tests in arious sub)populations. &t tis time$ te entuc!y State Laboratory is not performing &MT tests (it eiter assay.

Centers for &isease Control and 're%ention. Targeted tuberculin testing and treatment of latent tuberculosis

infection. MMWR 2000849(o. RR$:12<$29.

7/27/2019 QFT-GIT


Re(imen Options "o Teatment o" Latent TB In"ection in I-2e(ati,e Pesons

+u(

Re(imens

Comments+ail# Twice 9ee!l#

C&ilden Adults C&ilden Adults

+uation +uation +uation +uation

IN) months months months months

inimum of 980 doses administered within 39 months

Twice-weekl% regimens should consist of at least 8J doses administered within39 months/

Recommended regimen for pregnant women

Contraindicated for persons who hae actie hepatitis and end-stage lier disease

IN) OOOOOOOO J months OOOOOOOO J months

inimum of 370 doses administered within months

Twice-weekl% regimens should consist of at least $9 doses within months/

Recommended regimen for pregnant women

J-month regimen not recommended for those with fi"rotic lesions on chest

radiographs or children

Contraindicated for persons who hae actie hepatitis and end-stage lier disease

RI! 6 months 6 months Not recommended

inimum of 390 doses administered within J months

!or persons who are contacts of patients with IN)-resistant# RI!-suscepti"le TB

a% "e used for patients who cannot tolerate IN) or '\A

9AR2I27* Fatal and Se,ee Li,e InHuies a,e Been Associated 9it& Ri"ampin 'RIF) and P#ainamide 'PA) Teatment "o LTBI

RI!

and

'\A

Not recommended 9 months Not recommended 9 or 5 months

CO2SULT TB EXPERTS AT S2TC '-DTB-I2FO) BEFORE USI27.

Contraindicated for persons who hae actie hepatitis and end-stage lier disease/Aoid '\A for pregnant women "ecause of the risk of aderse effects to the fetus/

inimum of J0 doses to "e administered within 5 months/ Twice-weekl%regimens should consist of at least 3J doses to "e administered for 9 months or 96

doses to "e administered for 5 months/

a% "e used for IN)-intolerant patients/ This regimen has not "een ealuated in

)I?-negatie persons/

IN) 4 isoniaGid# RI! 4 rifampin# R!B 4 rifa"utin# '\A 4 p%raGinamide# EB 4 e tham"utol

irectl% o"sered treatment of 2TBI should "e used/Centers for &isease Control and 're%ention, Core Curriculum on Tuberculosis *9033,

Morbidit and Mortalit, ugust -, 2009, =ol. "0 5 o. 4



7/27/2019 QFT-GIT


Re(imen Options "o Teatment o" Latent TB In"ection "o Pesons wit& I In"ection

+u(

Re(imens

Comments Containdications+ail# Twice 9ee!l#

C&ilden Adults C&ilden Adults

+uation +uation +uation +uation

IN) months months months months

inimum of 980 doses administered within

39 months

Twice-weekl% regimens should consist of at least

8J doses administered within 39 months/

IN) can "e administered concurrentl% with NRTIs#'Is# or NNRTIs

irectl% o"sered treatment of latent TB infectionshould "e used when twice-weekl% dosing is used

)istor% of IN)-induced reaction#

including hepatic# skin or otherallergic reactions# or neuropath%

1nown exposure to person whohas IN)-resistant TB

Chronic seere lier disease

RI!

and

'\A&

Not recommended 9 months Not recommended 9-5 months

inimum of J0 doses to "e administered within5 months

Twice-weekl% regimens should consist of at least3J doses to "e administered for 9 months or

