NTP guidelines Flashcards
Presumptive Pulmonary TB
any person having:
1. 2 weeks or longer of any of the ff: cough, unexplained fever, unexplained weight loss
- chest xray findings suggestive of TB
presumptive extrapulmonary TB
signs and symptoms specific to extrapulmonary sites with or without general constitutional signs and symptoms such as unexplained fever, weight loss, nights sweats, fatigue or loss of appetite
4 cardinal signs and symptoms of TB
2 weeks cough unexplained fever weight loss night sweats
children in TB guidelines is referred to as
less than 15 years old
For those who do not have any of the cardinal signs/symptoms above or experienced
it for less than two weeks, offer chest X-ray screening if one has not been conducted
in the past year
TB risk factors
contacts of TB patients;
b. those ever treated for TB (i.e. with history of previous TB treatment);
c. people living with HIV (PLHIV);
d. elderly (> 60 years old);
e. diabetics;
f. smokers;
g. health-care workers;
h. urban and rural poor (indigents); and
i. those with other immune-suppressive medical conditions (silicosis, solid organ
transplant, connective tissue or autoimmune disorder, end-stage renal disease,
chronic corticosteroid use, alcohol or substance abuse, chemotherapy or other
forms of medical treatment for cancer)
Ask for the following signs and symptoms (lasting for ≥ 2 weeks): 1. cough 2. unexplained fever 3. unexplained weight loss 4. night sweats
If >/=1 is present —> Presumptive TB
If NONE –> Do Chest xray –> if suggestive of TB –>classify as Presumptive TB
When should we do symptom screening and chest xray in people living with HIV?
At the time of diagnosis of HIV and annually
If with signs and symptoms and chest xray finding of TB –> collect sputum sample –> request for Gene Xpert MTB/Rif assay
Every visit
screening for pulmonary TB (PTB) in children
< 15 years old:
Ask if the child has TB signs and symptoms. Identify as presumptive TB if the child has at least one of the three main signs and symptoms suggestive of TB:
a. coughing/wheezing of two weeks or more, especially if unexplained (e.g. not
responding to antibiotic or bronchodilator treatment);
b. unexplained fever of two weeks or more after common causes such as malaria or pneumonia have been excluded; and
c. unexplained weight loss or failure to thrive not responding to nutrition therapy
Ask if the child is a close contact of a known TB case. If the child is a contact,
the presence of fatigue, reduced playfulness, decreased activity, not eating well or
anorexia that lasted for two weeks or more should also be considered and identify
them as a presumptive TB
All patients with chest X-ray findings suggestive of TB should be identified as presumptive
TB. Sputum should be collected for an Xpert MTB/RIF test.
Chest xray screening in DS-TB contacts should be done in the ff:
All 5 years old and above (symptom
screening only for < 5 years old)
• If chest X-ray not available, do symptom
screening
Chest xray should be done in DR-TB contacts in the ff:
All contacts
• If chest X-ray not available, do
Xpert test directly for all contacts.
Diagnostic test in DS-TB contacts and DR-TB contacts
DS-TB contacts: Xpert, if not available SM/loop mediated isothermal amplification (TB LAMP)
DR-TB contacts: Xpert
What should be given in DS-TB contacts?
If active TB ruled-out : Consider TB preventive treatment (TPT)
What should be done in DR-TB contacts?
TPT currently not recommended
In DS-TB contacts, follow up should be done
Every six months for two years
(Symptom screen every six months, chest
X-ray every year)
In DR-TB contacts, follow up should be done
Every six months for two years
(Symptom screen every six months,
chest X-ray every year. If chest X-ray
not available, do Xpert test directly.)
refers to a patient from whom a biological specimen,
either sputum or non-sputum sample, is positive for TB by smear microscopy, culture or
rapid diagnostic tests (such as Xpert MTB/RIF, line probe assay for TB, TB LAMP).
