of TB among patients with renal dysfunction
• 2HRZE/4HR initially then adjusted based on subsequent renal function • For patients on hemodialysis on TB
treatment, anti-TB medications should be administered immediately after hemodialysis session.
• For patients on peritoneal dialysis, anti- TB medications may be administered regardless of PD schedule; begin with doses similar to those recommended for patients on hemodialysis. (Strong recommendation, low quality evidence)
• 2HRZ/6HR • Streptomycin and
ethambutol to be used with caution, increasing dose intervals instead of decreasing dose
Additional Recommendations for TB in HIV and Other High Risk Clinical Groups:
• For PHLIV with TB: Antiretroviral therapy should be initiated after the second week of TB treatment regardless of CD4 count. For patients with TB meningitis, antiretroviral therapy should be initiated after the intensive phase of TB treatment. Efavirenz is the preferred NNRTI for HIV patients on TB treatment. Avoid the use of nevirapine because of drug-drug interactions (Strong recommendation, high
quality evidence)
• Revised treatment regimens: 2HZE/12-18HE for post-SOT recipients without risk factors for DR-TB (Weak recommendation, moderate
quality evidence); 2RHZE/4-9RH for severe cases of TB (Weak recommendation, moderate quality evidence); 2HRSE/6HR,
2SHE/10HE or 9HRE for compensated liver cirrhosis
• Immediate referral to PMDT treatment centers: for management of DR-TB among high risk clinical groups similar to general population
(Strong recommendation, high quality evidence); for decompensated
liver cirrhosis for possible use of second line TB drugs
• Routine screening recommended for the following high risk groups: o PLHIV (when active disease is ruled out, patient is treated for
presumed LTBI, no screening needed) (Strong recommendation,
moderate quality evidence)
o Solid organ and hematologic transplant recipients (Strong
recommendation, low quality evidence)
o Rheumatoid arthritis patients on biologicals (Strong
recommendation, low quality evidence)
o Patients on chronic dialysis (Strong recommendation, low quality
evidence)
D. TB AMONG HIV AND OTHER HIGH RISK CLINICAL GROUPS
QUESTION/ISSUE 2016 CPG 2006 CPG
Screening for TB
among PLHIV • All newly diagnosed PLHIV should be screened for active TB (Strong recommendation, high quality evidence)
• HIV-infected patients should be screened for TB
Diagnosis of TB among persons living with HIV (PLHIV)
• Based on symptomatic screening (i.e. cough of any duration, fever, night sweats and weight loss), CXR, sputum Xpert® MTB/Rif
• Xpert® MTB/Rif as initial diagnostic test in adults with presumed HIV-associated TB (Strong recommendation, high quality evidence)
• All presumptive TB-HIV should be referred to the nearest DOTS facility with Programmatic Management of Drug-resistant Tuberculosis (PMDT) services or to an Xpert® MTB/Rif facility for screening and testing before initiating any form of TB treatment
(Strong recommendation, high quality evidence)
• If Xpert® MTB/Rif is negative, diagnosis for PTB will be based on a high index of clinical suspicion (Strong recommendation, high quality evidence)
• Both sputum smear examination and TB culture recommended as initial tests to diagnose TB in HIV- infected individuals • As in non- HIV patients, examination of 3 sputum specimens is recommended Treatment for
PTB in PLHIV • Same recommendation maintained• Co-trimoxazole prophylaxis at a total daily dose of 800 mg sulfamethoxazole + 160 mg trimethoprim should also be given to prevent Pneumocystis jirovecii pneumonia among PLHIV regardless of CD4 count (Strong recommendation, high quality evidence)
• Same as general population Management of TB among pregnant and lactating women
• Same recommendation for treatment regimen
• CXR with abdominal shield, if indicated, is considered to be relatively safe during pregnancy. An informed consent is necessary. Pregnancy should neither deter nor delay the diagnosis and management of PTB. (Strong recommendation, low quality evidence)
• 2HRZE/4HR with pyridoxine 25mg/day • Streptomycin is contraindicated Management of TB among patients with hepatic dysfunction
• Compensated liver cirrhosis - 2HRES/6HR; 2HSE/10HE or 9HRE • In patients with decompensated liver
cirrhosis, referral to specialized centers is warranted because of the possible use of second line TB drugs. The more advanced the liver disease, the less the number of
• 2HRES/6HR or 2HRE/6HE
• 2HES/10HE for those with more extensive liver damage