96 doses to "e administered for 5 months/

I! R!B is administered# patient should "e

monitored carefull% for potential R!B drug toxicit%and potential decreased antiretroiral drug actiit%/

ose ad<ustments# alternatie therapies# or other precautions might "e needed when rifam%cins are

used *e/g/# patient using hormonal contraceptiesmust "e adised to use "arrier methods# and

patients using methadone re(uire dosead<ustments,/

'Is or NNRTIs should generall% not "eadministered concurrentl% with RI!: in this

situation# an alternatie is the use of R!B and

'\A/

)istor% of a rifam%cin-inducedreaction# including hepatic# skin orother allergic reaction# or

throm"oc%topenia

'regnanc%

Chronic seere h%peruricemia

Chronic seere lier disease

R!B

and

'\A&

Not recommended 9 months Not recommended 9-5 months

IN) 4 isoniaGid: '\A- p%raGinamide: R!B- rifa"utin: RI!- rifampin: 'T- directl% o"sered preentie therap%: 'Is 4 protease inhi"itors: NNRTIs 4 nonnucleoside reerse transcriptase inhi"itors: NRTIs 4 nucleoside reerse transcriptase inhi"itors&!or patients with intolerance to '\A# some experts recommend the use of a rifam%cin *RI! or R!B, alone for preentie treatment/ ost experts agree that aaila"le data support the recommendation

that this treatment can "e administered for a short a duration as 6 months# although some experts would treat for J months/

The concurrent administration of rifa"utin is contraindicated with hard-gel sa(uinair and delairdine/ An alternatie is the use of r ifa"utin with indinair# nelfinair# amprenair# ritonair# efairenG#and possi"le soft-gel sa(uinair and neirapine/ Caution is adised when using rifa"utin with soft-gel sa(uinair and neirapine# "ecause data regarding the use of rifa"utin with soft-gel sa(uinair and

neirapine are limited/ Note> !or patients whose organisms are resistant to 3 or more drugs# administer at least 9 drugs to which there is demonstrated suscepti"ilit% and consult a TB medical expert/ Clinicians should reiewthe drug-suscepti"ilit% pattern of the / tu"erculosis strain isolated from the infecting source-patient "efore choosing a preentie therap% regimen/



9AR2I27* Fatal and Se,ee Li,e InHuies a,e Been Associated 9it&

Ri"ampin 'RIF) and P#ainamide 'PA) Teatment "o LTBI

7/27/2019 QFT-GIT





7/27/2019 QFT-GIT


+ecision to Initiate a Tu$eculosis 'TB) Contact In,esti(ation

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis, Recommendations from t3e ational TuberculosisControllers ssociation and C&C, &ecember -, 200", =ol."4, o. RR$-", ! ".



7/27/2019 QFT-GIT


PLA22I27 A CO2TACT I2ESTI7ATIO2

Consult the .tate TB 'rogram if %ou are planning a contact inestigation for more than 30 people*e/g/ a school# college# or large compan%,/ !or complete guidelines on structuring a contact

inestigation see the ]=uidelines for the Inestigation of Contacts of 'ersons with Infectious

Tu"erculosis#V +R 900$>$6 *No/ RR-36,/ The goals of a contact inestigation are 3, rapididentification of indiiduals who are high priorit% contacts to a known or suspected case of

pulmonar%# lar%ngeal# or pleural TB: 9, timel% initiation of appropriate treatment for those persons determined to "e recentl% infected or exposed with a significant risk for progression todisease: and 5, identification and treatment of additional indiiduals found to hae suspected TB

disease in order to preent further spread of disease/

+eteminin( t&e In"ectious Peiod "o a Patient wit& Acti,e TB +isease

etermining the infectious period for a case with actie TB disease focuses the inestigation on

those contacts most likel% to "e at risk for infection and sets the timeframe for testing contacts/Because the start of the infectious period cannot "e determined with precision "% aaila"le

methods# a practical estimation is necessar%/ 'er CC guidelines# an assigned start date# that is5 months "efore s%mptom onset or first positie finding consistent with actie TB disease# isrecommended *Ta"le# p/ $0,/ In certain circumstances# an een earlier start date should "e used/

!or example# a patient *or the patient^s associates, might hae "een aware of protracted illness *in

extreme cases# L3 %ear,/ Information from the patient interiew and from other sources should

