Madison Clinic
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Management of Active and Latent Tuberculosis in HIV Infected Patients

* LINK: Algorithm for Evaluation for Latent vs Active TB - NEW
[Figure 1; Page 28]

* LINK: Madison Clinic Latent TB Testing

*LINK: Screening & Isolation for TB in Madison Clinic

Sections

  1. Screening for Latent Tuberculosis Infection (LTBI)
  2. Screening for LTBI in Refugees and Immigrants - Endemic
  3. Treatment of LTBI
  4. Direct Observed Therapy (DOT)
  5. Diagnosis and Treatment of Active Tuberculosis
  6. Interactions with antiretrovirals
  7. References

I. Screening for Latent Tuberculosis Infection (LTBI) in Non-Immigrant Populations

  • Patients with HIV should be screened at initial presentation for tuberculosis with a PPD and an IGRA. Annual tuberculin skin testing is recommended for HIV-infected individuals at high risk for exposure to M. tuberculosis, such as persons living in shelters, jails, and prisons.
  • Practitioners should repeat tuberculin skin testing and IGRA for persons with advanced HIV disease who respond favorably to HAART and have a CD4 count increase to greater than 200 cells/mm, since the likelihood of response to either test increases with improved cellular immunity. Anergy testing is no longer recommended.
  • A history of BCG vaccination does not affect the interpretation of a PPD or IGRA.
  • Induration of > 5 mm in HIV-infected patients is considered positive and should be treated.
  •  HIV+ patients with close contact to a case of active tuberculosis should be treated for LTBI regardless of the PPD reaction or IGRA result.
  • Before beginning treatment of LTBI, active TB should be ruled out by history, physical examination, chest radiography, and, when indicated, bacteriologic studies.

II. Screening for LTBI in Refugees and Immigrants from Endemic Areas

  • The background rate of LTBI in immigrants from low income countries is about 33%. In patients who lived in refugee camps prior to immigration the backround rate is substantially higher.
  • The HMC Tb clinic recommends the approach found in table 1 (116kb PDF*) for evaluation of tuberculosis in immigrants.

III. Treatment of LTBI

  • The preferred regimen for LTBI is INH 300mg qd x 9months.
  • Vitamin B6 50mg qd should be given with INH to reduce the rate of peripheral neuropathy.
  • The regimen of rifampin/pyrazinamide x 2months is no longer recommended given the reports of liver failure in both HIV+ and HIV- patients.
  • For patients intolerant of INH or infected with an INH-resistant strain, daily rifampin (or rifabutin) for 4 months is preferred.

IV. Direct Observed Therapy (DOT) for LTBI

  • The TB clinic at HMC should be involved when patients with LTBI have problems with adherence. DOT can be arranged, if appropriate. The phone number for the clinic is 744-4579.

V. Diagnosis and Treatment of Active Tuberculosis

  • Diagnosis of active tuberculosis in patients with HIV is complicated by atypical pulmonary presentations of tuberculosis, the increased frequency of extra-pulmonary sites of infection, mycobacteria other than Tb that can cause pulmomary disease, and the prevalence of coexisting infections.
  • The initiation phase (eg the first two months of treatment) in HIV+ patients with active Tb is identical to in HIV- patients and consists of daily pyrazinamide, ethambutol, isoniazid, and rifampin (or rifabutin).
  • The continuation phase for patients with drug-susceptible organisms consists of daily or three times a week INH/rifampin (or rifabutin).
  • The TB clinic should be contacted at 744-4579 for patients with active tuberculosis.
  • The CDC website listed below should be consulted for more detailed treatment recommendations.

VI. Interactions between antiretroviral and anti-tuberculosis therapy

VII. References

*Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children - June 20, 2008

Joint guidelines from ATS, IDSA, and CDC on treatment of tuberculosis
http://www.cdc.gov/mmwr/PDF/rr/rr5211.pdf

Joint guidelines from ATS and CDC on targeted PPDs and treatment for LTBI
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm

Refer to CDC website at http://www.cdc.gov/ for updates

Information from Dr. Spach’s website on LTBI http://depts.washington.edu/hivaids/opinfectpro/case4/index.html

 

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