When Can Isolation Be Discontinued?

Transcription

1 When Can Isolation Be Discontinued? - It Depends on the Patient and the Setting. Masae Kawamura M.D. and Barbara Seaworth M.D. Texas: (800) TEX-LUNG New Jersey: ? HNTC Consultation Line California: (415) Florida: (800)-4TB-Info Can This Teacher Return to Work? School starts next week and His MD has cleared him. Science and computer teacher Presented with 10 months of constant cough treated with steroids and inhalers for presumed asthma. U.S. born but had lived for 10 years in South Africa. Returned to U.S. one year ago. Sputum is 4+ smear positive. Has received 10 days of RIPE therapy. 1

2 ER CXR: Chest Pain, Cough and Short of Breath Finally the realization that this is not just reactive airway disease! Cavitary Disease in Communication with Bronchi Although This One Was Easy--- Important Questions to Consider Is he still infectious? If so for how long? Is he at risk for drug resistant TB? Does that change criteria for release? Does he work in a Congregate Setting? Does that influence when he can return to work? 2

3 Release From Isolation When - If no risk of MDR - 3 negative sputum smears One induced 14 days of treatment Clinical improvement California TB Control Guidelines If risk of MDR Molecular test for drug resistance If MDR or mutations 3 negative sputum smears 14 + days of therapy for MDR TB Clinical improvement 2 negative cultures California TB Control Guidelines Molecular Detection of Drug Resistance CDC Report rifampin INH { ethambutol PZA quinolones injectables { 8 When to Release From Isolation- MMWR Controlling TB in U.S If no risk of MDR TB patients who are smear + can be released from isolation (to community) when they have had: Clinical improvement sputum smears which are decreasing or cough improved Appropriate therapy for 2-3 weeks by DOT Contacts identified, evaluated and treated if appropriate» MMWR

4 Patients in a Congregate Setting Patients who remain in hospitals or reside either temporarily or permanently in congregate settings (e.g., shelters and correctional facilities) are subject to different criteria for infectiousness. In such congregate settings, identification and protection of close contacts is not possible during the early phase of treatment. More stringent criteria for determining absence of infectivity (i.e., three consecutive AFB-negative sputum smears) should be followed. MMWR Controlling TB in the US, 2004 Is a School a Congregate Setting? Settings where groups of people meet or gather and share the same space for a period of time They include (but are not limited to) workplaces, shelters, schools, social and recreational settings and places of worship New Jersey Global TB Institute We Know Time to Conversion Median of 17.5 days for smear to become negative Median of 37 days for culture to become negative (drug susceptible) Fitzwater CID 2010 Mean time to culture conversion 34 +/- 26 days Mean time to smear conversion 38 +/- 32 days ~1/3 of those 4+ smear positive converted culture first Fortun JAC

5 How Much Treatment is Needed Before This Patient is not Infectious? No evidence that smear negative but culture positive patients on therapy do not transmit. BUT - no outbreak associated with patient on treatment > 1 day has been documented. Multiple studies of home based therapy do not show transmission once treatment is started even when smears remain positive (Madras study) Extensive Cavitary Disease Direct Communication of Cavity and Bronchus Patient was susceptible to all drugs. Isolation continued until sputum smears were negative x 3. Patient took > 2 months to convert smear. Despite isolation extensive transmission had already occurred More than 10 active cases all matched by genotype News media event Visiting football team brought its own water 5

6 -TB TB- The Gift That Keeps on Giving! 6