OBJECTIVE Alberta clinicians detect and manage active pulmonary tuberculosis (TB) that poses a public health risk.

Transcription

1 DIAGNOSIS AND MANAGEMENT OF ACTIVE TUBERCULOSIS Clinical Practice Guideline Nvember 2011 OBJECTIVE Alberta clinicians detect and manage active pulmnary tuberculsis (TB) that pses a public health risk. While extrapulmnary TB and preventative therapy fr latent tuberculsis infectin are relevant t primary care, they are utside the scpe f this guideline. TARGET POPULATION All EXCLUSIONS Nne RECOMMENDATIONS DIAGNOSIS (SEE TB DIAGNOSIS ALGORITHM.) Suspect TB in thse wh exhibit symptms such as: Sub-acute r chrnic cugh lasting > tw t three weeks Fever Night sweats Weight lss Hemptysis Radigraphic findings suggestive f TB Anrexia PRACTICE POINTS High Risk Ppulatins Include: Immigrant ppulatins First Natins peple Immuncmprmised Elderly Inner city ppulatins Anyne with epidemilgic link t infectin INVESTIGATIONS Physical examinatin including examinatin f cervical lymph ndes Chest X-ray Specimen culture fr Mycbacterium tuberculsis Determine c-mrbidities X DO NOT use tuberculin skin test (TST) and interfern Gamma Release Assay (IGRA). These recmmendatins are systematically develped statements t assist practitiner and patient decisins abut apprpriate health care fr specific clinical circumstances. They shuld be used as an adjunct t sund clinical decisin making.

2 Diagnsis and Management f Active Tuberculsis Nvember 2011 MANAGEMENT PUBLIC HEALTH SAFETY MEASURES When active TB is suspected: Islate patient pending further investigatins. Ntify TB Services (see Ntificatin sectin). Admit t hspital in a respiratry islatin rm if patient has ne r mre f: Cavitary disease Significant cugh High risk prfessin Children under the age f five Expsure t an immuncmprmised persn Cannt be hme islated Cnsider hme islatin if: Stable, single family residence N vulnerable husehld members, i.e., immuncmprmised persns r children under five years f age Islate if resident f a facility: Place patient in a negative pressure islatin rm. Place in a single rm with dr clsed until transfer t a negative pressure rm is pssible. D nt allw patients t leave rm except fr essential services, i.e., radilgic investigatins and brnchscpy. Ensure apprpriate infectin cntrl measures are in place fr transfer t and frm the islatin rm including: Staff shuld wear a high filtratin respiratr N95 mask during cntact with a suspect case. Patient shuld wear a surgical mask fr transprt t and frm islatin. Alert ther facilities t prepare fr apprpriate precautins, if/when the patient is transferred. Cnsider alchl, drug and tbacc withdrawal prtcls fr all patients in islatin. NOTIFICATION TO TB SERVICES Patients living in Edmntn r Calgary: Clinical Practice Guideline Page 2 f 8 Recmmendatins

