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Презентация на тему Targeted tuberculosis (tb) testing and treatment of latent tb infection

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Targeted TB Testing and Treatment of Latent TB InfectionTargeted TB testing is used to focus program activities and provider practices on groups at the highest risk for TB.Treatment of LTBI substantially reduces the risk that
Targeted Tuberculosis (TB) Testing and  Treatment of Latent TB Infection Targeted TB Testing  and Treatment of Latent TB InfectionTargeted TB testing Latent TB Infection (LTBI) diagnosis and treatment Latent TB Infection (LTBI)   LTBI is the presence of M. LTBI vs. Pulmonary TB Disease    Latent TB Infection LTBI vs. Pulmonary TB Disease    Latent TB Infection Targeted TB TestingEssential TB prevention and control strategyDetects persons with LTBI who Treatment of LTBI – Milestones Treatment of persons with LTBI to prevent Treatment of LTBI – Milestones 1965: 	American Thoracic Society (ATS) recommends treatment Treatment of LTBI – Milestones 1974:	CDC and ATS guidelines established for pretreatment Treatment of LTBI – Milestones 1983:	CDC recommends clinical and laboratory monitoring of Treatment of LTBI – Milestones 2000:	CDC and ATS issue updated guidelines for Treatment of LTBI – Milestones2001:	Owing to liver injury and death associated with Treatment of LTBI – Milestones2011:	CDC recommends 12-doses (3 months) of isoniazid (INH) Risk Factors That Lead to Development of TB Disease Persons at Risk for Developing  TB DiseasePersons at high risk Increased Likelihood of Exposure to   Persons with TB DiseasePersons at Increased Risk for Progression to  TB Disease Persons more likely to Increased Risk for Progression to  TB Disease Persons more likely to Increased Risk for Progression to  TB Disease  Persons more likely Testing for M. tuberculosis Infection Testing for M. tuberculosis InfectionThere are two testing methods available for the Mantoux Tuberculin Skin Test Skin test that produces delayed-type hypersensitivity reaction in Administering the TST   Inject 0.1 ml of 5 TU PPD Reading the TST   Measure reaction in 48 to 72 hoursMeasure Reading the TST   Educate patient and family regarding significance of TST Interpretation     5 mm induration is interpreted as TST Interpretation  5 mm induration is interpreted as positive inOrgan transplant TST Interpretation     10 mm induration is interpreted as TST Interpretation    10 mm induration is interpreted as positive TST Interpretation     15 mm induration is interpreted as Factors That May Cause False-  Positive TST Reactions  Nontuberculous myobacteriaReactions Factors That May Cause False-  Negative TST Reactions  AnergyInability to Factors That May Cause False-  Negative TST Reactions  Recent TB Factors That May Cause False-  Negative TST Reactions  Live virus BoostingSome people with LTBI may have a negative skin test reaction when Two-Step Testing A strategy to determine the difference between boosted reactions and Two-step TST Testing Interferon-Gamma Release Assays (IGRAs) Interferon-Gamma Release   Assays (IGRAs)Whole-blood test used to detect M. tuberculosis How IGRAs Works Blood test that measures and compares amount of interferon-gamma How IGRAs WorkCells that recognize the antigen release interferon- Amount of interferon Administering IGRAsConfirm and arrange for delivery of blood sample within specific time-frame Interpretation of IGRA Test   Results   IGRA Test Advantages of IGRAs Requires a single patient visit to conduct testResults can Disadvantages/Limitations of   IGRAs Errors in collecting and transporting blood, or Disadvantages/Limitations of IGRAs Tests may be expensiveLimited data on the use of Selecting a Test to Detect TB   Infection  IGRAs are Selecting a Test to Detect   TB Infection Before initiating treatment Evaluation of Persons with Positive  TB Test Results LTBI Treatment regimens Initiating TreatmentBefore initiating treatment for LTBIRule out TB disease by history, physical Treatment Regimens for LTB I Note: Rifampin (RIF) and Pyrazinamide (PZA) should Latent TB Infection Treatment   Regimens – Isoniazid (INH) 9-month regimen Latent TB Infection Treatment   Regimens – Isoniazid (INH)DosesINH daily for LTBI Treatment Regimens – Isoniazid (INH) and Rifapentine (RPT) 3-month regimen of LTBI Treatment Regimens – Isoniazid (INH) and Rifapentine (RPT) Not recommended for Latent TB Infection Treatment   Regimens – Rifampin Rifampin (RIF) given LTBI Treatment Regimens for Specific   Situations – HIV-Infected PersonsHIV-Infected PersonsConsult LTBI Regimens for Specific   Situations – Fibrotic LesionsPersons with Fibrotic LTBI Treatment Regimens for Specific Situations – Multidrug-Resistant TBContacts of Persons with LTBI Treatment Regimens for   Specific Situations - PregnancyPregnancy and Breast-Feeding9 Completion of TherapyCompletion of therapy is based on the total number of Management of Patient Who   Missed DosesExtend or re-start treatment if Monitoring Drug Treatment Clinical Monitoring Instruct patient to report signs and symptoms of adverse drug Clinical Monitoring Monthly visits should include a brief physical exam and a Clinical MonitoringIncidence of hepatitis in persons taking INH is lower than previously Laboratory Monitoring Baseline liver function tests (e.g., AST, ALT, and bilirubin) are Laboratory Monitoring  Repeat laboratory monitoring if patient has:Abnormal baseline resultsCurrent or Laboratory Monitoring Asymptomatic elevation of hepatic enzymes seen in 10%-20% of people Meeting the Challenge of TB   PreventionFor every patient:Assess TB risk
Слайды презентации

