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chemoprophylaxis for tuberculosis

Management: 1) RULE OUT active tuberculosis prior to TB chemoprophylaxis 2) indications for TB chemoprophylaxis a) a positive TST conversion within 2 years regardless of age b) persons with a history of untreated TB or radiographic evidence of previous TB c) all TST-positive individuals < 35 years of age. d) persons with a positive TST who are at high risk for TB e) new TST converters > 15 mm on serial testing f) household members & close contacts of patients with TB who have a positive TST (treat until PPD is negative 12 weeks later) 3) INH prophylaxis 300 mg PO QD plus pyridoxine 50 mg QD for 6-9 months (12 months if HIV+) -> twice weekly schedule (directly observed therapy) is an alternative [9] 4) rifapentine + INH weekly for 3 months for latent TB [4,11,13] a) otherwise healthy, >= 12 years of age b) high risk of developing TB - includes patients with HIV not taking antiretroviral c) weekly dosing, total of 12 doses d) directly observed therapy 5) rifampin + INH daily for 3 months for latent TB [4] 6) rifampin 600 mg PO QD for 4-6 months [9] a) alternative to INH b) add to INH if likely exposure to INH-resistant TB 7) rifampin 600 mg PO QD + pyrazinamide 1.5-2.0 g PO QD for 2 months a) cases (including fatal cases) of hepatotoxicity [7] b) check liver function tests (LFTs) every 2 weeks [7] c) NO LONGER recommended [8] 8) rifabutin (Mycobutin) a) substitute for rifampin in HIV patients taking indinavir, nelfinavir or amprenavir b) adjust rifabutin dose to minimize risk of drug interactions 9) multidrug-resistant tuberculosis a) pyrazinamide & quinolone (ciprofloxacin) or ethambutol for 6-9 months b) pyrazinamide 15-30 mg/kg PO QD (max 2 grams/day) + levofloxacin 250 mg PO QOD for 9 months 10) routine liver function testing no longer recommended except for patients with HIV, liver disease, chronic alcoholism or pregnant patients 11) directly observed therapy for HIV-infected patients & homeless patients 12) 5% of individuals with recent conversion of tuberculin skin testing (TST) will develop active disease within 1 year if left untreated. 13) adequate treatment reduces risk of active disease - risk of active disease after contact with TB is 1% within 4 years [12] - number needed to treat: 88 to prevent 1 case of active tuberculosis [12]

Related

tuberculosis

General

antibiotic prophylaxis

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 183-86
  3. American Thoracic Society: Am J Crit Care Med 149:1359-1374 1994
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 19. American College of Physicians, Philadelphia 1998, 2006, 2021.
  5. Prescriber's Letter 7(7):40 2000
  6. Kaiser Permanente, Northern California, Infection Control Update, 9/2000
  7. Journal Watch 21(19):155, 2001 MMWR Morb Mort Wkly Rep 50:733, 2001
  8. Prescriber's Letter 10(9):50 2003
  9. Lardizabal A et al, Enhancement of treatment completion for latent tuberculosis infection with 4 months of rifampin. Chest 2006, 130:1712 PMID: 17166986 - Ashkin D et al, Consider rifampin BUT be cautious Chest 2006, 130:1638 PMID: 17166975
  10. American Thoracic Society, Targeted Testing and Treatment of Latent Tuberculosis Infection, Am J Respir Crit Care Med 161:S221, 2000 http://www.atsjournals.org
  11. CDC Press Release May 16m 2011 Session B9, oral presentation: Sterling, PREVENT TB: Results of a 12-Dose, Once-Weekly Treatment of Latent Tuberculosis Infection (LTBI) http://www.cdc.gov/nchhstp/newsroom/PREVENTTBPressRelease.html - Sterling TR et al Three Months of Rifapentine and Isoniazid for Latent Tuberculosis Infection N Engl J Med 2011; 365:2155-2166 PMID: 22150035 http://www.nejm.org/doi/full/10.1056/NEJMoa1104875 - Dye C Practical Preventive Therapy for Tuberculosis? N Engl J Med 2011; 365:2230-2231 PMID: 22150042 http://www.nejm.org/doi/full/10.1056/NEJMe1111859 - Centers for Disease Control and Prevention Recommendations for Use of an Isoniazid-Rifapentine Regimen with Direct Observation to Treat Latent Mycobacterium tuberculosis Infection MMWR. December 9, 2011 / 60(48);1650-1653 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6048a3.htm - Prescriber's Letter 19(2): 2012 Detail-Document#: 280210 (subscription needed) http://www.prescribersletter.com
  12. Anger HA et al. Active case finding and prevention of tuberculosis among a cohort of contacts exposed to infectious tuberculosis cases in New York City. Clin Infect Dis 2012 May 1; 54:1287 PMID: 22412056
  13. Centers for Disease Control and Prevention (CDC). Recommendations for use of an isoniazid-rifapentine regimen with direct observation to treat latent Mycobacterium tuberculosis infection. MMWR Morb Mortal Wkly Rep. 2011 Dec 9;60(48):1650-3. PMID: 22157884
  14. Centers for Disease Control and Prevention Treatment for Latent TB Infection http://www.cdc.gov/tb/topic/treatment/ltbi.htm