poor glycemic control, diabetics exposed to active TB or those who are smokers (Weak recommendation, moderate quality evidence) o Pregnant patients with known exposure to active TB, injection
drug users, or immunocompromised. (Strong recommendation,
low quality evidence)
• TST preferred among high risk clinical groups in resource-limited setting like the Philippines (Strong recommendation, low quality evidence); Routine LTBI screening using TST or IGRA for rheumatoid arthritis on biologic therapy (Strong recommendation, low quality evidence) • Recommended treatment for LTBI: INH 300mg for 6 months under
DOT (Strong recommendation, moderate-high quality evidence) E. PREVENTION AND CONTROL OF TB:
QUESTION/ISSUE 2016 CPG 2006 CPG
Management
of LTBI • High risk groups for LTBI screening and treatment (Refer to
Chapter 5 on TB- HIV and Other High Risk Clinical Groups)
• At this time, treatment of patients with LTBI not a priority in the Philippines. While TB remains uncontrolled, resources must be focused on the “source” case. • High risk groups include for
LTBI treatment are: diabetics on immunosuppressive treatment, patients on hemodialysis presenting with fibrotic lesions, health care workers who convert from negative to positive, HIV patients
Additional Recommendations on Prevention and Control of TB in the General Population:
• Covering one’s mouth when coughing to minimize spread of potentially infectious aerosols, including those laden with MTB.
(Strong recommendation, low quality evidence)
• Use of surgical face masks among patients presumed or confirmed to have infectious PTB until deemed non-infectious; NOT recommended to wear face-piece respirator masks since these masks are primarily meant to prevent inhalation of the infectious droplets. (Strong
recommendation, low quality evidence)
• No evidence on use of 2 or more surgical face masks in layers for additional protection. (Strong recommendation, moderate quality evidence) • Use of filtering face-piece respirator masks (i.e., N95 or FFP2) among
exposed health care workers when performing procedures with high risk of aerosolization
• Regular fit testing for filtering face-piece respirator masks to ensure proper use (Strong recommendation, high quality evidence)
• Household contacts of active TB cases at increased risk of infection and disease should be screened for disease activity according to CPG recommendations on diagnosis, or an CXR at the least, specially if the index case is bacteriologically confirmed, cavitary, with frequent coughs and has yet to receive or in the early stages of the recommended treatment regimen. (Strong recommendation, high
quality evidence)
• Smokers, alcoholics (i.e., > 40 g/day) and underweight individuals (i.e., BMI < 20) have slightly increased risk of contracting TB and progressing to disease compared to general population. As modifiable risk factors, clinicians must address these appropriately i.e., identify and advise smokers to quit, and offer dietary or lifestyle modifications.
• The risk of progression to disease is strongly significant among persons with recent TB infection (i.e., < 2 years) and upper lobe fibro- nodular disease on chest x-ray. Periodic monitoring for symptoms suggestive of disease activity and a repeat CXR after 4-6 months to establish radiographic stability is recommended for early detection of disease activity in these individuals. (Strong recommendation,
moderate quality evidence)
• BCG re-vaccination is NOT recommended. (Strong recommendation,
moderate quality evidence)
• Isolation is recommended for: (1) bacteriologically confirmed PTB cases who have not started or are in the early stages of anti-TB treatment (including EPTB cases with potential for aerosol generation) and (2) presumptive DR-TB or known MDR/XDR-TB cases
• Documented HIV/AIDS cases or those with strong clinical evidence for HIV/AIDS should be isolated from active TB cases. (Strong
recommendation, moderate quality evidence)
• Administrative control for all health facilities dealing with presumptive and confirmed TB cases through identification of people with TB symptoms (triage); separation of infectious cases; minimizing time in health care facilities; ensuring prompt and effective full treatment; cough etiquette promotion; surveillance of TB disease among health workers; assessment at all levels of the health system and in congregate settings
• Ensure environmental controls are in place such that health facility design, construction, renovation and use are appropriate – e.g., good ventilation is assured.
• Provide appropriate personal protective equipment for health care workers in areas at high-risk for TB transmission (Strong