"e assem"led to assist in estimating the infectious period/ )elpful details are the approximatedates that TB s%mptoms were noticed# m%co"acteriologic results# and extent of disease

*especiall% the presence of large lung caities# which impl% prolonged illness and

infectiousness,/

The infectious period is closed when the following criteria are satisfied> 3, effectie treatment *as

demonstrated "% M. tuberculosis suscepti"ilit% results, for L9 weeks: 9, diminished s%mptoms:and 5, m%co"acteriologic response *e/g/# decrease in grade of sputum smear positiit% detected

on sputum-smear microscop%,/ The exposure period for indiidual contacts is determined "%how much time the% spent with the index patient during the infectious period/ ultidrug-

resistant TB *R TB, can extend infectiousness if the treatment regimen is ineffectie/ An%

index patient with signs of extended infectiousness should "e continuall% reassessed for recentcontacts/

ore stringent criteria should "e applied for setting the end of the infectious period if

particularl% suscepti"le contacts are inoled/ A patient returning to a congregate liing setting

or to an% setting in which suscepti"le persons might "e exposed should hae at least three

consecutie negatie sputum A!B smear results from sputum collected L7 hours apart *with onespecimen collected during the earl% morning, "efore "eing considered noninfectious/

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis,

Recommendations from t3e ational Tuberculosis Controllers ssociation and C&C, &ecember -,

200", =ol."4, o. RR$-", ! -2.



7/27/2019 QFT-GIT


Initial Assessment o" Contacts

uring the initial contact encounter# which should "e accomplished within 5 working da%s of thecontact haing "een listed in the inestigation# the inestigator gathers "ackground health

information and makes a face-to-face assessment of the person^s health/ 'erforming a TB Risk

Assessment and administering a T.T or drawing "lood for a BAT at this time accelerates the

diagnostic ealuation/

The health department record should include>

• 'reious M. tuberculosis infection or actie TB disease and related treatment:

• Contact^s er"al report and documentation of preious T.T or BAT results:

• Current s%mptoms of actie TB disease *e/g/# cough# chest pain# hemopt%sis# feer# chills#

night sweats# appetite loss# weight loss# malaise# or eas% fatiga"ilit%,:

• edical conditions or risk factors making actie TB disease more likel%

o )I? infection

o Infants and children aged less than fie %ears:

o 'ersons who are receiing immunosuppressie therap% such as tumor necrosis

factor--alpha *TN!-, antagonists# s%stemic corticosteroids e(uialent to D3$ mg

of prednisone per da%# or immune suppressie drug therap% following organ

transplantation:o 'ersons recentl% infected with Mcobacterium tuberculosis *within the past

two *9, %ears:

o 'ersons with a histor% of inade(uatel% treated actie TB disease:

o 'ersons with silicosis# dia"etes mellitus# chronic renal failure# leukemia#

l%mphoma# cancer of the head# neck# or lung:

o 'ersons who hae had a gastrectom%# or <e<unoileal "%pass:

o 'ersons with low "od% weight *BI F 3,:

o Cigarette smokers and persons who a"use drugs or alcohol/

• ental health disorders *e/g/# ps%chiatric illnesses and su"stance a"use disorders,

• T%pe# duration# and intensit% of TB exposure: and

• .ociodemographic factors *e/g/# age# race or ethnicit%# residence# and countr% of "irth,

*see ata anagement and Ealuation of Contact Inestigations,/



7/27/2019 QFT-GIT


Pioitiation o" Contacts E%posed to Pesons wit& Acid-Fast Bacilli

'AFB) Sputum Smea-Positi,e o Ca,ita# Tu$eculosis 'TB) Cases



200", =ol."4, o. RR$-", ! -2.



