Clinical Practice Guideline

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1 ITBS LTBI ITBS Management 1 of 6 ITBS Contact ITBS Oversight ITBS Disease Professional Advisory 1.0 PURPOSE: 1.1 Provide clinical practice and operational guidance to Public Health Nurses to ensure consistency in the ordering of chest X-rays (CXR) for the diagnosis and/or management of active tuberculosis (TB) disease and/or latent tuberculosis infection (LTBI) in outpatient/community settings. 2.0 SCOPE and GOAL: 2.1 This practice guideline is applicable for the care of adult outpatient clients in the community with suspected or confirmed active TB disease and/or who are contacts to cases of infectious TB disease being assessed for LTBI. 2.2 This practice guideline will apply primarily (but not exclusively) to adult clients who do not have timely access to a health care provider for assessment/treatment related to suspected or confirmed active TB disease and/or LTBI. 2.3 This practice guideline describes under which clinicians names CXR requisitions should be issued by PPH TB Team Public Health Nurses (PHNs), for adult persons with suspected or confirmed active TB disease and persons identified as contacts to a person with infectious active TB disease. 3.0 DEFINITIONS 3.1 Active TB disease: active clinical disease due to Mycobacterium tuberculosis (MTb) that is usually symptomatic and for which microbiologic tests are usually positive and radiologic tests usually abnormal. 3.2 Contact: a person identified as having been exposed to (MTb) by sharing space with an infectious case of TB. 3.3 Infectious TB: the condition whereby the person can transmit MTb infection to others by virtue of the production of aerosols containing TB bacteria. Persons with smear-positive, cavitary and laryngeal TB disease are usually the most infectious. 3.4 Latent tuberculosis infection (LTBI): the presence of latent or dormant infection with MTb. Persons with LTBI have no evidence of clinically active TB disease, i.e.

2 ITBS LTBI ITBS Management 2 of 6 ITBS Contact ITBS Oversight ITBS Disease Professional Advisory they have no symptoms, no evidence of radiologic changes that suggest active TB disease and negative microbiologic tests; they are not infectious. 3.5 Public Health Nurse: a Public Health Purse (PHN) working with the WRHA Population and Public Health TB team, who collaborates with the client s health care team as a case manager. 3.6 Sputum for AFB: procedure whereby client coughs up lung secretions (sputum) for laboratory evaluation by smear (to visualize acid fast bacilli [AFB] microscopically) and culture (to grow the mycobacteria to confirm MTb and to determine antimicrobial susceptibilities). 3.7 Suspected TB disease: Indicates illness in a client where there is a high index of suspicion of active TB disease and no other diagnosis has been made. 4.0 BACKGROUND 4.1 The CXR combined with a clinical assessment, with the option of including sputum for AFB, will assist in the diagnosis and appropriate treatment of latent TB infection (LTBI) or the possible early detection of active TB disease. 4.2 In the assessment of people who are identified to have been in contact ("Contacts") with person(s) having infectious active TB disease ("Cases"), CXRs and possibly sputum for AFB may be done early in the clinical assessment to identify people who may themselves be suspected or at risk of having active TB disease, and to avoid inadvertently treating a "Case" of TB disease with antimicrobial monotherapy. 4.3 In the interest of the client with active TB disease or who is being assessed for LTBI, timely ordering of CXRs and/or sputum for AFB may be facilitated, on behalf of clinicians, in the community by PHNs; this is especially helpful for more challenging clients who may have difficulty accessing fixed clinic settings. 4.4 For guidance on the ordering of sputum for AFB, please refer to Clinical Practice Guideline Process for Sputum AFB Collection by the WRHA PPH TB Team for Adult Clients in the Winnipeg Health Region. 5.0 PROCEDURE (Cases of Active TB Disease)

