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Revision > TB & NTM > Flashcards

TB & NTM Flashcards

1
Q

Eligibility of neonates for BCG vaccine in low incidence area?

A

1) Born in area of high incidence
2) Have at least one parent or grandparent born in high-incidence country
3) Fhx of TB in past 5 years

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2
Q

Which new entrants should get BCG?

A

High incidence country, Mantoux negative, not had vaccine before, <16 (or <35 if sub-saharan africa or country with incidence >500/100000)

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3
Q

Managing TB contacts - who should be vaccinated?

A

<35 and no previous vaccine. Or >36 if healthcare or lab worker

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4
Q

Which other jobs should get BCG vaccine?

A

Vets, Abattoir, Prison staff working directly with prisoners, Care home staff, Hostel staff for homeless/refugess/asylum seekers, those going to work with local people in high-incidence country

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5
Q

New employee check - what does it entail?

A

Hx, IGRA tests within last 5 years OR BCG scar

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6
Q

How to you screen TB contacts?

A

Mantoux but if lots then IGRA

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7
Q

How to you screen for latent TB in severe immunocompromise e.g. CD4<200

A

IGRA and Mantoux

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8
Q

How do you screen for latent TB in immunocompromised?

A

IGRA

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9
Q

What are risk factors for people with latent TB for developing active TB?

A

HIV
<5yrs
ETOH excess or IVDU
Solid organ tx
Haematological malignancy
Chemotherapy
Jejunoileal bypass
Diabetes
CKD or on HD
Gastrectomy
Anti-TNF or other biologic
Silicosis

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10
Q

What is treatment of latent TB?

A

3 months isoniazid (with pyridoxine) and rifampicin
OR 6 months isoniazid (with pyridoxine)
OR 4 months rifampicin if isoniazid resistance

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11
Q

What is the eligibility for latent TB treatment?

A

35-65 years without concern of hepatotoxicity

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12
Q

What tests do prior to starting treatment for latent TB?

A

HIV, Hepatitis B&C

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13
Q

When should TB treatment be started if symptoms and signs consistent with TB?

A

Immediately - don’t wait for culture

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14
Q

Should TB treatment be stopped if already started and culture turns out to be negative?

A

Consider completing treatment

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15
Q

When should rapid TB PCR be carried out?

A

HIV
Rapid info would alter care
Need for large contact-tracing

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16
Q

What is the sensitivity and specificity of Gene Xpert?

A

Sensitivity around 90% - Xpert Ultra is higer
Specificity 100%

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17
Q

What is an adenosine deaminase assay?

A

ADA can be used to test for TB. False positive if have lymphoma, empyema, malignancy. Present even if small number of bacteria. Can do on e.g. pleural fluid, CSF

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18
Q

What is MDR TB?

A

Rifampicin and Isoniazid resistant - note that lone R resistance rare, where as lone I resistance common

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19
Q

How long should drug-sensitive TB be treated if no complicating factors?

A

2 months RIZE (rif, ison, pyraZ, etham0
4 months RI

Note E can be stopped if culture confirms fully sensitive

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20
Q

How does CNS involvement change TB management?

A

Continuation phase increased to 10 months
High dose pred or dex should be given and tapered over 4-8 weeks
Note that spinal TB without cord involvement is treated normally

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21
Q

What dosing regimens of TB meds are there?

A

Daily is best
Can do 3/week if DOT/VOT

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22
Q

Does HIV affect the duration of TB treatment?

A

Not if well controlled

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23
Q

When should steroids be used in TB treatment?

A

CNS invovlement - high dose of dex or pred tapered over 4-8 weeks
Pericardial TB - given 60mg a day for 2-3 weeks then taper

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24
Q

What is MDR TB?

A

Resistance to Rifampicin and Isoniazid

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25
Q

What is XDR TB?

A

Resistance to Rifampicin, Isoniazid, Fluroquinolone (levo/moxi) and another group A drug (bedaq/linez)

26
Q

What does the GeneXpert MTB/RIF test for?

A

TB and common rpoB gene mutation

27
Q

When should MDR TB be suspected and Gene Xpert done?

A

Hx of TB treatment
Contact of MDR-TB
Birth or residence in country where >5% cases MDR

28
Q

How treat Isoniazid resistant TB?

A

2 months Rifampicin, Pyrazinamide and Ethambutol
7 -10 months Rifampicin and Ethambutol

29
Q

How treat Pyrazinamide or Ethambutol resistant TB?

A

2 months R, I and Z or E
4 months RI if E resist, 7 months RI if Z resist

30
Q

How treat Rifampicin resistant TB?

A

Like MDR - at least 6 drugs

31
Q

How manage MDR TB?

A

At least 6 drugs

32
Q

Do patients with active TB need to be isolated?

A

If in hospital, then isolate until 2 weeks after starting treatment

33
Q

Side effects of Rifampicin?

A

Hepatotoxicity, Drug interactions, GI upset, Rash

34
Q

Side effects of Isoniazid?

A

Hepatotoxicity, Peripheral neuropathy, Optic neuritis, Drug interactions

35
Q

Side effects of Pyrazinamide?

A

Hepatotoxicity, GI upset, Arthralgia, Gout

36
Q

Side effects of Ethambutol?