7/27/2019 QFT-GIT


Pioitiation o" contacts

'rioritiGation of contacts is "ased on the characteristics of the case# the indiidual risk factors ofthe contact# and the enironment in which the exposure occurred/

=. Case C&aacteistics to conside*

'ulmonar%# lar%ngeal# or pleural TB disease

.uspected pulmonar%# lar%ngeal# or pleural TB disease

'ositie A!B .putum smear

NAA positie or not done

Negatie A!B .putum smear with a"normal chest x-ra%# consistent with actie TB

disease

Caitar% lesion on chest x-ra%

Chest x-ra% consistent with TB disease

5. Contact Ris! Factos*a. i(& pioit# contacts*

)I?-infected

)ousehold contacts

Contacts liing in congregate settings

Contacts aged less than $ %ears

Contacts during medical procedures# e/g/# "ronchoscop%# sputum induction# or

autops%

Contacts with medical risk factors that increase the likelihood for progression to

actie TB disease# e/g/ silicosis# dia"etes mellitus# a histor% of gastrectom% or <e<unoileal "%pass surger%/

Contacts receiing L3$mg of 'rednisone or its e(uialent for L 6 weeks/

Contacts receiing other immunosuppressie agents# including chemotherap%#anti-re<ection therap%# tumor necrosis factor alpha *TN!-alpha, antagonists

Contacts who exceed the enironmental exposure limits for high-priorit% contacts/

$. Medium pioit# contacts*

Contacts aged $ through 36 %ears

Contacts who exceed the enironmental exposure limits for medium-priorit% contacts/

c. Low pioit# contacts*

Contacts who are "elow the threshold for classification as medium-priorit% contacts



7/27/2019 QFT-GIT


7/27/2019 QFT-GIT


$/ 'roide medication if indicated

J/ Ensure monthl% monitoring of those on treatment for 2TBI

8/ 'roide expert guidance for treatment and management issues

+ocumentation 6 Repotin(*

The contact inestigation roster should "e completed for all initiated contact inestigations/ A

linking identification *I, num"er should "e assigned to the contact roster and documented in themedical record of the index case and all identified contacts/ A recommended format for the

contents of the linking I num"er is ]count% code plus %ear *9 digits, plus local TB case num"erfor the %ear# e/g/ 003-30-003 would "e the code for the first TB case for 9030 in Adair Count%/

A detailed listing of count% codes is located in the AR ?olume II> 'atient .erices Reporting

.%stem/

A cop% of the Contact Inestigation .ummar% should "e completed and maintained in the

medical record of the index case/ The Contact Inestigation .ummar% form is in the TB !ormschapter/ The contact inestigation roster should "e kept in a separate file and should not "e

placed in the medical record of the index case or the medical record of an% of the identified

contacts/

A cop% of the contact inestigation roster and contact inestigation summar% shall "e sent to the

state TB 'rogram 50 da%s after initiating the contact inestigation/

Initiation o" contact in,esti(ation*

Initiate a contact inestigation within one "usiness da% of "ecoming aware of a new actie TB

case/ .tart with a face to face interiew with the actie TB case and;or famil% mem"ers#wheneer possi"le/ Additional steps in the inestigation should meet the timeframes for initial

follow-up of contacts of persons exposed to actie TB disease *see# Ta"le p/ 6,/

E,aluation o" contacts*3/ Ealuate high-priorit% contacts to lar%ngeal# pulmonar%# or pleural actie TB

disease within 8 da%s of notification/

9/ Ealuate medium-priorit% contacts to lar%ngeal# pulmonar%# or pleural actie

TB disease within 36 da%s of notification/5/ 2ow priorit% contacts should not "e tested unless o"<ecties for high and

medium-priorit% contacts are "eing met/ If a decision to do a T.T or BAT on a low-

priorit% contact has "een made# the initial test can "e dela%ed until 7-30 weeks after the mostrecent exposure/

6/ Complete initial inestigation of contacts within 50 da%s/

$/ Infants# children aged less than $ %ears and )I? positie indiiduals hae

highest priorit% for immediate ealuation and initiation of 2TBI treatment as indicated/J/ 'roide )I? counseling# testing# and referral on all contacts/

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis, Recommendations from t3e ational Tuberculosis Controllers ssociation and C&C, &ecember -,

200", =ol."4, o. RR$-", ! -2.



