Last reviewed: November 2017
Last updated: November  2017

Important updates

New US guideline on treatment of drug-susceptible tuberculosis

  • Interruptions in therapy are common in the treatment of tuberculosis. The decision is then whether to restart a complete course of treatment or simply to continue. As a general guide, the earlier in the course of treatment and the greater the length of the lapse, the more likely the need to return to the beginning of the intensive phase of treatment.

  • For patients co-infected with HIV and TB who have not started on antiretroviral therapy, consider extending TB treatment to 9 months (i.e., an additional 3 months of the continuation phase).

  • Consider the use of directly observed treatment for all patients with HIV and TB co-infection.

See Management: approach

Original source of update

WHO treatment guideline for multidrug-resistant tuberculosis

  • Short or longer regimens are recommended for the treatment of people with multidrug-resistant (MDR) TB:

    • The shorter regimen is a course of treatment for rifampicin-resistant TB or MDR TB lasting 9 to 12 months, which is largely standardised, consisting of 2 distinct parts: an intensive phase of 4 months (which can be extended to a maximum of 6 months in case of a lack of sputum smear conversion) and a continuation phase of 5 months.

    • The longer term regimen lasts 18 months or more and may be standardised or individualised. It should consist of at least 5 drugs in the intensive phase.

See Management: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • cough
  • fever
  • anorexia
  • weight loss
  • malaise

Other diagnostic factors

  • night sweats
  • pleuritic chest pain
  • haemoptysis
  • psychological symptoms
  • abnormal chest auscultation
  • asymptomatic
  • dyspnoea
  • clubbing
  • erythema nodosum

Risk factors

  • exposure to infection
  • birth in an endemic country
  • HIV infection
  • immunosuppressive medicines
  • malignancy
  • silicosis
  • ESRD
  • apical fibrosis
  • intravenous drug use
  • malnutrition
  • alcoholism
  • diabetes
  • high-risk congregate settings
  • low socio-economic status or black/Hispanic/Native American ancestry
  • age
  • tobacco smoking

Diagnostic investigations

1st investigations to order

  • CXR
  • sputum acid-fast bacilli (AFB) smear
  • sputum culture
  • FBC
  • nucleic acid amplification tests (NAAT)
Full details

Investigations to consider

  • gastric aspirate
  • bronchoscopy and bronchoalveolar lavage (BAL)
  • tuberculin skin testing (TST)
  • interferon-gamma release assays (IGRAs)
  • empirical treatment
  • susceptibility testing
  • genotyping
  • HIV test
  • CT of chest
  • Xpert MTB/RIF
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

David J. Horne

Assistant Professor

Division of Pulmonary and Critical Care Medicine

Department of Medicine

University of Washington

Seattle

WA

Disclosures

DJH declares that he has no competing interests.

Masahiro Narita

Professor of Medicine

Division of Pulmonary and Critical Care Medicine

Department of Medicine

University of Washington

Seattle

WA

Disclosures

MN declares that he has no competing interests.

Peer reviewers VIEW ALL

Professor

Division of Infectious Diseases

University of Colorado at Denver and Health Sciences Center

Denver

CO

Disclosures

WB declares that he has no competing interests.

Consultant Chest Physician

Llandough Hospital

Llandough

Penarth

South Wales

Disclosures

IC declares that he has no competing interests.

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