Management of Patients with TB Infection Catalina Navarro, RN, BSN April 7, 2015 Tuberculosis Infection Diagnosis and Treatment April 7, 2015 El Paso, TX EXCELLENCE EXPERTISE INNOVATION Catalina Navarro, RN, BSN has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
Management of Patients with TB Infection Catalina Navarro RN, BSN April 7, 2015 Tuberculosis Infection Diagnosis and Treatment El Paso, TX April 7, 2015 EXCELLENCE EXPERTISE INNOVATION Why is TBI treated? To prevent people from developing TB Disease Interrupt transmission of disease The next step that must be taken to move toward TB elimination in the US Evidence that this works? 1953: 52.6 cases/100,000 US Population 2013: 3.0 cases/100,000 US Population 2
Case Study: TBI in a Homeless Man A 45-year old man referred to the local HD clinic from a homeless shelter Protocol required evaluation for TB Infection (TBI) and/or TB disease. Patient reported staying at four different shelters and with a friend during the past year. Patient has had repeated TST s in the past and is always positive, but was never treated. Patient not allowed to stay unless he shows evidence that he does not have TB disease. 3
Born in the U.S. Patient Medical/Social History History of psychiatric illness currently taking psych medication No steady job for years Denied other chronic illnesses Denied substance abuse Middle aged man with average weight; no abnormal findings What should the clinic do with this man who was referred for clearance to stay at the shelter? A. Explain the purpose of TB screening and the importance of preventing TB disease B. Inquire about signs and symptoms of TB C. Place a TST (since no documentation exists for previous TSTs) then collect locating information for the patient in the event he does not return for the TST reading, OR draw blood for Interferon Gamma Release Assay (QFT-G or TSPOT) as a replacement for the TST D. All of the above 0% 0% 0% 0% A. B. C. D. 4
Answer D all of the above a) Ask about clinical s/sx of TB to assess the possibility of TB disease and need for further diagnostic evaluation b) If documentation of his previous TST result not available, proceed with placement of a TST at this time c) Can Use IGRA as a replacement for a TST. IGRA is preferred for testing persons from groups that historically have low rates of returning to have TSTs read d) Important to collect information on how to contact the patient for follow-up. Get a physical location where he may be found or a telephone number where message could be left, etc. A TST was placed Follow- Up TST reaction : 15mm induration No records of a previous TST or Chest x-ray(cxr)had been found. The patient reported his last CXR was about seven months ago and it was just fine 5
What should be done for the patient at this point? A. Delay ordering a CXR because he already had one in the last year B. Explain the risk of exposure to TB in congregate settings and the importance of continued cooperation in his diagnostic evaluation; send patient for a current CXR C. Prescribe a one-month supply of LTBI medication D. Recommend against any further follow-up once you ascertain that he does not have TB disease; LTBI treatment in homeless is rarely successful 0% 0% 0% 0% A. B. C. D. B Send for a current CXR and explain the risk of exposure to TB in congregate settings and the importance of continued cooperation in his diagnostic evaluation. a) He is at risk of loss to follow-up. Education helps build trust and ensure follow-up and future treatment adherence Answer 6
Follow-Up Patient returned to the clinic and expressed a willingness to take the standard treatment, no matter how long it takes. He wants to administer the medication himself and declines directly observed therapy (DOT). His CXR was read as normal. What Should the Clinic NOT Do? A. Identify potential barriers to treatment adherence and discuss adherence strategies B. Inquire about alcohol and other drug use and talk him out of LTBI treatment If he uses either C. Check with the health departments rules for reporting TST results and LTBI treatment in homeless patients D. Offer HIV counseling and testing 0% 0% 0% 0% A. B. C. D. 7
Answer B Inquire about alcohol and other drug use and talk him out of LTBI treatment If he uses either a) HCW should encourage patients to quit alcohol and find resources or institutions to enroll those who needs help. Follow - Up The patient did not keep his second scheduled follow-up appointment. Six months later the patient presented to the same clinic and stated he had stopped taking INH about 4-5 months ago because of stomach pain 8
What should the clinic do for this patient who has interrupted his anti-tb Medications? A. Count the first two months as completed and restart INH treatment where he left off B. Do not restart treatment, as this patient is unreliable C. Consider re-starting treatment, but the patient will need to begin as if starting over which will include a symptom screen, baseline LFT s and repeat CXR D. Warn the patient that erratic INH treatment could cause INH-resistant TB disease and admonish him to be more responsible 0% 0% 0% 0% A. B. C. D. Answer C - Consider re-starting treatment, but the patient will need to begin as if starting over which will include a symptom screen, baseline LFT s and a repeat CXR. a) A 9 month course (270) doses of INH treatment must be completed within 12 months of initiating therapy. Thus, after five months of treatment interruption, LTBI patients are advised to begin a new 9 month treatment regimen. The patient should be thoroughly counseled that treatment must be restarted, and not just continued from the point he was lost to follow up. b) He should not begin LTBI treatment until TB disease and hepatotoxicity have been ruled out again. 9