Bacteriologically confirmed TB (BCTB)
refers to a patient for which the criterion for bacteriological
confirmation is not fulfilled but diagnosis is made by the attending physicians on the basis
of clinical findings, X-ray abnormalities, suggestive histology and/or other biochemistry or
imaging tests.
Clinically diagnosed TB (CDTB)
refers to a patient who has never had treatment for TB or who has taken anti-TB drugs
for less than one month. Preventive treatment is not considered as previous TB treatment.
New
refers to a patient who had received one month or more of antiTB drugs in the past. Also referred to as Retreatment
Previously treated for TB
previously treated for TB, new
TB cases that are contacts of con firmed DR-TB cases or non-converter among patients on
DS-TB regimens
High risk for multidrug-resistant tuberculosis (MDR-TB)
resistance to rifampicin detected using phenotypic
or genotypic methods, with or without resistance to other anti-TB drugs. It includes any
resistance to rifampicin, whether monoresistance, multidrug resistance, polydrug resistance
or extensive drug resistance
Rifampicin-resistant TB (RR-TB)
All presumptive TB patients who are at high risk for MDR-TB shall be referred for Xpert MTB/
RIF testing. If not accessible, a sputum transport system shall be used or patient shall be
referred to the nearest health facility with DR-TB services for screening
primary diagnostic test for PTB and EPTB in adults and children
A rapid diagnostic test (RDT), such as Xpert MTB/RIF
shall be used only as an adjuvant when there is doubt in making a clinical diagnosis of TB in children
Tuberculin skin test (TST), also known as purified protein derivative (PPD) test or Mantoux test
considered a positive TST reaction
An induration of at
least 10 mm regardless of bacille Calmette-Guerin (BCG) vaccination status or 5 mm in
immunocompromised children (e.g. severely malnourished)
If sputum or non-sputum specimen tested by Xpert MTB/RIF, SM or TB LAMP shows
MTB detected or positive result, classify as
bacteriologically confirmed PTB or EPTB
Approach to diagnosis of TB in children (< 15 years old)
in Presumptive TB
Ask to expectorate sputum OR gastric lavage sample,
if available
Do Xpert MTB/Rif
MTB Positive +/ Rif Resistance –>BCTB
MTB Negative / Cannot Expectorate –> Request Chest X-ray if not done –> Strongly suggestive of TB with clinical S/S –> Clinically diagnosed TB
If Normal or uncertain --> Consider giving broad spectrum antibiotics. Follow-up after 2 weeks. IF S/S persists, • If contact of a known TB case, may classify as CDTB • If not a contact, perform TST If TST (+), may classify as CDTB. If TST (−) or unavailable but S/S persistent, • Refer to specialist for further investigation and management (less likely to be TB) • If referral not possible, attending physician to decide based on best clinical judgment (consider if clinically unstable or if with other risk factors for TB). If treated as active TB, classify as CDTB.
If chest X-ray finding is strongly suggestive of TB based on the following (Fig. 6),
classify as clinically diagnosed TB
Markedly enlarged unequal hilar lymph gland (i.e. > 2 cm in size) with or without opacification
ο Miliary mottling
ο Large pleural effusion (≥ 1/3 of pleural cavity, usually common in children >5 years old)
ο Apical opacification with cavitation (rare in younger children, common in adolescents.
Chest X-ray findings strongly suggestive of PTB in < 10 years of age
Signs and symptoms: Persistent fever, weight loss, cough, and irritability
Right hilar lymphadenopathy
Chronic pneumonia
Miliary pattern
Chest X-ray findings strongly suggestive of PTB 10–18 years of age
Signs and symptoms: Persistent fever, adynamia, and
expectoration (bloody sputum)
Pulmonary cavitations
Pleural effusion
Diagnose EPTB either bacteriologically or clinically
4.1 EPTB can be confirmed bacteriologically using Xpert MTB/RIF.
4.2 For presumptive EPTB cases where it is not possible to get body fluid or tissue
sample, give an antibiotic trial and follow-up after one to two weeks.