3 Diagnsis and Management f Active Tuberculsis Nvember 2011 Refer immediately t a TB clinic- lcated in Edmntn r Calgary: Patients living utside f Edmntn r Calgary: There is a virtual TB clinic that wrks with lcal cmmunity/public health centres t prvide service t rural Alberta, including First Natin reserve cmmunities. (See web link abve.) PRACTICE POINT Yur rle as an Albertan clinician: Suspicin f TB Diagnstics Determine patient cmrbidities Cnsider islatin Call AHS public health prir t psitive X-ray r sputum Ensure patients are nt lst t fllw-up BACKGROUND PREVALENCE TB is a glbal public health threat with nine millin new cases per year and apprximately 1.3 millin deaths per year 1. It is a leading cause f death in high-prevalence regins such as Sutheast Asia and sub-saharan Africa. In cntrast, TB is nt a cmmn cause f mrtality in lw-prevalence cuntries. The incidence f TB in Canada is apprximately 4.8 per , and in Alberta 5.1 per The relatively lw incidence in ur setting pses a challenge t the apprpriate and timely detectin and management f active TB. Furthermre, fr healthcare prviders frm endemic cuntries the practices fr diagnsis and referral may differ significantly frm their previus experience. The rate f TB in Alberta has increased in the past seven years 3 and delays in the diagnsis f tuberculsis have resulted in increased mrbidity and mrtality, increased transmissin f infectin, greater need fr prlnged islatin, and higher healthcare csts. In recent years several cases in Alberta with delayed diagnses have had majr public health cnsequences. ETIOLOGY In Canada and Alberta, TB is primarily a cnditin f immigrant ppulatins and First Natins peple. Hwever, the diagnsis shuld be cnsidered amng the immuncmprmised, the elderly, inner city ppulatins and anyne wh has had an epidemilgic link t infectin. Imprtant questins t explre with patients include previus histry f active TB r knwn latent infectin, cuntry f birth, abriginal ancestry, knwn expsure t TB, travel t an endemic cuntry, time spent in a crrectinal facility, wrk in health care, hmelessness, and general health status. 4 Apprximately 70-80% f TB in Canada invlves the respiratry tract, 2 which includes pulmnary TB, tuberculsis pleurisy, primary TB, TB f intrathracic lymph ndes, and the upper airway. Clinical Practice Guideline Page 3 f 8 Backgrund

4 Diagnsis and Management f Active Tuberculsis Nvember 2011 SUSPECTING TB The diagnsis is suspected in thse wh exhibit symptms such as sub-acute r chrnic cugh lasting greater than tw t three weeks, fever, night sweats, anrexia, weight lss and hemptysis. 5 The diagnsis is als mre likely in thse wh are f an epidemilgic risk grup such as immigrant ppulatins and First Natins peple (see backgrund fr mre detail) and thse wh have radigraphic (X-ray) findings suggestive f TB. Physical examinatin is ften nrmal in active pulmnary tuberculsis, althugh examinatin f cervical lymph ndes may help detect TB lymphadenitis. The diagnsis may be suspected n the basis f abnrmal chest imaging. The typical findings in active tuberculsis include upper lbe cnslidatin with r withut cavitatin. Hwever, in the immuncmprmised, pediatric r geriatric ppulatin, chest X-ray findings may be atypical. Specifically, lwer lbe cnslidatin may ccur, cavitatin is less frequent and mediastinal r hilar lymphadenpathy may be a prminent r slitary finding. X-rays may be nrmal in HIV infected individuals r very early in the TB disease. Other findings suggestive f active TB include pleural effusin, ndular changes, particularly ndularity in a pattern f endbrnchial spread. 5 Overall the chest X-ray has limited sensitivity (70-80%) and specificity (60-70%). 6,7,8 There is als a high degree f inter-reader variability in interpretatin f chest radigraphs. 8 TB DIAGNOSTIC TESTS The tuberculin skin test (TST) and Interfern Gamma Release Assay (IGRA) are nt recmmended fr diagnsis f active tuberculsis. 9 Bth are useful in diagnsing latent tuberculsis infectin, and prir knwledge f a psitive TST is helpful in assessing risk f current active TB. Hwever, the TST may be falsely negative in the setting f active infectin, and a psitive test cannt distinguish latent infectin frm active disease. The IGRA test is mre specific fr the presence f TB infectin when cmpared t the tuberculin skin test. Hwever, it t cannt distinguish active disease frm latent infectin, s its rle in the wrkup f active TB has nt been established. 9 The gld standard fr diagnsis f active TB is a psitive culture fr Mycbacterium tuberculsis. 10 In respiratry disease, three spntaneus mrning sputa in an individual wh is able t prduce sputum is the apprpriate first step t achieving the diagnsis. 10,11 A health care wrker shuld attempt the initial spt sputum cllectin and cach the patient n techniques t imprve the quality f specimen. At times, sputum inductin is necessary t imprve the sensitivity f respiratry cultures. This is supervised by a respiratry therapist 2 and invlves inhalatin f hypertnic saline by nebulizer t help prduce a lwer respiratry tract specimen. 12,13 Extrapulmnary specimens may be required t btain a culture diagnsis fr ther frms f TB, such as TB lymphadenitis. Bipsy specimens submitted fr TB culture shuld nt be fixed in frmaldehyde. Fr details regarding the cllectin f extrapulmnary specimens, see the Alberta TB Cntrl Manual 2010 p Specimens are first sent fr cncentrated smear, which determines if the individual has a high burden f rganisms and is therefre cnsidered highly infectius. Even if the smear is negative, a patient with a psitive respiratry culture fr Mycbacterium tuberculsis is cnsidered infectius. If the specimen is smear psitive, a mlecular-based assay identifying the mycbacterial rganism as tuberculsis can be perfrmed and is generally reprted within Clinical Practice Guideline Page 4 f 8 Backgrund

