Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC• Living with children < five years of age who have not been evaluated by a public health physicianfor window period prophylaxis for LTBI• Settings where the patient or a family member requires care from HCWs (home helps, nursingstaff) for several hours a day7. Completed at least two weeks of standard multi drug anti-TB treatment8. Three consecutive sputum AFB negative samples taken at least 24 hours apart with at least oneearly morning specimen (if patient cannot produce sputum i.e. non-productive cough discuss withclinical, public health and infection prevention and control teams). 77MDR-TB suspected or confirmedPatients who are confirmed or suspected with infectious MDR-TB should not be discharged home in mostsituations unless the following criteria (1-7) are met:1. Clinical symptoms are improving2. Current treatment with anti-TB regimen to which the strain is known or likely to be susceptible3. Three consecutive sputum AFB negative samples taken at least 24 hours apart with at least onesample an early morning specimen (if patient cannot produce sputum i.e. no productive cough,discuss with clinical and infection prevention and control teams)4. Can be discharged to a stable residence at a verified address5. Is willing and able to observe risk reduction activities e.g. respiratory hygiene, cough etiquetteand follow discharge instructions (see appendix 11)6. Willing and able to follow up with DOT (see appendix 9)7. Arrangements are in place for outpatient clinic review.These patients should not be discharged to the following situations unless they fulfil criterion 8 belowin addition to criteria 1-7 above:• Congregate setting (hostel, nursing or care home, prison, etc.)• Living with immunosuppressed individuals• Living with children < five years of age who have not been evaluated by a public health physicianfor window period prophylaxis for LTBI• Settings where the patient or a family member requires care from health care workers (homehelp, nursing staff) for several hours a day 778. Three consecutive sputum samples are smear and culture negative after six weeks incubation.If patient cannot produce sputum i.e. does not have a productive cough, discuss with clinical,public health and infection prevention and control teams 30-85-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCFigure 6.2: Criteria for discharging patients with suspected or confirmed infectious TB from a hospitalTreatment with anti-TBregime commenced to whichorganisms are known or likelyto be susceptibleYesAssess if patient can be treated as outpatientYesPatient is medically and mentallystable, has clinically improved(even if sputum AFB positive)and is ready for dischargeNoContinueinpatient careDoes the patient meet ALL of the following8 criteria?1. Can be discharged to a stable residenceat a verified address2. Will NOT be discharged to a congregatesetting such as a shelter, nursing home,hostel, prison, etc3. Will not have significant contact or livewith immunosuppressed* individuals4. Patient or a family member in the homewill not need attendant or visiting nursingservices for several hours a day5. Is willing and able to observe riskreduction activities e.g. respiratoryhygiene, cough etiquette and followdischarge plan (see appendix 11)6. Willing and able to follow up with DOT ifnecessary7. If there are children < five years at homea plan for evaluation by public healthdepartment must be in place for windowprophylaxis for LTBI8. MDR-TB not suspected or confirmedYesEducate patient aboutdischarge plan and outpatienttreatmentSee appendix 11 fordischarge instructionsEnsure that1. OPD appointment ismade2. DOT referral form (seeappendix 9) is sent topublic health nursingdepartment if required3. Discharge letter to GP iscompletedDischarge from hospitalSee section 6.7 for discharge criteria for patientsnot meeting 1-8 aboveAdapted with kind permission from Tuberculosis, Clinical Policies and Protocols. New York City Department of Health and MentalHygiene (2008). Available from www.nyc.gov/html/doh/downloads/pdf/tb/tb-protocol.pdf.6.8 EducationHealthcare workersThere should be an ongoing education programme for HCWs that includes the following:• Signs and symptoms of TB• Definition of infectious TB• Local guidelines and protocols for the management of TB• Local incidence of TB• Management of dual action, negative pressure ventilated rooms or neutral pressure designrooms*Immunosuppressed is defined as either due to disease or therapies e.g. HIV, individuals receiving >15mg prednisone or equivalentfor more than four week or other immunosuppressive agents for cancer, chemotherapeutic agents, anti-rejection drugs for organtransplantation and TNF-α antagonists or as defined by the attending consultant.-86-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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