7/27/2019 QFT-GIT


+, Ti/s !n the C!n0ent%i0 Ci%0$e A//%!&0h

3, .tart A.A'

9, +ork in the field *not <ust the office,

5, Begin in the center ring and work outward6, 'roceed simultaneousl% on all three fronts

$, ont "e pressured easil% to expand %our circles: keep control/ +e know there can "e

panic when a group or communit% of people find out a"out a case of TB "einginestigated among them

J, ont forget that there are circles in time as well as space

8, Ealuate %our data eer% step of the wa%/ +hat are the% telling %ou a"out the sourcecaseY +hat needs to "e done nextY

7, If st%mied# let people know %ou must and will proceed with or without them/

, Call for reinforcement if necessar%30, ont forget the follow-up T.T or BAT at 7 to 30 weeks/ .ome contacts will not hae

conerted until then/

Remem$e* Because priorit% assignments are practical approximations deried from imperfectinformation# priorit% classifications should "e reconsidered throughout the inestigation as

findings are anal%Ged/

#ee1 Contact In%estigation for Tuberculosis8 C&C #elf$#tud Module >, ! 9-.

'age $0 of $9Core Clinical .erice =uide


Contact In,esti(ation and t&e Concentic Cicle Appoac&

Ste/s in & C!nt&0tIn1estig&ti!n

The first step in a contact

inestigation is to reiew the TB patients medical records and ask the

clinician for information to determine

whether the patient has "een

infectious# and if so# when/ 1nowingthe index patients infectiousness

helps decide which contacts to focus

on and which contacts are at risk/

Collect "asic data>

The site of actie TB disease

TB s%mptoms and date s%mptoms

"egan

A!B .mear; TB culture resultsC_R date and results

T or self-administered treatment

TB treatment *drugs# dosage# and date

treatment started,

9o! o

Sc&ool

En,ionment

Leisue o

Receational

En,ionment

High Priority Contacts

Medium Priority Contacts

Low Priority Contacts

ouse&old 6 Residence En,ionment

Medium Priority

Low Priority

!ig$ %riority

Inde&Patient

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7/27/2019 QFT-GIT


E,aluation3 Teatment3 and Follow-Up o" Tu$eculosis 'TB) Contacts

A(ed J K ;eas



200", =ol."4, o. RR$-", ! -".



7/27/2019 QFT-GIT


E,aluation3 Teatment3 and Follow-Up o" Immunocompomised Contacts

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis, Recommendations from t3e ational Tuberculosis Controllers ssociation and C&C, &ecember -,

200", =ol."4, o. RR$-", ! -.



7/27/2019 QFT-GIT


E,aluation3 Teatment3 and Follow-Up o" Contacts wit& a

+ocumented Pe,iousl# Positi,e Tu$eculin S!in Test

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis, Recommendations from t3e ational TuberculosisControllers ssociation and C&C, &ecember -, 200", =ol."4, o. RR$-", ! -9.



7/27/2019 QFT-GIT


Time Fames "o Initial Follow-up o" Contacts o"

Pesons E%posed to Tu$eculosis 'TB)

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis, Recommendations from t3e ational Tuberculosis

Controllers ssociation and C&C, &ecember -, 200", =ol."4, o. RR$-", ! 9.

'age $$ of $9Core Clinical .erice =uide


7/27/2019 QFT-GIT


7uidelines "o Estimatin( t&e Be(innin( o" t&e Peiod o" In"ectiousness o"

Pesons wit& Tu$eculosis 'TB)3 $# Inde% Case C&aacteistic

MMWR 6uidelines for t3e In%estigation of Contacts of 'ersons it3 Infectious Tuberculosis, Recommendations from t3e ational TuberculosisControllers ssociation and C&C, &ecember -, 200", =ol."4, o. RR$-", ! ;.