Слайд 2 Targeted TB Testing and Treatment of Latent TB

Targeted TB Testing and Treatment of Latent TB InfectionTargeted TB testing

Infection
Targeted TB testing is used to focus program activities

and provider practices on groups at the highest risk for TB.

Treatment of LTBI substantially reduces the risk that persons infected with M. tuberculosis will progress to TB disease.

Слайд 3 Latent TB Infection (LTBI) diagnosis and treatment

Latent TB Infection (LTBI) diagnosis and treatment

Слайд 4 Latent TB Infection (LTBI)
LTBI is

Latent TB Infection (LTBI)  LTBI is the presence of M.

the presence of M. tuberculosis organisms (tubercle bacilli) without

signs and symptoms or radiographic or bacteriologic evidence of TB disease.


Слайд 5 LTBI vs. Pulmonary TB Disease

LTBI vs. Pulmonary TB Disease  Latent TB Infection

Latent TB Infection

Pulmonary TB
Disease

Positive TST* or IGRA† TST or IGRA result is usually positive
Chest radiograph Chest radiograph is normal usually abnormal



*tuberculin skin test
†Interferon-Gamma Release Assay


Слайд 6 LTBI vs. Pulmonary TB Disease

LTBI vs. Pulmonary TB Disease  Latent TB Infection

Latent TB Infection

Pulmonary TB
Disease
No symptoms or physical Symptoms may include findings suggestive of TB one or more of the following: fever, cough, night sweats, weight loss, fatigue, hemoptysis, decreased appetite


If done, respiratory Respiratory specimens specimens are smear are usually culture and culture negative positive (smear positive in about 50% of patients )



Слайд 7 Targeted TB Testing
Essential TB prevention and control strategy

Detects

Targeted TB TestingEssential TB prevention and control strategyDetects persons with LTBI

persons with LTBI who would benefit from treatment

De-emphasizes testing

of groups that are not at high risk for TB

Can help reduce the waste of resources and prevent inappropriate treatment


Слайд 8 Treatment of LTBI – Milestones
Treatment of

Treatment of LTBI – Milestones Treatment of persons with LTBI to

persons with LTBI to prevent TB disease is for

more than 3 decades an essential component of TB prevention and control in the United States.


Слайд 9 Treatment of LTBI – Milestones
1965: American Thoracic

Treatment of LTBI – Milestones 1965: 	American Thoracic Society (ATS) recommends

Society (ATS) recommends treatment of LTBI for those with

previously untreated TB, tuberculin skin test (TST) converters, and young children.
1967: Recommendations expanded to include all TST positive reactors ( 10 mm).


