Teacher Evaluation in a Tight Spot: The Vision of University Administrators
3. Análisis de resultados
Latent TB Infection Infection (LTBI) (LTBI)
The presence of
The presence ofM. tuberculosisM. tuberculosis organisms without symptoms or organisms without symptoms or radiographic evidence of TB disease
radiographic evidence of TB disease
Persons are Persons are -- AsymptomaticAsymptomatic -- Not infectiousNot infectious
Diagnosis Diagnosis -- TSTTST
-- QuantiFERON assayQuantiFERON assay
Treatment Treatment
-- Reduces risk that infection will develop intoReduces risk that infection will develop into TB disease
TB disease
-- Certain groups have higher risk forCertain groups have higher risk for developing TB disease after infection developing TB disease after infection
Give
Give LTBI LTBI Treatment Treatment To To IfIf M. tuberculosisM. tuberculosistest result is…test result is…
Highest risk groups Highest risk groups -- ImmunocompromisedImmunocompromised -- Recent contactsRecent contacts -- XR indicates previous TBXR indicates previous TB
> 5 mm
> 5 mm
Before Before beginning beginning treatment:
treatment:
-- Exclude Exclude diagnosis diagnosis of of TB TB Other Other high-risk high-risk groups groups > > 10 10 mmmm -- Ensure patient has no history ofEnsure patient has no history of
adverse reactions resulting adverse reactions resulting from prior LTBI treatment from prior LTBI treatment
Patients
Patients with with no no risks risks > > 15 15 mmmm
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TT uu bb ee rr cc uu ll oo ss ii ss
Reactivation Reactivation TB Disease TB Disease
LTBI progresses to active T
LTBI progresses to active TB disease in…B disease in…
-- Small number of persons soon Small number of persons soon after infectionafter infection
-- 5-10% persons with untreated LTBI sometime during infection5-10% persons with untreated LTBI sometime during infection
~10% patients with HIV and untreated LTBI per year
~10% patients with HIV and untreated LTBI per year Clinical
Clinical Presentation Presentation
-- CoughCough -- Weight lossWeight loss -- FeverFever -- Night sweatsNight sweats
-- HemoptysisHemoptysis -- FatigueFatigue
-- Decreased appetiteDecreased appetite -- Chest painChest pain
Other lung infections (anaerobic) Other lung infections (anaerobic) and carcinoma can mimic and carcinoma can mimic
CXR CXR
-- Upper lobe infiltrates (particularly apical and posterior segments)Upper lobe infiltrates (particularly apical and posterior segments) -- Cavitation commonCavitation common
-- Miliary pattern seen in hematogenous spread (very immune compromised; only on Miliary pattern seen in hematogenous spread (very immune compromised; only on CT)CT)
Lab Lab Evaluation Evaluation -Sputum Sputum
-- Obtain 3 specimens for smear and culture, at least 8 hoursObtain 3 specimens for smear and culture, at least 8 hours apart
apart
-- Positive AFB smear gives presumptive diagnosis in Positive AFB smear gives presumptive diagnosis in properproper setting (not definitive)
setting (not definitive) -- Culture = gold standardCulture = gold standard
-- Pay attention to infection control during collectionPay attention to infection control during collection -- Nucleic Acid Amplification can speed diagnosis,Nucleic Acid Amplification can speed diagnosis,
doesn’t r/o TB in smear (
doesn’t r/o TB in smear (-) disease-) disease
-- Interferon based assays can’t distinguish latent vsInterferon based assays can’t distinguish latent vs active
active
-- Routine drug susceptibility testingRoutine drug susceptibility testing
Treatment Treatment
When to consider When to consider initiating
initiating
-- Positive AFB smearPositive AFB smear
-- Don’t delay becauseDon’t delay becauseof negative AFB smear if high clinical suspicionof negative AFB smear if high clinical suspicion – – 1) history cough + weight loss, 1) history cough + weight loss, 2) characteristic findings on CXR, 3) emigration from high-incidence country
2) characteristic findings on CXR, 3) emigration from high-incidence country
Basic Principles Basic Principles
-- Provide safety, most effective therapy in shortest timeProvide safety, most effective therapy in shortest time -- Multiple drugs to which organisms are susceptibleMultiple drugs to which organisms are susceptible -- Never add a single drug to Never add a single drug to failing regimenfailing regimen -- Ensure adherence to therapy (i.e. DOT)Ensure adherence to therapy (i.e. DOT)
Antituberculosis Antituberculosis Drugs
Drugs
First-Line First-Line
-- Isoniazid (INH)Isoniazid (INH) -- Rifampin (RIF)Rifampin (RIF) -- Pyrazinamide (PZA)Pyrazinamide (PZA) -- Ethambutol (EMB)Ethambutol (EMB) -- RifapentineRifapentine
Second-Line Second-Line
(for MDR, lower cure rates) (for MDR, lower cure rates)
-- Streptomycin (SM))Streptomycin (SM)) -- CycloserineCycloserine
-- p-aminosalicyclic acidp-aminosalicyclic acid -- EthionamideEthionamide
-- CapreomycinCapreomycin
-- Not FDA-approved for TB use: amikacin or Not FDA-approved for TB use: amikacin or kanamycin,kanamycin, levofloxacin, moxifloxacin, gatifloxacin
levofloxacin, moxifloxacin, gatifloxacin
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Compiled by Abbie Pettigrew, class of Compiled by Abbie Pettigrew, class of 20162016
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Initial Phase -- Standard 4 drug regimens for 2 monthsStandard 4 drug regimens for 2 months -- One excludes PZAOne excludes PZA
Continuation Continuation Phase Phase
-- Additional 4 months (or 7 months)Additional 4 months (or 7 months)
When
-- Cavitary pulmonary disease and + sputum cultures at completion oCavitary pulmonary disease and + sputum cultures at completion o f initialf initial phase
phase
-- Once-weekly INH and rifapentine started in continuation phase and sputumOnce-weekly INH and rifapentine started in continuation phase and sputum specimen collected at end of initial phase is culture positive
specimen collected at end of initial phase is culture positive -- HIV infection with positive 2-month sputum cultureHIV infection with positive 2-month sputum culture -- Initial phase excluded PZAInitial phase excluded PZA
Why Why extend?
