Pulmonary tuberculosis (TB), in adults

B20.0

• Diagnosis
• General measures
• Medicine treatment
• TB chemoprophylaxis/isoniazid preventive therapy (IPT), in adults
• TB control programme: medicine regimens in adults

DIAGNOSIS

Pulmonary TB is diagnosed on Xpert MTB/RIF testing, sputum smear or culture.

• Send 1 sputum specimen for Xpert MTB/RIF.
  • If Xpert MTB/RIF is positive: treat for TB and send a sputum specimen for smear microscopy. (The smear is used for reporting, not for diagnosis).
  • If Xpert MTB/RIF is positive and susceptible to RIF: treat for TB.
  • If Xpert MTB/RIF is positive and resistant to RIF: commence MDR treatment and send sputum for drug susceptibility testing to confirm MDR TB.
  • If Xpert MTB/RIF is negative and patient is HIV-infected: send sputum for culture and chest X-ray, if available.
  • If Xpert MTB/RIF is negative and patient is HIV negative: treat with antibiotics and consider further investigation only if symptoms persist.

Note: If the patient was recently treated for TB, the Xpert MTB/RIF test could be falsely positive. Send sputum for smear microscopy and culture instead.

• If Xpert MTB/RIF is not available, send 2 sputum specimens for smear microscopy.
  • If both smears are negative, send another sputum specimen for culture.
  • In all patients who have had TB previously, send a sputum specimen for culture and sensitivity.
• 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.

LoEI[30]

GENERAL MEASURES

• Counsel patients about the disease. Explain the importance of completing treatment.
• Avoid the use of tobacco.
• Avoid excessive alcohol.
• If more than two doses of treatment are missed, extra effort should be made to identify and manage any problems the patient might have.

MEDICINE TREATMENT

Administer total daily amount of each medicine in one dose and not as divided doses.

Important medicine interactions

Rifampicin may reduce the efficacy of low dose combined oral contraceptives, resulting in possible unplanned pregnancies. See: Family planning.

• Alter the oral contraceptive to a high dose preparation for the duration of TB treatment or use an injectable contraception or IUD.
• Use additional contraception in patients using a progestin-only subdermal implant for the duration of TB therapy. See: Antiretroviral therapy, adults.

CAUTION

Antiretroviral medicines frequently interact with TB medicines.

Consult the National Department of Health antiretroviral treatment guidelines.

Dose adjustment

Ethambutol should be given on alternative days in patients with impaired renal function (eGFR < 10 mL/min).

Adverse effects of TB medicines include:

• Nausea.
  • Taking medicines with meals can minimise nausea.
• Hepatitis must be excluded, if there is new onset nausea. Request serum alanine aminotransferase test urgently in these patients.
• Hepatitis (drug induced liver injury)
  • Rifampicin, isoniazid and pyrazinamide may cause hepatitis. Cotrimoxazole and antiretrovirals (efavirenz, nevirapine, lopinavir + ritonavir) can also cause hepatitis.
  • Patient may present with jaundice and/or complaining of hepatitis symptoms (e.g. nausea, malaise, abdominal pain).
  • Refer to hospital for urgent (same day) ALT and further management
  • If jaundiced, stop TB treatment and medicines known to cause hepatitis before referring. See Section: 11.1 Antiretroviral therapy, adults.
• New onset skin rash.
  • Refer if suspected drug rash.
• Neuropathy.
  • Can be prevented by taking pyridoxine.
• Arthralgia.
  • Exclude gout, and treat symptomatically.

TB CHEMOPROPHYLAXIS/ISONIAZID PREVENTIVE THERAPY (IPT) IN ADULTS

See: Isoniazid preventive therapy.

TB CONTROL PROGRAMME: MEDICINE REGIMENS IN ADULTS

15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

Treatment should be given once daily seven days per week in both the intensive and continuation phases.

R – Rifampicin

H – Isoniazid

Z or PZA– Pyrazinamide

E or EMB – Ethambutol

• Keep strictly to the correct dose and the duration of treatment.
• Weigh patient frequently and adjust the dose according to current weight.