Слайд 10 Treatment of LTBI – Milestones
1974: CDC and ATS

Treatment of LTBI – Milestones 1974:	CDC and ATS guidelines established for

guidelines established for pretreatment screening to decrease risk of

hepatitis associated with treatment
Treatment recommended for persons ≤ 35 years of age


Слайд 11 Treatment of LTBI – Milestones
1983: CDC recommends clinical

Treatment of LTBI – Milestones 1983:	CDC recommends clinical and laboratory monitoring

and laboratory monitoring of persons  35 who require

treatment for LTBI

1998: CDC recommends 2 months of rifampin (RIF) plus pyrazinamide (PZA) as an option for HIV-infected patients (later changed)


Слайд 12 Treatment of LTBI – Milestones
2000: CDC and ATS

Treatment of LTBI – Milestones 2000:	CDC and ATS issue updated guidelines

issue updated guidelines for targeted testing and LTBI treatment1


9-month regimen of isoniazid (INH) is preferred
2-month regimen of RIF and PZA and a 4 month regimen of RIF recommended as options (later changed)


Слайд 13 Treatment of LTBI – Milestones
2001: Owing to liver injury

Treatment of LTBI – Milestones2001:	Owing to liver injury and death associated

and death associated with 2-month regimen of RIF and

PZA, use of this option de-emphasized in favor of other regimens2
2003: 2-month regimen of RIF and PZA generally not recommended — to be used only if the potential benefits outweigh the risk of severe liver injury and death


Слайд 14 Treatment of LTBI – Milestones
2011: CDC recommends 12-doses (3

Treatment of LTBI – Milestones2011:	CDC recommends 12-doses (3 months) of isoniazid

months) of isoniazid (INH) and rifapentine (RPT) as an

option equal to the standard 9-month INH regimen for certain groups*

Слайд 15 Risk Factors That Lead to Development of TB Disease

Risk Factors That Lead to Development of TB Disease

Слайд 16 Persons at Risk for Developing TB Disease
Persons at high

Persons at Risk for Developing TB DiseasePersons at high risk

risk for developing TB disease fall into 2 categories:
Those

who have an increased likelihood of exposure to persons with TB disease

Those with clinical conditions that increase their risk of progressing from LTBI to TB disease

Слайд 17 Increased Likelihood of Exposure to Persons with TB

Increased Likelihood of Exposure to  Persons with TB DiseasePersons at

Disease
Persons at risk for exposure to persons with TB

disease include:
Close contacts to person with infectious TB
Residents and employees of high-risk congregate settings (e.g., correctional facilities, homeless shelters, health care facilities)
Recent immigrants from TB-endemic regions of the world (within 5 years of arrival to the country)

Слайд 18 Increased Risk for Progression to TB Disease
Persons more

Increased Risk for Progression to TB Disease Persons more likely to

likely to progress from LTBI to TB disease include:
HIV-infected

persons

Those with a history of prior, untreated TB or fibrotic lesions on chest radiograph

Children  5 years with a positive TST


Слайд 19 Increased Risk for Progression to TB Disease
Persons more

Increased Risk for Progression to TB Disease Persons more likely to

likely to progress from LTBI to TB disease include:
Underweight

or malnourished persons

Injection drug users

Those receiving TNF-α antagonists for treatment of rheumatoid arthritis or Crohn’s disease

Слайд 20 Increased Risk for Progression to TB Disease

Increased Risk for Progression to TB Disease  Persons more likely

Persons more likely to progress from LTBI to TB

disease include:
Those with certain medical conditions such as:
Silicosis
Diabetes mellitus
Chronic renal failure or on hemodialysis
Solid organ transplantation (e.g., heart, kidney)
Carcinoma of head or neck
Gastrectomy or jejunoilial bypass


Слайд 21 Testing for M. tuberculosis Infection

Testing for M. tuberculosis Infection

Слайд 22 Testing for M. tuberculosis Infection

There are two testing

Testing for M. tuberculosis InfectionThere are two testing methods available for

methods available for the detection of M. tuberculosis infection

Mantoux

tuberculin skin test (TST)


