Pulmonary tuberculosis: Difference between revisions
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** [[Is treated by::Pyrazinamide]] 25mg/kg/d, max 2g daily |
** [[Is treated by::Pyrazinamide]] 25mg/kg/d, max 2g daily |
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** [[Is treated by::Ethambutol]] 20mg/kg/d, max 1.2g daily, which can be dropped once susceptibility testing shows that it is pan-susceptible |
** [[Is treated by::Ethambutol]] 20mg/kg/d, max 1.2g daily, which can be dropped once susceptibility testing shows that it is pan-susceptible |
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* Standard duration for uncomplicated disease is 6 months |
* Standard duration for uncomplicated disease is 6 months total |
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=== Special populations === |
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* For the elderly, or those at elevated risk of hepatotoxicity: can do induction phase ''without'' [[pyrazinamide]] and extend continuation phase to 7 months (from 4) |
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* For pregnant women: can consider dropping [[pyrazinamide]] and extending the course by 3 months, but if there is severe disease then likely should follow standard treatment |
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* For high risk of relapse, including extensive or cavitary disease in the first 2 months of treatment, culture-positivity after 2 months of treatment, or cavitary disease on CXR at end of treatment: the consolidation phase should be extended by 3 months (to 9 months total treatment) |
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* For severe liver disease: |
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** Avoid [[rifampin]], [[isoniazid]], and [[pyrazinamide]] |
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** Recommend a fluoroquinolone, [[ethambutol]], and [[amikacin]] for 2 months followed by fluroquinolone and ethambutol for 18 months |
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** Can consider adding [[rifampin]] if they are monitored closely |
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=== Infection control === |
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* Airborne precautions until: |
* Airborne precautions until: |
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** Treated for at least 2 weeks |
** Treated for at least 2 weeks |
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Revision as of 03:52, 14 November 2019
Background
Microbiology
Clinical Presentation
- Presents as reactivation of latent infection months or years after primary tuberculosis
- Subacute or chronic cough (at least 2 to 3 weeks) eventually becoming productive and occasionally involving hemoptysis
- Should be suspected in any patient with cough and HIV infection
- Constitutional symptoms, with fevers, night sweats, and unexplained weight loss
- Usually from reactivation of latent tuberculosis infection, and usually reactivates in lung apices
- May transiently improve with partially-active antibiotics such as fluoroquinolones
Investigations
- Spontaneous sputum, induced sputum, or bronchoalveolar lavage specimens should be sent for
- Acid-fast staining of a smear
- Culture
- PCR
Management
- Standard HREZ x2mo then HR x4mo
- Isoniazid 5mg/kg/d, max 300mg daily, with pyridoxine 25 mg po daily
- Rifampin 10mg/kg/d
- Pyrazinamide 25mg/kg/d, max 2g daily
- Ethambutol 20mg/kg/d, max 1.2g daily, which can be dropped once susceptibility testing shows that it is pan-susceptible
- Standard duration for uncomplicated disease is 6 months total
Special populations
- For the elderly, or those at elevated risk of hepatotoxicity: can do induction phase without pyrazinamide and extend continuation phase to 7 months (from 4)
- For pregnant women: can consider dropping pyrazinamide and extending the course by 3 months, but if there is severe disease then likely should follow standard treatment
- For high risk of relapse, including extensive or cavitary disease in the first 2 months of treatment, culture-positivity after 2 months of treatment, or cavitary disease on CXR at end of treatment: the consolidation phase should be extended by 3 months (to 9 months total treatment)
- For severe liver disease:
- Avoid rifampin, isoniazid, and pyrazinamide
- Recommend a fluoroquinolone, ethambutol, and amikacin for 2 months followed by fluroquinolone and ethambutol for 18 months
- Can consider adding rifampin if they are monitored closely
Infection control
- Airborne precautions until:
- Treated for at least 2 weeks
- 3x negative sputum smears, which can be collected hourly, but ideally at 8- to 24-hour intervals, including one early morning collection
- Improvement in symptoms
References
- ^ Chandrasekaran Padmapriydarsini, Megha Mamulwar, Anant Mohan, Prema Shanmugam, N S Gomathy, Aarti Mane, Urvashi B Singh, Nathella Pavankumar, Abhijeet Kadam, Hemanth Kumar, Chandra Suresh, Devaraju Reddy, Poornaganga Devi, P M Ramesh, Lakshmanan Sekar, Shaheed Jawahar, R K Shandil, Manjula Singh, Jaykumar Menon, Randeep Guleria. Randomized Trial of Metformin With Anti-Tuberculosis Drugs for Early Sputum Conversion in Adults With Pulmonary Tuberculosis. Clinical Infectious Diseases. 2021;75(3):425-434. doi:10.1093/cid/ciab964.
