Tuberculosis, Prophylaxis Medications

Drugs associated with Tuberculosis, Prophylaxis

The following drugs and medications are in some way related to, or used in the treatment of Tuberculosis, Prophylaxis. This service should be used as a supplement to, and NOT a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners.

Tuberculosis

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis (MTb). Almost all infection in humans is caused by inhalation of droplet nuclei - infectious particles of aerosolized respiratory secretions coughed up by a person with pulmonary tuberculosis. It may either result in a lifelong silent (latent) infection or in a clinically recognizable disease.

The need for improved detection and treatment of tuberculosis has been significantly increased by the recent outbreaks of multidrug-resistant TB, especially in HIV-infected persons.

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Background

Epidemiology

The most common disease is pulmonary tuberculosis; however, extrapulmonary cases do occur. In low-incidence areas such as the United States, most TB cases are attributed to endogenous reactivation of latent infection; however, significant outbreaks can occur from exposure to a person with active pulmonary tuberculosis.

Over 26,000 cases of TB were reported in 1991, and an estimated 15 million persons in the United States are infected with tubercle bacilli. Incidence is higher in urban settings, among populations with low socioeconomic status, among racial and ethnic minority groups (particularly Hispanics and African Americans), and in medically underserved areas. The risk of TB is higher for persons living in crowded, confined areas, such as residential drug treatment programs, homeless shelters, nursing homes, correctional institutions, migrant worker camps, and long-term care facilities.

Since 1986, the morbidity from TB has been increasing. The increase has occurred mostly in geographic areas and demographic groups with a high incidence of HIV/AIDS cases. The 1991 data also show:

• Twenty-seven percent of cases of active TB occurred in foreign-born persons, compared with 20 percent in 1985. Forty-one percent of these persons had been in the United States less than 5 years.
• Seventy-one percent of reported TB cases were in racial and ethnic minorities.
• Twenty-three percent of cases occurred in the elderly.

Among children with TB, 86 percent of cases occurred in minority groups. Screening for TB should be provided for any child exposed to a person who is or should be receiving treatment for active TB.

Course of the Disease

Most persons who are exposed to a person with active TB and become infected do not develop active disease, but rather have latent, asymptomatic infection for long periods of time. Such patients may benefit from preventive therapy with isoniazid.

Active TB is usually the result of reactivation of latent infection. The symptoms of active disease include fatigue, fever, weight loss, cough, pleuritic chest pains, and hemoptysis. TB is, however, a treatable disease. Treatment requires taking multiple anti-TB drugs for at least 6 to 9 months. The length of treatment may vary, especially in HIV-positive persons. Adherence to the appropriate drug regimen and adequate medical followup are required to complete successful treatment.

Although active TB is usually the result of reactivation of latent infection, health care providers need to be aware that with the increasing numbers of cases of active TB, some patients may present with active disease following recent exposure to a person with active tuberculosis. HIV-infected persons are at particular risk for the development of active TB following a recent exposure. Reactivation of latent TB because of the immunosuppression associated with HIV infection, as well as TB following exposure to a person with active TB, occurs more frequently in the HIV-infected person. There may be rapid progression of the TB infection in such an HIV-infected person.

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Program Issues for Drug Treatment Settings

Drug treatment programs funded under the Substance Abuse Prevention and Treatment Block Grant are now required by law to provide tuberculosis services to patients or to ensure that patients receive such services. Section 1924(a) of the ADAMHA Reorganization Act of 1992 (P.L. 102-321) states that

States must require treatment entities receiving funds under grant to make available tuberculosis services to each individual receiving treatment; in the case of an individual denied admission due to lack of capacity, the treatment entity will refer the individual to another provider of tuberculosis services (defined as counseling, testing, treatment).

Transmission of tuberculosis is most effectively reduced by identifying and treating persons with active pulmonary tuberculosis. A full course of isoniazid preventive therapy can reduce the risk of developing active TB in infected persons (i.e., persons with positive skin tests) by more than 90 percent.

Because patients receiving methadone maintenance come to drug treatment centers frequently - often on a daily basis - for extended time periods, methadone maintenance treatment programs are in a unique position to provide daily or twice weekly preventive therapy for the recommended 6- to 12-month period. This preventive service can usually be provided in collaboration with the public health agency.

Screening and Treatment

• In general, all persons entering drug treatment programs should have a Mantoux intradermal skin test for tuberculosis.
• Persons who have a negative skin test for TB, as well as nonreactive control skin tests, should be considered to be anergic. HIV-infected persons are especially at high risk for the development of TB. Any person who fails to react to the TB skin test as well as the skin tests controls and is, therefore, anergic needs to be carefully evaluated to be certain there is no evidence of active TB and to be tested for HIV if the person's HIV status is unknown.
• Persons who have a positive skin test or who have symptoms compatible with TB should be medically evaluated for possible active TB and appropriate treatment or for TB preventive therapy.
• Tuberculin skin tests using the Mantoux method should be repeated annually for patients whose initial skin test is negative.
• Patients with chronic cough (over 3 weeks duration), fever, and other symptoms should be rapidly evaluated for possible active tuberculosis disease. If active tuberculosis is suspected or confirmed, the client should be immediately placed on multiple anti-TB medication and placed in respiratory isolation if institutionalized.