Interferon-gamma release assays (IGRA)



Слайд 23 Mantoux Tuberculin Skin Test
Skin test that produces

Mantoux Tuberculin Skin Test Skin test that produces delayed-type hypersensitivity reaction

delayed-type hypersensitivity reaction in persons with M. tuberculosis infection


TST is useful for:
Determining how many people in a group are infected (e.g., contact investigation)
Examining persons who have symptoms of TB disease
Multiple puncture tests (e.g., Tine Test) are inaccurate and not recommended

Слайд 24 Administering the TST

Inject 0.1 ml

Administering the TST  Inject 0.1 ml of 5 TU PPD

of 5 TU PPD tuberculin

solution intradermally on volar surface of lower arm using a 27-guage needle

Produce a wheal 6 to 10 mm in diameter

Слайд 25 Reading the TST

Measure reaction

Reading the TST  Measure reaction in 48 to 72 hoursMeasure

in 48 to 72 hours

Measure induration, not erythema

Record reaction

in millimeters, not “negative” or “positive”

Ensure trained health care professional measures and interprets the TST

Слайд 26 Reading the TST

Educate patient

Reading the TST  Educate patient and family regarding significance of

and family regarding significance of a positive TST result

Positive

TST reactions can be measured accurately for up to 7 days

Negative reactions can be read accurately for only 72 hours

Слайд 27 TST Interpretation

 5

TST Interpretation    5 mm induration is interpreted as

mm induration is interpreted as positive in

HIV-infected persons

Close contacts

to an infectious TB case

Persons with chest radiographs consistent with prior untreated TB

Слайд 28 TST Interpretation
 5 mm induration is

TST Interpretation  5 mm induration is interpreted as positive inOrgan

interpreted as positive in

Organ transplant recipients

Other immunosuppressed patients (e.g.

, those taking the equivalent of > 15 mg/d of prednisone for 1 month or those taking TNF-α antagonists)

Слайд 29 TST Interpretation

 10

TST Interpretation    10 mm induration is interpreted as

mm induration is interpreted as positive in

Recent immigrants

Injection

drug users

Residents or employees of congregate settings

Mycobacteriology laboratory personnel

Слайд 30 TST Interpretation

 10 mm

TST Interpretation   10 mm induration is interpreted as positive

induration is interpreted as positive in

Persons with clinical

conditions that place them at high risk

Children < 4 years; infants, children, and adolescents exposed to adults at high-risk

Слайд 31 TST Interpretation

 15

TST Interpretation    15 mm induration is interpreted as

mm induration is interpreted as positive in

Persons with no

known risk factors for TB.

Although skin testing programs should be conducted only among high-risk groups, certain individuals may require TST for employment or school attendance. Diagnosis and treatment of LTBI should always be tied to risk assessment.



Слайд 32 Factors That May Cause False- Positive TST Reactions

Factors That May Cause False- Positive TST Reactions Nontuberculous myobacteriaReactions caused

Nontuberculous myobacteria
Reactions caused by nontuberculous mycobacteria are usually 10

mm of induration

BCG vaccination
Reactivity in BCG vaccine recipients generally wanes over time;
positive TST result is likely due to TB infection if risk factors are present



Слайд 33 Factors That May Cause False- Negative TST Reactions

Factors That May Cause False- Negative TST Reactions AnergyInability to react


Anergy

Inability to react to a TST because of a

weakened immune system

Usefulness of anergy testing in TST-negative persons who are HIV infected has not been demonstrated




Слайд 34 Factors That May Cause False- Negative TST Reactions

Factors That May Cause False- Negative TST Reactions Recent TB InfectionDefined

Recent TB Infection

Defined as less than 10 weeks after

exposure

Very young age

Newborns (< 6 months)




Слайд 35 Factors That May Cause False- Negative TST Reactions

Factors That May Cause False- Negative TST Reactions Live virus vaccinationFor

Live virus vaccination
For example, measles or smallpox
Can temporarily suppress

TST reactivity

Overwhelming TB Disease

Poor TST administration technique
For example, TST injection too shallow or too deep, or wheal is too small





Слайд 36 Boosting
Some people with LTBI may have a negative

BoostingSome people with LTBI may have a negative skin test reaction

skin test reaction when tested years after infection because

of a waning response.

