eMedicine Specialties > Emergency Medicine > Infectious Diseases

Tuberculosis: Follow-up

Author: Erica Bang, MD, BS, Clinical Assistant Instructor, State University of New York Downstate Health Center, Brooklyn/Kings County Hospital
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center; James Li, MD, Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine
Contributor Information and Disclosures

Updated: Jan 26, 2009

Follow-up

Further Inpatient Care

  • Provide isolation and maintain precautions as discussed above.
  • Arrange for identification and prophylactic treatment of all contacts.
  • Baseline laboratory studies for patients undergoing treatment of active TB include liver transaminases, bilirubin, blood count, platelet count, urea nitrogen, creatinine, and, if therapy includes PZA, uric acid. On discharge, conduct monthly follow-up appointments with sputum mycobacterial culture and sensitivity.
  • Directly observed therapy (DOT) has proved successful in ensuring ongoing compliance with TB therapy, particularly in areas with high rates of multidrug resistance.
  • Consider HIV testing.

Complications

  • Complications of TB may include the following:
    • Cavitary lesions
    • Spread to susceptible persons
    • Drug resistance

Prognosis

  • Full resolution is generally expected with few complications in cases of non-MDR-TB and non-XDR-TB when the drug regimen is completed.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Patients with active TB who are persistently nonadherent with treatment present a public health hazard. Accordingly, legal measures have been initiated in several states allowing for civil or criminal detention of such patients for DOT.9
    • At this writing, such measures have been enacted in the following locations:
      • New York City (New York City Health Code 1994;11.47 and 11.55)
      • Louisiana
      • California (Calif Health and Safety Code 1996;120175-121400)
      • Massachusetts (Mass Gen Laws 1996;94(A)-94(H))
      • Florida (Fla Pub Health Code 1996;309.02-392.69)
    • In 1997, federal legislation established a cooperative agreement between Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont on the legal detention of patients with TB who refuse treatment (Senate Bill S97-0388, passed Senate and House June 11, 1997).

Special Concerns

  • Among immunocompetent adults who have latent TB, the risk of reactivation is approximately 0.5-1% per year or 15% during the course of a lifetime.10
    • The risk of reactivation is greatest in the first 2 years following initial infection.
    • In patients with HIV and TB infection, the risk of reactivation is 10% per year.
    • Patients who have HIV without latent disease have a 5% per year risk of developing active primary disease.11
    • Consider isoniazid (INH) prophylaxis in anyone (regardless of age) who has a positive PPD test result in the last 2 years due to the significant likelihood of reactivation of disease later in life.
      • In addition, prophylaxis is recommended for those patients (regardless of age) who have distant conversions (>2 y prior), who are HIV positive, who use intravenous drugs, or who have comorbid medical conditions. Prophylaxis also is recommended for known contacts of patients with active TB.
      • Additionally, prophylaxis is recommended for patients younger than 35 years with distant conversions who are foreign-born, impoverished, employed as health care workers, or living in long-term institutions.
      • Pregnant women with recent skin conversions can begin INH following the first trimester. Those with distant conversions can wait until after delivery.
    • Protocols vary as follows:
      • Three common protocols include INH 300 mg PO qd for 12 months (75% risk reduction), INH 300 mg PO qd for 6 months (65% risk reduction), and INH 900 mg PO twice weekly for 12 months (unknown risk reduction but likely efficacious).
      • The dose for children is INH 10-20 mg/kg/d. Recently, INH 300 mg PO qd and rifampin (RIF) 600 PO qd for 3 months was demonstrated to provide a 60% risk reduction in patients who are HIV positive.
      • Alternatives currently being studied include RIF 600 mg PO qd for 4 months and RIF 600 mg PO qd plus pyrazinamide (PZA) 1 g PO qd for 2 months. The latter course recently was demonstrated to provide identical risk reduction when compared to 12 months of daily INH.12
    • A common concern relating to INH prophylaxis is the rate of INH-associated hepatitis. Such rates are age-dependent and are greatly increased with significant ethanol consumption.
      • Instruct patients on INH prophylaxis to refrain from ethanol use.
      • For patients younger than 35 years, the relative risk of death from reactivation TB (>6%) outweighs the risk of death from INH-related hepatitis (<1%).
      • Halt INH therapy if liver transaminase levels rise to 3 times or more above pretreatment levels.
    • The rate of INH toxicity is probably much lower than has been reported. Recent analysis of data from a longitudinal survey of 11,141 consecutive patients treated with preventive INH therapy yielded a total rate for hepatotoxic reactions of 0.10% (n=11) and no mortality. This compares to previously reported rates of 0.5-2%. Such data should give clinicians greater confidence in the safety of INH preventive therapy.
  • In 1996, due to increased rates of MDR-TB, the CDC released updated recommendations for use of the BCG vaccine within the United States.
    • Published data evaluating the efficacy of BCG vaccination in preventing pulmonary TB, particularly when used in adulthood, have been disappointing.
    • BCG vaccination's greatest utility appears to be in the prevention of meningeal and miliary TB in children, for whom it has demonstrated efficacy rates of 65-95%.
  • The CDC recommends BCG vaccination for the following 2 populations.
    • Health care workers employed in settings with a high likelihood of transmission of TB resistant to both INH and RIF, provided other TB control precautions have failed to prevent transmission
    • Children or infants living in settings where the risk of TB (drug resistant or not) transmission is high, when removal of such children from such settings is not possible
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Diana Brainard, MD, to the development and writing of this article.



More on Tuberculosis

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Differential Diagnoses & Workup: Tuberculosis
Treatment & Medication: Tuberculosis
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Multimedia: Tuberculosis
References
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Further Reading

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Keywords

tuberculosis, TB, lung disease, pulmonary disease, pulmonary infection, treatment of TB, Mycobacterium tuberculosis, M tuberculosis, mycobacterial infection, Pott's disease, Pott disease, scrofula, miliary disease, extrapulmonary TB, multi–drug-resistant tuberculosis, MDR-TB, extensively drug resistant tuberculosis, XDR-TB

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Contributor Information and Disclosures

Author

Erica Bang, MD, BS, Clinical Assistant Instructor, State University of New York Downstate Health Center, Brooklyn/Kings County Hospital
Erica Bang, MD, BS is a member of the following medical societies: American Academy of Emergency Medicine, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

James Li, MD, Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine
Disclosure: Nothing to disclose.

Medical Editor

Theodore J Gaeta, DO, MPH, FACEP, Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine
Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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