5 Diagnsis and Management f Active Tuberculsis Nvember 2011 hurs. Hwever, the perfrmance characteristics f these mlecular assays are nt sufficiently high t rule in r ut tuberculsis in the setting f smear negative specimens. 14,15 Once the cncentrated smear is perfrmed, the Prvincial Labratry will hld the specimen fr culture. This is psitive in active TB within tw t fur weeks in mst cases. Hwever, culture results are nly reprted as negative after seven weeks f incubatin. 5,9 A psitive culture is nt nly cnfirmatry f active disease, but it als allws fr perfrmance f drug susceptibility testing which is very helpful in guiding treatment. When patients are diagnsed clinically withut culture cnfirmatin we d nt have access t drug susceptibility infrmatin. PUBLIC HEALTH SAFETY MEASURES When the diagnsis f active TB is suspected, the individual shuld be islated frm thers while awaiting further evaluatin. Patients wh have cavitary disease, a significant cugh, are in a high risk prfessin, have children under the age f five, are expsed t an immuncmprmised persn r cannt be hme islated fr anther reasn shuld be prmptly admitted t hspital in a respiratry islatin rm with ntificatin t TB Services. HOME ISOLATION Outpatients may require hme islatin, which includes avidance f wrk and activities invlving cntact with the public until sputum specimens are btained and smear results are available. Hme islatin may be a cnsideratin fr patients wh have a stable, single family residence with n vulnerable husehld members such as immuncmprmised persns r children under five. FACILITY ISOLATION In an institutinal setting the patient shuld be placed in a negative pressure islatin rm. If respiratry islatin is nt available, the patient shuld be in a single rm with the dr clsed until transfer t a facility with a negative pressure rm is pssible. Alchl, drug and tbacc withdrawal prtcls may be cnsidered fr all patients in islatin. Patients shuld be ut f the rm nly fr essential services such as radilgic investigatins and brnchscpy. Apprpriate infectin cntrl measures fr transfer t and frm the rm shuld be bserved. Staff shuld wear a high filtratin respiratr N95 mask when in cntact with a suspect case and the patient shuld wear a surgical mask fr transprt t and frm islatin. Facilities t which the patient is being transferred fr further wrkup shuld be alerted t the suspected diagnsis s that they can use apprpriate precautins. 4 NOTIFICATION TO TB SERVICES Patients living in Edmntn r Calgary shuld be referred immediately t the Edmntn r Calgary Tuberculsis Clinic. If the patient resides utside f Edmntn r Calgary he r she shuld be sent fr urgent chest radigraphy with ntificatin t Alberta Health Services (AHS) TB services and public health. Clinical Practice Guideline Page 5 f 8 Backgrund