An initial skin test may stimulate (boost) the ability to react to tuberculin.

Positive reactions to subsequent tests may be misinterpreted as new infections rather than “boosted” reactions.





Слайд 37 Two-Step Testing
A strategy to determine the difference

Two-Step Testing A strategy to determine the difference between boosted reactions

between boosted reactions and reactions due to recent infection.

If

1st test positive, consider infected; if negative, give 2nd test 1–3 weeks later

If 2nd test positive, consider infected; if negative, consider uninfected

Use two-step tests for initial baseline skin testing of adults who will be retested periodically (e.g., health care workers).





Слайд 38 Two-step TST Testing

Two-step TST Testing

Слайд 39 Interferon-Gamma Release Assays (IGRAs)

Interferon-Gamma Release Assays (IGRAs)

Слайд 40 Interferon-Gamma Release Assays (IGRAs)

Whole-blood test used to detect

Interferon-Gamma Release  Assays (IGRAs)Whole-blood test used to detect M. tuberculosis

M. tuberculosis infection

Two U.S. Food and Drug Administration (FDA)

approved IGRAs are commercially available in the U.S.
QuantiFERON® -TB Gold-in-tube test (QFT-GIT)

T.SPOT® .TB test (T-Spot)

Слайд 41 How IGRAs Works

Blood test that measures and

How IGRAs Works Blood test that measures and compares amount of

compares amount of interferon-gamma (IFN-) released by blood cells

in response to antigens

Entails mixing blood samples with antigens from M. tuberculosis and controls


Слайд 42 How IGRAs Work

Cells that recognize the antigen release

How IGRAs WorkCells that recognize the antigen release interferon- Amount of

interferon-

Amount of interferon released in response to M.

tuberculosis antigens is compared to amount released in response to other antigens


Слайд 43 Administering IGRAs
Confirm and arrange for delivery of blood

Administering IGRAsConfirm and arrange for delivery of blood sample within specific

sample within specific time-frame to ensure viability of blood

samples

Draw blood sample according to test manufacturer’s instructions

Schedule a follow up appointment to receive test results, medical evaluation and possible treatment if needed


Слайд 44 Interpretation of IGRA Test Results

IGRA

Interpretation of IGRA Test  Results  IGRA Test  Results

Test Results Reported as

QFT-GIT

Positive, negative,
indeterminate

T-Spot Positive, negative,
indeterminate, borderline



Слайд 45 Advantages of IGRAs

Requires a single patient visit

Advantages of IGRAs Requires a single patient visit to conduct testResults

to conduct test

Results can be available within 24 hours

Does

not boost responses measured by subsequent tests

Prior BCG vaccination does not cause false-positive IGRA test result






Слайд 46 Disadvantages/Limitations of IGRAs

Errors in collecting and transporting

Disadvantages/Limitations of  IGRAs Errors in collecting and transporting blood, or

blood, or in interpreting assays can decrease accuracy of

IGRAs

Limited data on use of IGRAs to predict who will progress to TB disease in the future



Слайд 47 Disadvantages/Limitations of IGRAs

Tests may be expensive

Limited data

Disadvantages/Limitations of IGRAs Tests may be expensiveLimited data on the use

on the use of IGRAS for

Children < 5 years

of age;

Persons recently exposed to M. tuberculosis;

