Latent Tuberculosis Infection (LTBI) Treatment Guidelines
The National Tuberculosis Controllers Association (NTCA) and Centers for Disease Control and Prevention (CDC) have issued updated treatment guidelines for latent tuberculosis infection (LTBI) among persons who live in the United States. [93]
The recommended 2020 LTBI treatment guidelines include three preferred rifamycin-based regimens and two alternative daily-isoniazid monotherapy regimens. These recommendations are intended for Mycobacterium tuberculosis infections with presumed susceptibility to isoniazid or rifampin. M tuberculosis strains that are resistant to both isoniazid and rifampin are exempt from these recommendations.
Generally, rifamycin-based treatment regimens administered in short courses are preferred over isoniazid monotherapy administered in longer courses for the treatment of LTBI.
Preferred treatment regimens for LTBI
The rifamycin-based preferred regimens for LTBI are as follows:
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Once-weekly isoniazid plus rifapentine for 3 months (strongly recommended in adults and children >2 years, including those with HIV infection) OR
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Daily rifampin for 4 months (strongly recommended in HIV-negative adults and children of all ages) OR
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Daily isoniazid plus rifampin for 3 months (conditionally recommended in adults and children of all ages and in HIV-positive persons)
Prescribing providers or pharmacists should note that rifampin and rifapentine are not interchangeable, and care should be taken to administer the correct medication for the intended regimen.
Alternative treatment regimens for LTBI
The alternative treatment regimens are as follows:
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Daily isoniazid for 6 months (strongly recommended in HIV-negative adults and children of all ages and conditionally in HIV-positive adults and children of all ages) OR
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Daily isoniazid for 9 months (conditionally recommended in adults and children of all ages regardless of HIV infection status)
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Acid-fast bacillus smear showing characteristic cording in Mycobacterium tuberculosis.
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This radiograph shows a patient with typical radiographic findings of tuberculosis.
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This is a chest radiograph taken after therapy was administered to a patient with tuberculosis.
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Anteroposterior chest radiograph of a young patient who presented to the emergency department (ED) with cough and malaise. The radiograph shows a classic posterior segment right upper lobe density consistent with active tuberculosis. This woman was admitted to isolation and started empirically on a 4-drug regimen in the ED. Tuberculosis was confirmed on sputum testing. Image courtesy of Remote Medicine (remotemedicine.org).
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Lateral chest radiograph of a patient with posterior segment right upper lobe density consistent with active tuberculosis. Image courtesy of Remote Medicine (remotemedicine.org).
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Pulmonary tuberculosis with air-fluid level.
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Under a high magnification of 15549x, this scanning electron micrograph depicts some of the ultrastructural details seen in the cell wall configuration of a number of Gram-positive Mycobacterium tuberculosis bacteria. As an obligate aerobic organism, M. tuberculosis can only survive in an environment containing oxygen. This bacterium ranges in length between 2-4 microns, with a width between 0.2-0.5 microns. Image courtesy of the Centers for Disease Control and Prevention/Dr. Ray Butler.
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Numerous acid-fast bacilli (pink) from a bronchial wash are shown on a high-power oil immersion.
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Necrotizing granuloma due to tuberculosis shown on low-power hematoxylin and eosin stain. There is central caseous necrosis and a multinucleated giant cell in the central left. Mixed inflammation is seen in the background.
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This chest radiograph shows asymmetry in the first costochondral junctions of a 37-year-old man who presented with cough and fever. Further clarification with computed tomography is needed.
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Axial noncontrast enhanced computed tomography with pulmonary window shows a cavity with an irregular wall in the right apex of a 37-year-old man who presented with cough and fever (same patient as above).
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Coronal reconstructed computed tomography image shows the right apical cavity in a 37-year-old man who presented with cough and fever (same patient as above).
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This posteroanterior chest radiograph shows right upper lobe consolidation with minimal volume loss (elevated horizontal fissure) and a cavity in a 43-year-old man who presented with cough and fever.
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Axial chest computed tomography without intravenous contrast with pulmonary window setting shows a right apical thick-walled cavity and surrounding lung consolidation in a 43-year-old man who presented with cough and fever (same patient as above).
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Coronal reconstructed computed tomography image shows the consolidated, partially collapsed right upper lobe with a cavity that is directly connected to a bronchus in a 43-year-old man who presented with cough and fever (same patient as above).
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The posteroanterior chest radiograph shows a large cavity with surrounding consolidation in the lingular portion of the left upper lobe in a 43-year-old man who presented with cough and hemoptysis. There are also a few nodular opacities in the right mid-lung zone.
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Axial chest computed tomography without intravenous contrast with pulmonary window setting through the mid-chest shows a large, irregular-walled cavity with nodules and air-fluid level and two smaller cavities in a 43-year-old man who presented with cough and hemoptysis (same patient as above). Small, patchy peripheral opacities are also present in the left lower lobe. In the right mid-lung, nodular opacities are in a tree-in-bud distribution, suggestive of endobronchial spread.
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Coronal reconstructed computed tomography image shows the lingular cavity with irregular nodules and right mid-lung nodular opacities in a 43-year-old man who presented with cough and hemoptysis (same patient as above).