3 ITBS LTBI ITBS Management 3 of 6 ITBS Contact ITBS Oversight ITBS Disease Professional Advisory 5.1 Chest X-rays for adult clients being treated for suspected or confirmed active respiratory TB disease: Clients diagnosed with suspected or confirmed active respiratory TB disease will have any required CXRs obtained at the follow-up appointment with the treating clinician If a CXR is not obtained at the follow-up appointment (e.g., the client does not attend the follow-up appointment) the PHN will confirm in advance with the treating clinician whether a CXR should be obtained prior to the clinic appointment If the treating clinician requests a CXR be obtained, the PHN will provide the client with a requisition (the WRHA Request for Diagnostic Imaging Form). The form will bear the name, address, telephone, fax, and number of the treating clinician; and also include the name, address, phone, and fax number of the TB CD Coordinator for the WRHA in the Extra Report to section A clinician s actual signature is NOT required; a designate can sign the requisition on behalf of the clinician. For example: Lea Smith, RN, as ordered by Dr. Martha Ainslie The requisition will indicate the CXR is a Follow-up X-ray to monitor the response to therapy of a client with active respiratory TB disease, and that additional X-ray reports are located at a specific site (e.g., HSC).

4 ITBS LTBI ITBS Management 4 of 6 ITBS Contact ITBS Oversight ITBS Disease Professional Advisory The client will be encouraged to obtain the CXR at the same facility the treating clinician is located, however some clients may only be willing to attend a community X-ray location (e.g., outpatient private lab) other than where the treating clinician works. If this happens, the PHN will write on the requisition "Please send a CD copy of the film to the named clinician". 6.0 PROCEDURE (Contacts to Cases of Infectious TB Disease) 6.1 Chest X-rays for adult contacts: Under most circumstances a CXR can be ordered for an adult contact under the name of a primary care clinician with whom an appointment will be scheduled for LTBI assessment: For asymptomatic clients with a positive TST: a site for Community LTBI assessment and management will be identified based on factors such as client address, convenience of access, and Community LTBI workloads at either LTBI Klinic or Access Downtown HAC LTBI Services; the CXR will be ordered by the PHN in the name of the Medical Director for the appropriate clinic (currently Dr. Michael Dillon for Klinic and Dr. Cynthia Sawatzky for Access Downtown HAC); appropriate clinical information will be included (i.e. comment that client is asymptomatic) and all CXR requisitions will include "Contact of Case of Active Tuberculosis: rule out active TB"; Public Health TB CD Coordinator will send referral package to appropriate LTBI Community Site, including a copy of the CXR requisition that was given to the client; CXR results will be tracked by LTBI Community Site Administrative Teams to ensure reports are directed to appropriate practitioner and/or other clinician depending on the acuity of the report and the clinician(s) most likely to be involved in the clinical care of the client.

5 ITBS LTBI ITBS Management 5 of 6 ITBS Contact ITBS Oversight ITBS Disease Professional Advisory For clients with minimal symptoms suggestive of TB (i.e., pre-existing chronic cough, fatigue), regardless of TST result: a site for Community LTBI assessment and management will be identified based on factors such as client address, convenience of access, and Community LTBI workloads at either LTBI Klinic or Access Downtown HAC LTBI Services; the CXR will be ordered by the PHN in the name of the Medical Director for the appropriate clinic (currently Dr. Michael Dillon for Klinic or Dr. Cynthia Sawatzky for Access Downtown HAC); appropriate clinical information will be included such as details about specific symptoms, and all CXR requisitions will include "Contact of Case of Active Tuberculosis: rule out active TB"; Public Health TB CD Coordinator will send referral package to appropriate LTBI Community Site, including a copy of the CXR requisition that was given to the client; CXR results will be tracked by LTBI Community Site Administrative Teams to ensure reports are directed to appropriate practitioner and/or other clinician depending on the acuity of the report and the clinician(s) most likely to be involved in the clinical care of the client For clients with definitive symptoms of TB disease (such as new onset cough, fever, night sweats, hemoptysis, and/or weight loss), or for clients who are immune compromised: urgent referral should be made to an appropriate TB specialist with or without a CXR; the CXR will normally be ordered by the treating clinician at the first clinic visit; assessment for the need for a CXR prior to the clinic visit can be discussed as needed with the TB specialist and/or the Medical Officer of Health 7.0 RECOMMENDED READING

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