Immunocompromised persons; and

Serial testing



Слайд 48 Selecting a Test to Detect TB Infection

Selecting a Test to Detect TB  Infection IGRAs are preferred

IGRAs are preferred method of testing for

Groups of people

who have poor rates of returning to have TST read

Persons who have received BCG vaccine

TST is the preferred method of testing for

Children under the age of 5


Слайд 49 Selecting a Test to Detect TB Infection
Before

Selecting a Test to Detect  TB Infection Before initiating treatment

initiating treatment for LTBI

Either TST or IGRA can be

used without preference for other groups that are tested for LTBI

Routine testing with TST and IGRA is NOT recommended



Слайд 50 Evaluation of Persons with Positive TB Test Results

Evaluation of Persons with Positive TB Test Results

Слайд 51 LTBI Treatment regimens

LTBI Treatment regimens

Слайд 52 Initiating Treatment
Before initiating treatment for LTBI
Rule out TB

Initiating TreatmentBefore initiating treatment for LTBIRule out TB disease by history,

disease by history, physical examination, chest radiography and, when

indicated, bacteriologic studies

Determine prior history of treatment for LTBI or TB disease

Assess risks and benefits of treatment

Determine current and previous drug therapy



Слайд 53 Treatment Regimens for LTB I
Note: Rifampin (RIF)

Treatment Regimens for LTB I Note: Rifampin (RIF) and Pyrazinamide (PZA)

and Pyrazinamide (PZA) should not be offered to persons

with LTBI. RIF and PZA should continue to be administered in multidrug regimens for the treatment of persons with TB disease.

Слайд 54 Latent TB Infection Treatment Regimens – Isoniazid (INH)

Latent TB Infection Treatment  Regimens – Isoniazid (INH) 9-month regimen


9-month regimen of isoniazid (INH) is one of the

preferred regimens
6-month regimen is less effective but may be used if unable to complete 9 months
May be given daily or intermittently (twice weekly)
Use directly observed therapy (DOT) for intermittent regimen
Preferred regimen for children 2-11 years of age



Слайд 55 Latent TB Infection Treatment Regimens – Isoniazid (INH)
Doses
INH

Latent TB Infection Treatment  Regimens – Isoniazid (INH)DosesINH daily for

daily for 9 months - 270 doses within 12

months

INH twice/week for 9 months - 76 doses within 12 months

INH daily for 6 months - 180 doses within 9 months

INH twice/week for 6 months - 52 doses within 9 months





Слайд 56 LTBI Treatment Regimens – Isoniazid (INH) and Rifapentine

LTBI Treatment Regimens – Isoniazid (INH) and Rifapentine (RPT) 3-month regimen

(RPT)
3-month regimen of INH and RPT is an

option equal to 9-month INH regimen for treating LTBI in certain groups, such as otherwise healthy people, 12 years of age and older, who were recently in contact with infectious TB or who had tuberculin skin test conversions or positive blood test for TB

Must use directly observed therapy (DOT)



Слайд 57 LTBI Treatment Regimens – Isoniazid (INH) and Rifapentine

LTBI Treatment Regimens – Isoniazid (INH) and Rifapentine (RPT) Not recommended

(RPT)

Not recommended for children younger than 12 years

of age, HIV-infected people taking antiretroviral therapy, pregnant women, or women expecting to be pregnant within the 12-week regimen

INH and RPT once a week for 3 months - 12 doses within 4 months




Слайд 58 Latent TB Infection Treatment Regimens – Rifampin
Rifampin

Latent TB Infection Treatment  Regimens – Rifampin Rifampin (RIF) given

(RIF) given daily for 4 months is an acceptable

alternative when treatment with INH is not feasible.

In situations where RIF cannot be used (e.g., HIV-infected persons receiving protease inhibitors), rifabutin may be substituted.

RIF daily for 4 months - 120 doses within 6 months





Слайд 59 LTBI Treatment Regimens for Specific Situations – HIV-Infected

LTBI Treatment Regimens for Specific  Situations – HIV-Infected PersonsHIV-Infected PersonsConsult

Persons
HIV-Infected Persons
Consult an expert in managing HIV and TB
INH

daily for 9-mo, rather than 6-mo, is optimal: 270 doses within 12 months
RIF is generally contraindicated for persons taking protease inhibitors or delavirdine
Rifabutin with dose adjustments can sometimes be substituted for RIF
INH/RPT regimen not recommended for HIV-infected people taking antiretroviral therapy