- 3 EPTB can be assessed as clinically diagnosed TB by the health facility physician based on signs and symptoms, imaging studies, histology or other laboratory tests.
- 4 As necessary, refer presumptive EPTB to health facilities capable of performing appropriate diagnostic procedures.
For patients with Xpert result: MTB without rifampicin resistance classify as
classify as drug susceptible TB (DS-TB).
Positive for MTB using rapid diagnostic modalities (i.e. Xpert MTB/RIF) with resistance to rifampicin
Bacteriologically confirmed
rifampicin-resistant TB
(BC RR-TB)
Positive for MTB complex with resistance to at least both isoniazid and rifampicin from an NTP-recognized laboratory
Bacteriologically confirmed multidrug-resistant TB
BC MDR-TB
Positive for MTB complex with resistance to any fluoroquinolone
(FQ) and to at least one second-line injectable drug (e.g. amikacin, streptomycin), in addition to multidrug resistance from an NTPrecognized laboratory
Bacteriologically confirmed extensively drug-resistant TB (XDRTB)
(BC XDR-TB)
A patient with at least one of the following:
•specimens tested in an NTP-recognized laboratory that is
negative for MTB complex but with clinical deterioration and/or
radiographic findings consistent with active TB; or
•specimen/s with other resistance pattern (i.e. mono DR-TB or poly
DR-TB) with clinical deterioration and/or radiographic findings
consistent with active TB; or
•laboratory diagnosis not done due to specified conditions but with
clinical deterioration and/or radiographic findings consistent
with active TB; or
•diagnosis showing resistance to both isoniazid and rifampicin in a
non-NTP-recognized laboratory;
and there has been no response to a course of empiric antibiotics
and/or symptomatic medications; and
who has been decided by the TB Medical Advisory Committee (TB
MAC) to have TB disease requiring a full course of second-line antiTB chemotherapy similar to BC MDR-TB.
Clinically diagnosed multidrugresistant TB
CD MDR-TB
A patient with resistance to one first-line anti-TB drug, except rifampicin whether bacteriologically confirmed (regardless of the date of collection, with or without radiographic abnormalities) or clinically diagnosed
monoresistant TB
A patient with resistance to more than one first-line anti-TB drug, other than both isoniazid and rifampicin, whether bacteriologically confirmed
(regardless of date of collection, with or without radiographic abnormalities) or clinically diagnosed
polydrug-resistant TB
previously treated for TB and declared cured or treatment completed,
but is presently diagnosed with active TB disease
relapse
previously treated for TB but failed most recent course
based on a positive SM follow-up at five months or later, or a clinically diagnosed TB patient who does not show clinical improvement anytime during treatment
Treatment after failure
previously treated for TB but did not complete
treatment and lost to follow-up for at least two months in the most recent course
Treatment after lost to follow-up
previously treated for TB but whose outcome
in the most recent course is unknown
Previous treatment outcome unknown
patients who do not fit
any of the categories listed above or previous treatment history is unknown (this
group will be considered as previously treated also)
Patients with unknown previous TB treatment history
PTB or EPTB (except central nervous system [CNS], bones, joints) whether new or
retreatment, with final Xpert result:
ο MTB, RIF sensitive
ο MTB, RIF indeterminate
Regimen 1
2HRZE/4HR
• New PTB or new EPTB (except CNS, bones, joints), with positive SM/TB LAMP or
clinically diagnosed, and:
ο Xpert not done*
ο Xpert result is MTB not detected
Regimen 1
2HRZE/4HR
• EPTB of CNS, bones, joints whether new or retreatment, with final Xpert result:
ο MTB, RIF sensitive
ο MTB, RIF indeterminate
Regimen 2
2HRZE/10HR
• New EPTB of CNS, bones, joints, with positive SM/TB LAMP or clinically
diagnosed, and:
ο Xpert not done*
ο Xpert result is MTB not detected
Regimen 2
2HRZE/10HR
TB treatment in HIV co-infection
Antiretroviral treatment (ART) should be started in all TB patients living with HIV, regardless of CD4 cell count.