A

Optic neuropathy (particularly in T2DM and CKD)

37
Q

Pt with new diagnosis of pulmonary TB is still smear positive at 2 months. What treatment should they have?

A

Continue standard treatment

38
Q

By how much does treatment of latent TB reduce risk?

A

Down to 1-2% (otherwise approx 5-10%)

39
Q

How does HIV affect chance of TB?

A

Much more likely to get early progressive disease following exposure.
3-14% risk/year if latent (compared to 5% lifetime risk for non-HIV)

40
Q

What are RFs for NTM?

A

Chronic lung disease
Thin, tall, post-menopausal lady
High humidity

41
Q

How is NTM diagnosed?

A

Symptoms
AND
Radiology (tree-in-bud, bronchecitasis, cavities, nodules, consolidation) –> nb all should get CT
AND
exclusion of other diagnoses
AND
+ve culture x2 sputum (separate days) or x1 BAL/biopsy

42
Q

How treat M.avium complex? (nb. same for M.malmoense)

A

Rifampicin + Ethambutol + Macrolide
+/- 3/12 amikacin (IV or neb) if severe
nb. use Isoniazid +/- amikacin instead if macrolide-resistant

Until 12 months post-sero conversion

–> need to test all isolates for clarithromycin and amikacin resistance

43
Q

How treat M.kansasii?

A

Rifampicin + Isoniazid + Ethambutol

–> need to test all isolates for Rifampicin resistance

44
Q

How treat M.xenopi?

A

Rifampicin + Ethambutol + Azithromycin + moxifloxacin or isoniazid
+ 3/12 amikacin (IV or neb) if severe

45
Q

How treat M.abscessus?

A

1month: IV amikacin + tigecycline + imipnem + PO clarithromycin

Then: Neb amikacin + clarithromycin + 1-3 of: clofazimine/linezolid/minocycline/moxi/cotrim

–> need to test all isolates for clarithromycin, cefoxitin & amikacin (and preferably more)

46
Q

When should CT scan be done in NTM disease?

A

Prior to starting treatment and at end of treatment (or earlier if concern)

47
Q

Is M.abscessus a contraindication to lung tx?

A

No but high risk of recurrence with disseminated disease

48
Q

What is considered refractory NTM disease?

A

Presence in sputum after 6/12 guideline-based treatment

49
Q

What causes worse prognosis in NTM?

A

Low BMI, cavity, more symptoms, fungus, burden of disease

50
Q

Pt diagnosed with HIV and TB at the same time. What treatments should be started when?

A

TB straight away

HIV
- CD4<50: ASAP & within 2 weeks
- CD4 ≥50: 8 weeks
- Preg: ASAP
- TB meningitis: when initiating ART early, closely monitor as high rates of adverse events

51
Q

What is the difference between paradoxical IRIS and unmasking TB-IRIS?

A

Paradoxical - onset of IRIS within 3months of ART in pt previously diagnosed with TB + an initial response to treatment

Unmasking - TB with 3 months of ART with exaggerated immune response to sub-clinical infection (e.g. abscess, resp failure, SIRS, lymphadenitis)

52
Q

Pt has a single positive sample for NTM. What is next appropriate step?

A

HRCT - if consistent with NTM, then BAL

Nb. same for no positive samples but clinical suspicion

53
Q

What is disseminated BCG infection?

A

Rare granulomatous disease follwoing BCG immunotherapy used in treatment of bladder cancer. Looks like miliary TB

Caused by M.bovis = negative for AAFB

54
Q

How might you need to alter TB treatment in HIV?

A

Rifampicin will interact with protease inhibitor (ritonavir) –> use rifabutin instead at lower dose as less potent inducer.

Regimen still 6 months

Nb. rifampicin will also interact with methadone

55
Q

Employee has positive Mantoux on employee check. They have had BCG vaccine. What should happen next?

A

If from high incidence country, assess for active TB and if not signs then treat for latent (ie. BCG vaccine not relevant).

If not a high incidence country, then they shouldn’t have Mantoux if BCG. If Mantoux positive then do IGRA. Then assess for active TB etc

56
Q

What is considered a positive Mantoux test?
What is considered a positive Quantiferon?

A

Induration ≥5mm
>0.35IU/mL

57
Q

When restart TB treatment after hepatotoxicity?

A
  • Investigate other causes of acute liver reaction
  • Wait until ALT or AST falls below twice the ULN, bilirubin level normal and hepatotoxic symptoms resolved
  • Sequentially re-introduce drugs at full dose over 10 days - start with ethambutol + isoniazid or rifampicin

Nb. if severe/high infectious TB and hepatotoxicity, continue 2 drugs e.g. ethambutol and streptomycin +/- levo/moxifloxacin and monitor

58
Q

What do you do with TB treatment after cutaneous reaction in pt with severe/highly infectious tb?

A

Use two TB drugs e.g. ethambutol and streptomicin and monitor

59
Q

Who should be considered for DOT?

A

Don’t adhere (or haven’t in past)
Previously treated for TB
Hx of homelessness, drug or alcohol misuse
In prison, or have been <5 years ago
Major psych, memory or cognitive disorder
Denial of TB diagnosis
MDR
Request DOT
Too ill to give treatment to themselves

60
Q

What is treatment of M.bovis?

A

2 months Rif, Iso, Etham
7 months Rif, Iso

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