Слайд 60 LTBI Regimens for Specific Situations – Fibrotic Lesions
Persons

LTBI Regimens for Specific  Situations – Fibrotic LesionsPersons with Fibrotic

with Fibrotic Lesions Suggesting Previous TB
Should be treated for

LTBI if they have
A positive TST reaction (at least 5 mm) or IGRA result
No symptoms of infectious TB disease
No history of treatment for TB disease

Treat only after active disease excluded with sputum testing

Acceptable regimens include
9 months of INH
4 months of RIF (with or without INH)
3 months of INH and RPT (12-dose regimen)


Слайд 61 LTBI Treatment Regimens for Specific Situations – Multidrug-Resistant

LTBI Treatment Regimens for Specific Situations – Multidrug-Resistant TBContacts of Persons

TB
Contacts of Persons with Multidrug-Resistant TB

Consider risk for progressing

to MDR disease before recommending LTBI treatment

When prescribing treatment for these contacts, consult an MDR TB expert


Слайд 62 LTBI Treatment Regimens for Specific Situations - Pregnancy
Pregnancy

LTBI Treatment Regimens for  Specific Situations - PregnancyPregnancy and Breast-Feeding9

and Breast-Feeding

9 months of INH daily or twice weekly;

give with vitamin B6

If cannot take INH, consult with TB expert

Women at high risk for progression to TB disease should not delay LTBI treatment; monitor carefully

Breast-feeding not contraindicated


Слайд 63 Completion of Therapy
Completion of therapy is based on

Completion of TherapyCompletion of therapy is based on the total number

the total number of doses administered, not on duration

alone.



Слайд 64 Management of Patient Who Missed Doses
Extend or re-start

Management of Patient Who  Missed DosesExtend or re-start treatment if

treatment if interruptions were frequent or prolonged enough to

preclude completion

When treatment has been interrupted for more than 2 months, patient should be examined to rule out TB disease

Recommend and arrange for DOT as needed





Слайд 65 Monitoring Drug Treatment

Monitoring Drug Treatment

Слайд 66 Clinical Monitoring
Instruct patient to report signs and

Clinical Monitoring Instruct patient to report signs and symptoms of adverse

symptoms of adverse drug reactions:
Fever
Headache
Rash
Anorexia, nausea, vomiting, or

abdominal pain in right upper quadrant
Fatigue or weakness
Dark urine
Persistent numbness in hands or feet



Слайд 67 Clinical Monitoring
Monthly visits should include a brief

Clinical Monitoring Monthly visits should include a brief physical exam and

physical exam and a review of:

Rationale for treatment
Adherence with

therapy
Symptoms of adverse drug reactions
Plans to continue treatment



Слайд 68 Clinical Monitoring
Incidence of hepatitis in persons taking INH

Clinical MonitoringIncidence of hepatitis in persons taking INH is lower than

is lower than previously thought (as low as 0.1%)

Hepatitis

risk increases with age
Uncommon in persons < 20 years old
Nearly 2% in persons 50 to 64 years old

Risk increases with underlying liver disease or heavy alcohol consumption




Слайд 69 Laboratory Monitoring
Baseline liver function tests (e.g., AST,

Laboratory Monitoring Baseline liver function tests (e.g., AST, ALT, and bilirubin)

ALT, and bilirubin) are not necessary except for patients

with risk factors:
HIV infection

History of liver disease

Regular alcohol use

Pregnancy or in early postpartum period



Слайд 70 Laboratory Monitoring
Repeat laboratory monitoring if patient has:
Abnormal

Laboratory Monitoring Repeat laboratory monitoring if patient has:Abnormal baseline resultsCurrent or

baseline results

Current or recent pregnancy

High risk for adverse reactions

Symptoms

of adverse reaction

Liver enlargement or tenderness during examination



Слайд 71 Laboratory Monitoring
Asymptomatic elevation of hepatic enzymes seen

Laboratory Monitoring Asymptomatic elevation of hepatic enzymes seen in 10%-20% of

in 10%-20% of people taking INH
Levels usually return to

normal after completion of therapy

Discontinue treatment if transminase level exceeds 3 times the upper limit of normal if patient has symptoms of hepatoxicity, and 5 times the upper limit of normal if patient is asymptomatic



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