6 Diagnsis and Management f Active Tuberculsis Nvember 2011 REFERENCES 1. Wrld Health Organizatin. Glbal tuberculsis reprt WHO Press; Available frm: 2. Public Health Agency f Canada. Tuberculsis in Canada 2012 pre-release. Ottawa: Public Health Agency f Canada; Available frm: 3. Alberta Health and Wellness. Tuberculsis Surveillance Reprt Alberta Available frm: 4. Alberta Health and Wellness. Tuberculsis preventin and cntrl guidelines fr Alberta. Edmntn: Gvernment f Alberta; Available frm: 5. Canadian tuberculsis standards. 7th ed.: Canadian Thracic Sciety, Available frm: 6. Daley CL, Gtway MB, Jasmer RM. Radigraphic manifestatins f tuberculsis: a primer fr clinicians. 2nd ed. San Francisc: Francis J. Curry Natinal Tuberculsis Center; Available frm: 7. Tman K. Tuberculsis case-finding and chemtherapy: questins and answers. Geneva: Wrld Health Organizatin ; Available frm: 8. Kppaka R, Bck N. Hw reliable is chest radigraphy? Tman's tuberculsis: case detectin, treatment, and mnitring: questins and answers. 2nd ed. Geneva: Wrld Health Organizatin; p Menzies D, Pai M, Cmstck G. Meta-analysis: new tests fr the diagnsis f latent tuberculsis infectin: areas f uncertainty and recmmendatins fr research. Ann Intern Med. 2007;146(5): Erratum in: Ann Intern Med. 2007;146(9): Cruciani M, Scarpar C, Malena M, Bsc O, Serpellni G, Mengli C. Meta-analysis f BACTEC MGIT 960 and BACTEC 460 TB, with r withut slid media, fr detectin f mycbacteria. J Clin Micrbil. 2004;42(5): Mase SR, Ramsay A, Ng V, Henry M, Hpewell PC, Cunningham J, et al. Yield f serial sputum specimen examinatins in the diagnsis f pulmnary tuberculsis: a systematic review Int J Tuberc Lung Dis. 2007;11(5): Andersn C, Inhaber N, Menzies D. Cmparisn f sputum inductin with fiber-ptic brnchscpy in the diagnsis f tuberculsis. Am J Respir Crit Care Med. 1995;152(5 Pt 1): Carr DT, Karlsn AG, Stilwell GG. A cmparisn f cultures f induced sputum and gastric washings in the diagnsis f tuberculsis. May Clin Prc. 1967;42(1): Ling DI, Flres LL, Riley LW, Pai M. Cmmercial nucleic-acid amplificatin tests fr diagnsis f pulmnary tuberculsis in respiratry specimens: meta-analysis and meta-regressin. PLS ONE. 2008;3(2):e Grec S, Rulli M, Girardi E, Piersimni C, Saltini C. Diagnstic accuracy f in-huse PCR fr pulmnary tuberculsis in smear-psitive patients: meta-analysis and metaregressin. J Clin Micrbil. 2009;47(3): Clinical Practice Guideline Page 6 f 8 References

7 Diagnsis and Management f Active Tuberculsis Nvember 2011 SUGGESTED CITATION Tward Optimized Practice (TOP) Active Tuberculsis Wrking Grup Nvember. Diagnsis and management f active tuberculsis clinical practice guideline. Edmntn, AB: Tward Optimized Practice. Available frm: Fr mre infrmatin see GUIDELINE COMMITTEE The cmmittee cnsisted f representatives f internal medicine, cmmunity medicine, public health and preventive medicine, infectius disease and nursing. Nvember 2011 Minr revisin May 2014 Clinical Practice Guideline Page 7 f 8 References

8 Diagnsis and Management f Active Tuberculsis Nvember 2011 APPENDIX A These recmmendatins are systematically develped statements t assist practitiner and patient decisins abut apprpriate health care fr specific clinical circumstances. They shuld be used as an adjunct t sund clinical decisin making. Clinical Practice Guideline Page 8 f 8 Appendix A