Pulmonary tuberculosis: Difference between revisions

Revision as of 03:52, 14 November 2019

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

Spontaneous sputum, induced sputum, or bronchoalveolar lavage specimens should be sent for
- Acid-fast staining of a smear
- Culture
- PCR

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

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

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

@@ Line 23: / Line 23: @@
 ** [[Is treated by::Pyrazinamide]] 25mg/kg/d, max 2g daily
 ** [[Is treated by::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, but should be extended to 9 months if high-risk (including smear positive at 2 months or cavitations)
+* 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