Special Considerations With Infected Patients

Persons with close contact to a person with untreated tuberculosis of the lungs or larynx are at greatest risk of acquiring infection.

The treating physician should inform the case manager in the drug treatment program about patients who are being treated for active TB concerning activity restrictions and possible need for isolation methods to ensure compliance, and about precautions for staff. The need to monitor drug adherence and to determine drug efficacy and potential drug toxicity all highlight the importance of monitoring. For short-term treatment programs, treatment needs to be supervised and aftercare should be provided, including followup with a specific provider and case manager.

Medications for TB preventive therapy and treatment may interact with other drugs, such as methadone and disulfiram (Antabuse), thus requiring careful monitoring and possible dosage adjustment. Rifampin (RIF) may interact with either methadone or disulfiram and may require an increase in methadone dosage. Isoniazid (INH) must be given with care to patients on disulfiram, since such patients can have psychotic episodes or ataxia.

Considerations for Drug Treatment Staff

All health care personnel should have PPD skin tests every 6 to 12 months and at the time of and 3 months after any exposure to a patient with active, untreated TB. The following testing should be done:

• In general, all staff of drug treatment programs should receive a PPD skin test using the Mantoux method when they are first employed.
• Staff with initial negative skin tests should be retested every 6 to 12 months.
• Staff with positive skin tests should receive a prompt medical evaluation for possible active TB, should be considered for TB preventive therapy, and should be evaluated if symptoms of active TB develop.

Staff reading the results of tuberculin skin tests should be trained in the procedure. Training materials on skin testing produced by the Centers for Disease Control and Prevention (CDC) are available through each State health department TB program. See also the section at the end of this chapter, Role of the Health Department, on assistance that the local or State health department may offer to drug treatment centers in setting up a screening program.

Other Program Considerations

Patients Who Refuse Testing

The patient should have the right to refuse screening. However, to protect the safety and health of the other patients and staff, an individual seeking treatment who is thought to have active tuberculosis may be denied admission until it has been medically determined if the patient needs treatment prior to being admitted to the program. A program's drug treatment policies and procedures must be consistent with current local, State, and Federal laws. See section on Access to Treatment in "Legal and Ethical Issues" for further guidance on patients who refuse to be tested.

Local legal guidelines should be consulted for dealing with noncompliant patients who are public health risks, especially given cases of multidrug-resistant TB. (Any patient who is noncompliant with treatment for drug-susceptible or MDR-TB should not be allowed to enter the drug treatment facility; see the following MDR-TB guideline.)

Isolation of Persons With Infectious TB

Prompt, correct drug treatment of an active case of TB is essential. For persons with active or suspected tuberculosis, initiation of treatment as an outpatient may be considered if the person is only mildly ill and is able to care for himself or herself at home. For those with complicated illness or unable to care for themselves, hospitalization is indicated. Hospitalization should be strongly considered for persons with MDR-TB, and the decision not to hospitalize such a patient should be made only after consultation with a physician experienced in caring for patients with MDR-TB. Patients in residential drug treatment programs should be hospitalized unless appropriate respiratory isolation can be provided at the facility.

An active case of TB is usually not communicable once the sputum smears are negative for acid-fast bacilli (AFB) and the patient's symptoms, e.g., cough, have improved. The drug susceptibility of any given TB isolate may not be available, however, for 6 to 12 weeks. If there is any concern that the infected person may have resistant tuberculosis, appropriate respiratory isolation, with hospitalization if it is deemed necessary, should be continued until the person has smear-negative sputum samples or until the drug susceptibilities are known. When the drug susceptibilities are available, the therapy must be reevaluated to be certain that the person is on appropriate therapy and that the patient's adherence can be ensured by placing him or her on directly observed therapy.

General Guidelines

Programs should develop guidelines and procedures for decreasing transmission of tuberculosis through identification, appropriate isolation, and treatment of persons with infectious TB. For general environmental guidelines, refer to the CDC Guidelines in the Summary Statement in chapter 6; see also chapter 4, "Issues for Treatment Program Administrators." There should be adequate ventilation of living and work areas where persons with possible or proven TB congregate. Persons with known infectious TB should not be allowed to enter the living and work areas of a treatment facility until three sputum specimens have been obtained and are smear negative for AFB.

Sputum induction, sputum collection, and aerosolized pentamidine treatments should be done in areas with correct exhaust. If such areas are not available, sputum collection may be done outside the building. Consideration should be given to placing ultraviolet lights in clinic and residential areas where adequate ventilation and air exchange are not possible.

Reporting Procedures

All new cases of active TB must be reported to local/State health departments. Reporting is obligatory in all States. All suspected cases of TB should also be reported to the health department. Any cases of INH- or multidrug-resistant TB should be promptly reported. Contact tracing of all active TB cases must be implemented. Contact tracing is not required for most persons with only a positive PPD. However, in the case of a child with a positive PPD, an investigation should be undertaken to identify the source case.

• Persons with positive skin tests after exposure to MDR-TB should be reported.
• All persons with TB and all suspects, contacts, and others at high risk must have medical services made available by local/State health departments; services to screen for and treat TB should be available to such persons regardless of their ability to pay.
• Prompt attention should be given to any household where contacts of the infectious cases include children or immunosuppressed persons.
• State and local health departments should initiate prompt followup of contacts