TB treatment should be initiated first, followed by ART as soon as possible within the first eight weeks of treatment.
If with profound immunosuppression (e.g. CD4
counts less than 50 cells/mm3), HIV-positive TB patients should receive ART within the first two weeks of initiating TB treatment.
Patients with the TB–HIV co-infection should also receive co-trimoxazole as prophylaxis for
other infections.
People with HIV infection who, after careful evaluation, do not have active
TREATMENT OF TUBERCULOSIS 39
TB should be given TB preventive treatment for presumed latent tuberculosis infection
Gastrointestinal intolerance
Rifampicin, isoniazid,
pyrazinamide
Give drugs at bedtime or with small meals
Mild or localized skin reactions
Any of the drugs Give antihistamines
Orange-colored urine
Rifampicin
Reassure the patient
Burning sensation in the feet due
to peripheral neuropathy
Isoniazid
Give pyridoxine (Vit B6) 50–100 mg daily for
treatment; it can also be given 10 mg daily
for prevention
Arthralgia due to hyperuricemia
Pyrazinamide
Give aspirin or NSAID; if persistent,
consider gout and request uric acid
determination, manage accordingly or refer
Flu-like symptoms
fever, muscle pains, inflammation of the respiratory tract
Rifampicin
Give antipyretics
Severe skin rash due to hypersensitivity
Any of the drugs
Stop anti-TB drugs and refer to specialist
Jaundice due to hepatitis
Any of the drugs (especially isoniazid, rifampicin, pyrazinamide)
Stop anti-TB drugs and refer to specialist; if
symptoms subside, resume treatment and
monitor clinically
Impairment of visual acuity and
color vision due to optic neuritis
Ethambutol
Stop ethambutol and refer to
ophthalmologist
Oliguria or albuminuria due to renal disorder
Rifampicin
Stop anti-TB drugs and refer to specialist
Psychosis and convulsion
Isoniazid
Stop isoniazid and refer to specialist
Thrombocytopenia, anemia, shock
Rifampicin
Stop anti-TB drugs and refer to specialist
Isoniazid
10 (715) mg/kg,
Not to exceed 300 mg daily
Rifampicin (R)
15 (10–20) mg/kg,
Not to exceed 600 mg daily
Pyrazinamide (Z)
35 (30–40) mg/kg
Ethambuthol (E)
20 (15–25) mg/kg
sputum follow-up examinations for New, CDTB
ffup 1: End of Intensive phase (2nd month)
ffup 2: ONLY IF positive at end of intensive phase; end of 5th month
ffup 3: ONLY IF positive at end of intensive phase; end of treatment (6th month)
sputum follow-up examinations for
New, BCTB
• Retreatment
ffup 1: End of Intensive phase (2nd month)
ffup 2: end of 5th month
ffup 3: end of treatment (6th month)
If interruption is more than one month but less than two months
perform a SM and
decide on continuation of treatment based on results
If interruption is more than one month but less than two months
perform a SM and
decide on continuation of treatment based on results
For patients who interrupt treatment for less than one month
continue the treatment
and just prolong it to compensate for missed doses
If interruption is at least two months,
declare “lost to follow-up”. Exert all efforts to trace
patient, perform Xpert MTB/RIF test and refer to DR-TB treatment center if needed
A patient whose treatment was interrupted for at least two consecutive months.
A patient diagnosed with active TB but was not started on treatment (i.e., initial LTFU).
Lost to follow-up
LTFU
A patient for whom no treatment outcome is assigned.
This includes patients transferred to another facility for continuation of treatment but
the final outcome was not determined.
