TB 2016 Flashcards
For patients 15 years old and above, a presumptive TB has any of the following:
Cough of at least 2-weeks duration; unexplained cough of any duration in a close contact of a known active TB case; or CXR findings suggestive of PTB with or without symptoms
OR
ANY of the following symptoms:
cough of any duration, significant and unintentional weight loss, fever, bloody sputum or hemoptysis, chest pains not referable to any musculoskeletal disorders, easy fatigability or malaise, night sweats, shortness of breath or difficulty of breathing
Sputum collection for DSSM
• 2 specimens, either spot-spot one-hour apart or spot-early morning collection
t least 1 sputum smear positive is considered bacteriologically confirmed TB
Role of sputum TB culture with drug susceptibility testing (DST)
For all cases of retreatment, treatment failure, MDR suspects
• All smear-negative TB symptomatic who have risk factors for drug-resistant T
Also for known contacts of MDR-TB, PLHIV
Patients who cannot expectorate sputum
Sputum induction
Xpert® MTB/Rif should be requested among smear-negative, CXR-positive presumptive TB patients with no risk for DR-TB or HIV-TB
TRUE
Inclusion of Xpert® MTB/Rif
initial diagnostic test in adults with presumptive TB (Weak recommendation, high quality evidence) with pooled sensitivity of 89%, specificity 99%
In comparison with smear microscopy, Xpert® MTB/Rif increased TB detection among culture-confirmed cases by
23%
Pretreatment
Baseline serum ALT
creatinine
Provider initiated counseling and testing (PICT) for HIV
Screening for DM using FBS, RBS or 75g OGTT for all patients with TB
Serum uric acid testing NOT routinely recommended
Retreatment
patient who has received 1 month or more of anti-TB drugs in the past (excluding prophylaxis or treatment for latent TB infection
Treatment after lost to follow-up (TALF)
lost to follow-up after interruption of at least 2 consecutive months at the end of most recent course of treatment and is now bacteriologically confirmed or clinically diagnosed TB
Meds for new cases
2HRZE/4HR (Category I) for pulmonary and extra-pulmonary TB except meninges, bones or joints
2HRZE/10HR (Category Ia) for extra-pulmonary TB of meninges, bones, joints
Management of retreatment cases
2HRZES/1HRZE/5HRE (Category II) for retreatment of confirmed rifampicin-sensitive pulmonary and extra-PTB except meninges, bones or joints
2HRZES/1HRZE/9HRE (Category IIa) for retreatment of confirmed rifampicin-sensitive extra-PTB of meninges, bones or joints
Monitoring new cases for treatment response
DSSM (1 specimen) at the end of 2nd, 5th, 6th month of treatment among bacteriologicallyconfirmed PTB; at the end of 2nd month for clinically-diagnosed PTB
If smear-positive at the end of 5th month, classify as Treatment Failed;
The overall diagnostic yield of smear positivity among presumptive PTB with spontaneous sputum production was 15.15% that improved to 21.21% with sputum induction.
spontaneous sputum production was 15.15%
21.21% with sputum induction
Culture positivity with spontaneous samples was 18.18%, which improved to 27.27% with sputum induction.
Culture: 18.18% spontaneous sputum
27.27% with sputum induction.
With on-the-spot induced sputum, the yield for smear-positive cases was not increased, but the yield for culture positive cases increased to 46%
yield for culture positive cases increased to 46%
The NTP MOP requires at least —– for DSSM.
1 teaspoonful (5-10mL)
For the diagnostic evaluation of PTB, two (2) sputum specimens should be obtained for DSSM. (Strong recommendation, moderate quality evidence)
Same day (spot-spot) strategy using 2 consecutive specimens collected 1-hour apart is recommended for direct Ziehl-Neelsen microscopy (Strong recommendation, moderate quality evidence)
direct Ziehl-Neelsen microscopy
A systematic review of 37 studies showed that the overall weighted average percentage of cases detected with the first sputum specimen was 85.8%.
First sputum specimen positive at 85.6%
11.9% is attained with the second specimen and the average incremental yield from the third sputum specimen was 2.3%
What is the preferred type of microscopy for DSSM?
light-emitting diode (LED) microscopy is the preferred diagnostic microscopy method for DSSM replacing conventional ZN microscopy
The systemic review and meta-analysis done by the WHO revealed that LED microscopy is statistically significantly more sensitive by 6% (95% CI, 0.1-13%), with no appreciable loss in specificity, when compared with direct ZN microscopy
LED microscopy more sensitive by 6%
Positivity of sputum smears correlate with the patient’s baseline infectiousness which is 10x more among smear-positive TB cases compared to those who are smear-negative.
10x more
The 2012 national Drug Resistance Survey (DRS) revealed that 44% of re-treatment cases had drug resistant TB of which 21% had MDR TB (Macalalad, 2012).
44% of re-treatment = drug resistant TB =
and of which 21% had MDR TB
GeneXpert: As initial diagnostic test in adults with presumptive TB (Weak recommendation, high quality evidence) with a pooled sensitivity of 89%, specificity 99%. (Strong recommendation, high quality evidence)
MTB XPERT SPUTUM: 89% sensitive, 99% specific
In comparison with smear microscopy, Xpert® MTB/Rif increased TB detection among culture-confirmed cases
by 23%
A systematic review showed that screening for DM among patients with TB yielded a prevalence o
1.9 to 35%,
The use of corticosteroids as adjunctive therapy is recommended ONLY for patients with T
tB meningitis and/or TB pericarditis.
dose of steroids in TB MENINGITIS
In TB meningitis, the recommended regimen is dexamethasone 0.4 mg/kg/24H with a reducing course over 6-8 weeks
• In TB pericarditis, the recommended regimen is
prednisolone 60 mg for the first 4 weeks, 30 mg for weeks 5-8, 15 mg for weeks 9-10 and 5 mg for week 11
The prevalence of polyneuropathy is—— among HIV-negative individuals receiving INH at 3-5 mg/kg/day.
2-12%
