Tuberculosis, pulmonary

A15.0-3/A15.7-8/A16.0-2/A16.3-4/A16.7-9/B20.0

* Notifiable medical condition.

• Description
• Medicine Treatment

Tuberculosis (TB) treatment guidelines are updated regularly. The most recent National Tuberculosis Control Programme Guidelines should be read in conjunction with recent guidelines.

DESCRIPTION

A chronic, granulomatous infection of the lungs caused by M. tuberculosis.

Pulmonary tuberculosis is a serious health problem in South Africa, which is exacerbated by HIV and multidrug resistant tuberculosis (MDR-TB).

Note: All patients on TB treatment must be notified.

Diagnosis

Molecular tests are used for the diagnosis of M.tuberculosis and the identification of drug resistant organisms. The initial diagnostic test for patients with suspected tuberculosis is the Xpert MTB/RIF Ultra® assay, which also detects rifampicin resistance. GenoType MTBDRplus® is a line probe assay (LPA) is used as a confirmatory test for rifampicin resistance detected by Xpert MTB/RIF Ultra® and also detects isoniazid resistance.

The diagnosis of pulmonary TB in adults is made on a positive XpertMTB/RIF Ultra® on sputum. In patients with negative sputum smears, notably HIV-infected patients, XpertMTB/RIF Ultra® is not an adequate ‘rule out’ test and HIV-infected TB suspects who are XpertMTB/RIF Ultra® negative require further investigation and may need empiric anti-tuberculosis therapy while awaiting TB cultures.

Note: XpertMTB/RIF Ultra® may identify DNA from M. tuberculosis in the absence of active disease in patients who have completed TB treatment, especially in the past 2 years; TB should be confirmed on culture in this setting.

All patients who are XpertMTB/RIF Ultra® positive require further sputum to be sent for AFB to allow for monitoring of treatment. XpertMTB/RIF Ultra® should not be used for monitoring.

A sputum sample for “DR-TB Reflex” testing should be sent in all patients with rifampicin resistance detected on XpertMTB/RIF Ultra® .

All TB patients must be screened for HIV. TB HIV co-infected patients are eligible for cotrimoxazole prophylaxis regardless of CD4 count.

Sputum induction with nebulised sodium chloride 5% should be attempted for patients unable to spontaneously produce sputum. A wide needle (e.g. 18G) aspiration for Xpert MTB/RIF Ultra® should be done in patients with suspected TB lymphadenitis.

LoEIII [45]

Urine lipoarabinomannan (LAM) is a good “rule-in” diagnostic test for HIV-infected patients with signs and symptoms of pulmonary and/or extrapulmonary TB and CD4 ≤100 cells/microL and for HIV-infected patients who are seriously ill.

LoEI [46]

MEDICINE TREATMENT

All patients with active TB who are Xpert MTB/RIF Ultra® positive and rifampicin sensitive, should receive 2 months’ intensive phase and 4 months continuation phase (see table below). Patients who are at risk of having resistant TB (e.g. previous episode of TB treatment, prisoners, and health care workers), should have sputum sent for a LPA or culture and sensitivity to exclude INH mono resistance.

National tuberculosis control programme guidelines

Fixed dose drug combinations available:

R – Rifampicin

Z – Pyrazinamide

H – Isoniazid (INH)

E – Ethambutol

Treatment for known or presumed drug sensitive TB

The use of INH may result in the development of a peripheral neuropathy due to drug-induced pyridoxine deficiency.

• Pyridoxine 25 mg daily is recommended prophylactically with INH, in patients at high risk of peripheral neuropathy (e.g. HIV, diabetes, alcoholics).

Close contacts (particularly children <5 years of age) of TB patients should be screened and managed as per National TB Guidelines.