Not Evaluated
Tuberculin skin test (TST) or interferon-gamma release assays (IGRA) shall not be required
prior to initiation of preventive treatment in the following eligible individuals
a. PLHIV;
b. children less than 5 years old who are household contacts of bacteriologically confirmed
PTB; and
c. individuals aged 5 years and older who are household contacts of bacteriologically
confirmed PTB and with other TB risk factors
Perform TST in the following individuals; if TST is not available, it is not recommended
to offer LTBI treatment to these individuals:
a. children less than 5 years old who are household contacts of clinically diagnosed
PTB;
b. household contacts of bacteriologically confirmed PTB cases who are 5 years and
older but with no other risk factors for TB;
c. close contacts of bacteriologically confirmed PTB; and
d. Other risk factors
• patients receiving dialysis
• patients preparing for an organ or hematological transplantation
• patients initiating anti-TNF treatment
• patients with silicosis
TB preventive treatment regimen
6H (isoniazid daily): Currently available under the program
3HP (isoniazid, rifapentine weekly) Weekly dosing for three months
Contraindicated in pregnant and < 2 years old
3 HR (isoniazid, rifampicin daily) Preferred for children if 3HP not available
4R (rifampicin daily) Preferred for adults if 3HP not available
Pregnant women
Isoniazid and rifampicin can be used in pregnant or breastfeeding women.
Rifapentine
should be avoided due to lack of data on safety in pregnant or breastfeeding women.
For pregnant women with HIV who are already on ART, defer preventive treatment until
three months post-partum
Pregnant women
Isoniazid and rifampicin can be used in pregnant or breastfeeding women.
Rifapentine
should be avoided due to lack of data on safety in pregnant or breastfeeding women.
For pregnant women with HIV who are already on ART, defer preventive treatment until
three months post-partum
Breastfeeding
Preventive treatment using isoniazid and or rifampicin can be safely given to breastfeeding
women. Supplemental pyridoxine (i.e. vitamin B6) should be given to the infant who is
taking isoniazid or whose breastfeeding mother is taking isoniazid.
Oral contraceptives
Rifampicin and rifapentine interact with oral contraceptive medications with a risk
of decreased protective efficacy against pregnancy. Advise a woman receiving oral
contraceptives while on rifampicin or rifapentine that she has the following options:
1) take an oral contraceptive pill containing a higher dose of estrogen (50μ), following
consultation with a clinician; or
2) use another form of contraception.
Liver disease or history of liver disease
Isoniazid and rifampicin/rifapentine are both associated with hepatitis.
Treatment
should not be initiated in individuals whose baseline liver transaminases is more than
three times the upper limit of normal (ULN).
Preventive treatment should not be given
to individuals with end-stage liver disease
Acute hepatitis (e.g. acute viral hepatitis)
Defer preventive treatment until the acute hepatitis has been resolved.
Renal failure
Isoniazid and rifampicin/rifapentine are eliminated by biliary excretion.
These drugs,
therefore, can be given in normal dosages to patients with renal failure.
Patients with severe renal failure should receive isoniazid with pyridoxine to prevent peripheral
neuropathy.
People living with HIV
Rifampicin and rifapentine can be co-administered with efavirenz without dose adjustment.
Rifampicin or rifapentine cannot be co-administered with protease inhibitors or nevirapine
Baby born to mother with active TB disease
a. Assess the newborn. If the newborn is not well, refer it to a specialist/pediatrician.
b. If the newborn is well (absence of any signs or symptoms presumptive of TB), do
not give BCG first. Instead give TB preventive treatment. Give Pyridoxine at 5–10
mg/day. Preventive treatment is not necessary if the mother has received more
than two months of anti-TB treatment and is not considered infectious.
c. At the end of treatment, perform TST. If TST is negative or not available, give BCG.
d. If the mother is taking anti-TB drugs, she can safely continue to breastfeed.
Mother and baby should stay together and the baby may be breastfed while on TB
preventive treatment.