'age $J of $9Core Clinical .erice =uide


7/27/2019 QFT-GIT


R"F"R"NC"S

3/ CC/ Core Curriculum on Tu"erculosis>

+hat the Clinician .hould 1now/

$

th

Edition/ Atlanta# =A> . epartment of)ealth and )uman .erices# CC# 9033#

http>;;www/cdc/go;t";education;corecurr;de

fault/htm /

9/ CC .elf .tud% odules on Tu"erculosis

*odules 3 4 $# , 4 9007

CC .elf .tud% odules on Tu"erculosis

*odules J 4 , 4 9000

http>;;www/cdc/go;t";education;ssmodules;

default/htm

5/ CC/ Targeted Tu"erculin Testing andTreatment of 2atent Tu"erculosis Infection#

+R 9000:6*No/ RR-J,/

6/ Tu"erculosis 2aws as found in the 1entuck%

Reised .tatues# Chapter 93$/$33 4 J00#

3tt!155c3fs..go%5d!35e!i5tb.

$/ Tu"erculosis Regulations>

09 1AR 9>090 4 00 *.ureillance# Control#

etection# 'reention,:

09 1AR 90>03J 4 900 *)ospital and

2ong-Term Care,/

J/ CC/ Treatment of Tu"erculosis/ +R

9005:$9*No/ RR-33,/

8/ CC/ Recommendations and Reports#

=uidelines for Inestigation of Contacts of

'ersons with Infectious TB/ +R 900$:

$6*No/ RR-3$,/

7/ American Academ% of 'ediatrics/ 900 Red

Book# 97th edition> Report of the Committee

on Infectious isease/ Elk =roe ?illage#I2> American Academ% of 'ediatrics

/ American Thoracic .ociet%;Centers forisease Control/ iagnostic .tandards and

Classification of Tu"erculosis in Adults and

Children/ Am @ Respir Crit Care ed 3:

J3>358J-$

30/ CC antoux Tu"erculin .kin Testing

?# 900J#http>;;www9c/cdc/go;podcasts;pla%er/aspY

fZ585 *'odcast,

http>;;www/cdc/go;t";education;antoux;de

fault/htm

33/ NI.) +e"site at>

3tt!155.cdc.go%5nios3.

39/ CC/ =uidelines for 'reenting the

Transmission of Mcobacterium tuberculosisin )ealth-Care .ettings 900$/ +R

900$:$6*No/ RR-38,/

35/ CC/ Controlling Tu"erculosis in the nited

.tates/ +R 900$:$6*No/ RR-39,/

36/ Core Clinical .erice =uide !orms>

http>;;chfs/k%/go;dph;2ocal`)ealth`e partment/htm/

3$/ )I'AA 'riac% Rule and 'u"lic )ealth#

+R# April 33# 9005 ; $9:3-39/

3J/ Curr% International Tu"erculosis Center#

9033> Tu"erculosis Infection Control> A

'ractical anual for 'reenting TB#

http>;;www/curr%t"center/ucsf/edu;products;p

roductOdetails/cfmYproductIZ+'T-39

CC TB =uidelines pu"lished in +R areaaila"le online# http>;;www/cdc/go;t";

pu"lications;guidelines;default/htm/

9old ealt& O(aniation 7lo$al TB +ata$ase Estimated Incidence

This information is listed in the forms and teaching sheets listing of the CC.= at

http>;;chfs/k%/go;dph;2ocal`)ealth`epartment/htm/

http://www.cdc.gov/tb/education/corecurr/default.htm


http://www.cdc.gov/tb/education/ssmodules/default.htm



http://chfs.ky.gov/dph/epi/tb


http://www2c.cdc.gov/podcasts/player.asp?f=3739



http://www.cdc.gov/tb/education/Mantoux/default.htm



http://www.cdc.gov/niosh

http://chfs.ky.gov/dph/Local+Health+Department.htm


http://www.currytbcenter.ucsf.edu/products/product_details.cfm?productID=WPT-12


http://www.cdc.gov/tb/publications/guidelines/default.htm














http://www.cdc.gov/niosh







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