Background
- Most patients can and should be managed as outpatients
- If a patient presents with features suggestive of TB, consider investigation as outpatient, including 3 morning sputum specimens for AAFB, rather than admission
- Urgent appointment can be booked respiratory clinic at CUH within the next two weeks after discussion with respiratory consultant or SpR
- If hospital admission is necessary, patient MUST be admitted to a side room if known / suspected pulmonary TB
- If no side room available on the respiratory ward, the patient must be kept in a side room or an acute medical admission area until a single side room becomes available on the respiratory ward or on the TB unit in St Finbarr’s hospital after consultation between CUH respiratory consultant and Dr Terry O’Connor, clinical lead for TB in Cork and consultant respiratory physician, Mercy Hospital. CUH in-patient Respiratory Protocols
- Known / suspected MDR TB (resistance to Rifampicin plus Isoniazid) MUST referred to TB unit SFH through Dr O’Connor
- When a patient is commenced on treatment a NOTIFICATION FORM (from respiratory consultant secretaries) must be completed
- Check sputum for AAFB on all patients – even if you have confirmed the diagnosis by another means – as the result affects contact screening procedures
- Try to get culture if at all possible – to confirm diagnosis and check sensitivities. For pleural effusions, best test is pleural biopsy, with specimens in saline to microbiology for AAFB, as well as in Formalin to histology
- Treatment of TB cases should be in accordance with British Thoracic Society Guidelines (If in doubt consult with Dr Henry CUH)
- All patients with TB aged 16-64 should be offered HIV test
- When commencing treatment remember to explain about the risk of side effects from the drugs
- All anti-tuberculous drugs should be prescribed from the Clinic (NOT General Practitioners). Normally prescribe 4 weeks at a time (including on first prescription even if next visit is in 2 weeks)
- Check LFTs prior to commencing on treatment and then at every visit, for the first two months of treatment. (After that, only if previously abnormal LFT or if symptoms)
- Apart from exceptional circumstances, drugs should be prescribed as combination tablets, i.e. Rifater during the initial phase and Rifinah during the continuation phase
- Unfortunately there are no combination tablets currently available that include Ethambutol but remember that the majority of patients should be on Ethambutol during the initial phase
- Normally treatment is reduced to two drugs after the first two months of treatment. However, please ensure that you have checked the sensitivity result before changing the drugs
When to Evaluate for TB
Maintain a high index of suspicion for TB.
Evaluate (clinical, x-rays and micro for AFB), any patient with unexplained:
- Productive cough of = 3 weeks duration with at least one additional symptom:
- fever, night sweats
- weight loss
- haemoptysis
- HIV infection and cough and fever
- High risk of TB with Dx of community acquired pneumonia who has not improved after seven days of treatment
Any patient at high risk for TB with incidental chest x-ray suggestive of TB, even if symptoms are minimal or absent.
High risk:
- Recent exposure to an infectious TB case
- Hx of a positive test result for TB
- HIV infection
- Alcohol or drug abuse (IV or non-IV)
- Foreign birth and immigration in the last 5 years from high endemic region (TB rate = 40/100,000 per annum)
- Residents and employees of high risk congregate settings (e.g. prisons)
- Socio-economic deprivation
- Immunocompromised e.g. diabetes