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).