Follow-up After 9 months Patient kept his clinic appointments No hepatotoxicity. His follow-up appointments were uneventful Some doses missed Treatment lasted nine months, but dose counts tallied indicated he completed 235 out of 270 doses of INH What is the next step for this patient? A. Congratulate him on completing nine months of treatment and do not mention the incomplete doses, they are not important B. Tell the patient he has missed too many doses and must start treatment over C. Tell the patient that unfortunately his erratic treatment has put him at risk for developing INH resistant active TB D. Give patient a prescription for a one month supply of daily INH and vitamin B6 0% 0% 0% 0% A. B. C. D. 10
Answer D Give patient a prescription for a one-month supply of daily INH and vitamin B6 a) Although the patient has completed nine months of INH treatment, he has taken 235 out of a planned 270 doses of INH. b) Encourage the patient to complete the 270 doses within 12 months allowed for completion, therapy should be continued. If not, treatment can be stopped at this time Follow-up The patient returned for his final follow up appointment after he successfully completed the full course (270 doses) of INH treatment for LTBI 11
What should be done to finish out management and care of this patient? A. Give the patient a letter or card documenting completion of LTBI treatment B. Instruct patient of potential signs and symptoms of TB disease because he is at particular risk for INH-resistant TB disease and give him information on where to go if he does have signs and symptoms C. Order a follow-up chest X-ray D. Instruct the patient that he is allergic to TST and he should never have one again 0% 0% 0% 0% A. B. C. D. Answer A - Give patient a letter or card documenting completion of LTBI treatment a) He will be screened and evaluated for TB in the future. He should understand that he will likely always have a positive TST, so he does not need to undergo repeat TST testing b) A laminated completion card would be ideal for this patient, 12
Eight Reasons for Non-Adherence to Treatment Patients no feel sick Lack of knowledge Personal or cultural beliefs Lack skills Lack of access to health care Reasons for Non-Adherence to Treatment Language barrier Poor relationships with health care workers. Lack of motivation 13
TBI Treatment Options INH x 9 months 300mg daily (270 doses) Rifampin x 4 months 600mg daily (120 doses) INH/Rifapentine x 3 months Once weekly DOTx12weeks (12 doses) Peripheral Neuropathy and Hepatotoxicity Tingling Numbness Rash Abdominal pain Nausea 14
All Medications Have Side Effects Most TB patients complete their treatment without any significant adverse drug effects Risk/Benefit ratio of medication used Explain beneficial effects of medications and possible side effects/adverse events The benefits provided by the medicine worth the risk Purpose of Monitoring Patient Recognize adverse drug events Assess appropriately Intervene rapidly Prevent further morbidity/mortality Minimize treatment interruptions Reduce opportunities for medical mismanagement Avoid development of psychological intolerance Support adherence and the therapeutic relationship 15
Baseline Medical Evaluation R/O active TB Determine if prior TB treatment or TBI treatment Determine co-existing medical conditions Obtain current and previous drug therapy Recommend HIV testing 16
Baseline Lab Testing It s NOT routinely indicated but indicated for: Patients with HIV Pregnant patients or immediate post partum Patients with history of liver disease Monthly Evaluations Why? Adherence to treatment Signs and symptoms of TB disease Adverse effects 17
Strategies The best strategies to improve adherence : Individualized education, mentoring and support from a trusted source and Replace lengthy regimen with one of shorter duration...sharing experiences DOT Another Strategy Should be considered: for children of all ages For persons who are at especially high risk for TB disease (HIV) and are either suspected of no adherence or are given an intermittent dosing regimen 18
Sticker Chart! Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 March 2015 Identifying Missed Opportunities For Preventing TB 21 patients with TB most of them had: Medical risk factors for LTBI Population risk factors LTBI Many of them were under medical care for years prior TB diagnosis Poster Abstract NTCA Workshop 19
21 patients 18 missed opportunities 9 6 3 Results Failure to TST when TB risk factor were present Not starting treatment for LTBI Not completed prescribed regimen 8 Foreign-born (excluded for analysis) ALL developed TB within 12 months (4 within 1 month) 2 Inadequate treatment prior entry 3 No TB exam prior entry 2 normal Chest X-ray prior entry 1 Classified as B2 How to Find The missed Better screening of people attending health facilities Engaging private providers TB testing and TBI treatment should received higher priority Educate other facilities like jails, homeless shelter, nursing homes and help in planning and implementing programs 20
21