extend?
-- Cavitary disease and positive sputum culture at 2 Cavitary disease and positive sputum culture at 2 months associated withmonths associated with increased relapse in clinical trials
increased relapse in clinical trials
-- Extended continuation phase decreased relapses in silicotuberculosis (20%Extended continuation phase decreased relapses in silicotuberculosis (20%
3%) 3%)
-- 4 regimens recommended to treat culture-positive TB differ primarily in d4 regimens recommended to treat culture-positive TB differ primarily in d osing intervals in continuationosing intervals in continuation phase
High clinical suspicion for active
High clinical suspicion for active T despite negativeT despite negative smears based on:
smears based on:
-- CXRCXR
-- Clinical symptomsClinical symptoms
-- No other diagnosisNo other diagnosis -- Positive TSTPositive TST Patient placed on initial phase regimen (INH, RIF, EMB, PZA) for 2 months
Patient placed on initial phase regimen (INH, RIF, EMB, PZA) for 2 months
Is initial
YES Continue Continue treatment treatment for for culture-positive culture-positive TBTB
NO after 2 months of after 2 months of
treatment?
treatment?
YES
YES Give continuation-phase treatment ofGive continuation-phase treatment of INH/RIF daily or twice weekly for 2 months INH/RIF daily or twice weekly for 2 months NO
NO
Discontinue treatment Discontinue treatment Patient presumed to have LTBI Patient presumed to have LTBI Treatment completed Treatment completed
Monitoring Monitoring
-- Monthly sputum for AFB smear and culture (until 2 consecutive cultures negative)Monthly sputum for AFB smear and culture (until 2 consecutive cultures negative) -- Serial sputum smears Q2 weeks to assess Serial sputum smears Q2 weeks to assess early responseearly response
-- Additional drug-susceptibility tests if culture-positive after 3 Additional drug-susceptibility tests if culture-positive after 3 months of treatmentmonths of treatment -- Periodic (minimum monthly) evaluation to assess adherence and ID Periodic (minimum monthly) evaluation to assess adherence and ID adverse reactionsadverse reactions Repeat CXR
Repeat CXR
-- At completion of initial treatment phase for patient At completion of initial treatment phase for patient with initial negative cultureswith initial negative cultures -- At end of treatment for patient with At end of treatment for patient with culture-negative TBculture-negative TB
-- Generally not necessary for patients with culture-positive TBGenerally not necessary for patients with culture-positive TB -- Renal function, AST/ALT, bilirubin, PLT count if abnormalities at baselineRenal function, AST/ALT, bilirubin, PLT count if abnormalities at baseline
-- Visual acuity & color vision monthly if EMB used (>2 months or Visual acuity & color vision monthly if EMB used (>2 months or doses >15-20 mg/kg)doses >15-20 mg/kg) Determining
-- Completion primarily defined by number of ingested doses within Completion primarily defined by number of ingested doses within specific time framespecific time frame -- Consider therapy interrupted if target doses not Consider therapy interrupted if target doses not met within specified time periodmet within specified time period Specified doses must be administ
Specified doses must be administered within…ered within… 3 months3 months – – initial phase initial phase 6 months
6 months – – 4-month continuation phase 4-month continuation phase
Special Situations Special Situations
-- Drug resistanceDrug resistance -- HIVHIV
-- Children and adolescentsChildren and adolescents -- Pregnancy and breastfeedingPregnancy and breastfeeding
-- Renal insuffiencyRenal insuffiency -- Liver diseaseLiver disease -- Extrapulmonary TBExtrapulmonary TB
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