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/HPSC4 Laboratory Diagnosis of Tuberculosis4.1 It is a mandatory requirement for clinical directors of diagnostic laboratories to notify cases of activeTB disease to the MOH (director of public health (DPH) or designate) (section 4.1).4.2 Culture is necessary to achieve the “gold standard” for the diagnosis of active TB disease (section4.1).4.3 Microscopy and culture for TB should only be performed in those laboratories where there issufficient throughput to ensure proficiency (section 4.1).4.4 Laboratories should aim to meet the “goals” set down by CDC and others (section 4.1).4.5 All mycobacterial isolates should be referred to the Irish Mycobacteria Reference Laboratory (IMRL)for identification and susceptibility testing once its new facility is opened (section 4.1).4.6 All M. tuberculosis complex isolates should be referred to the IMRL with immediate effect formolecular typing where typing is now offered. (section 4.1).4.7 The results of all M. tuberculosis complex isolates which have already had identification,susceptibility and molecular typing performed should be forwarded to the IMRL for incorporationinto a national repository of M. tuberculosis complex isolates (section 4.1).4.8 Reasonable efforts should be made to obtain the best quality sample possible depending on thesite of disease and to deliver it in a timely fashion to the analysing laboratory (section 4.2).4.9 It is recommended that solid media is used in combination with a liquid culture system (section 4.3).4.10 All those wishing to undertake nucleic acid amplification tests (NAAT) on suspected cases ofpulmonary TB should seek advice from the local consultant microbiologist. It is recommended thatNAAT should be made available at the IMRL (section 4.3).4.11 Recommendations in the Seventh Schedule of S.I. 146/1994 Safety, Health and Welfare at Work(Biological Agents) Regulations 1994 should be interpreted as mandatory in relation to working withM. tuberculosis complex (section 4.7).4.12 All relevant legislation (national and international) for the transport and handling of specimens andcultures for TB should be strictly adhered to at all times (section 4.7).4.13 Laboratories should participate in internal and external quality assurance schemes for all testsperformed (section 4.8).5 Clinical Management5.1 All persons with an otherwise unexplained productive cough lasting three or more weeks with atleast one additional symptom, including fever, night sweats, weight loss or haemoptysis should beevaluated for TB. This will include clinical, radiological and bacteriological examinations (section5.1).5.2 All cases of suspected active TB should be referred to a TB clinic and have a clinical assessmentat the next available clinic. If immediate evaluation is required, consult with the clinical teamregarding the need for more urgent clinical assessment. The management of suspect TB cases canbe undertaken in collaboration with the clinical team (respiratory or infectious diseases) who willadvise on sputa collection and the clinical management (including commencement of therapy, if thesputa are positive for acid-fast bacillus (AFB)), until the next clinic appointment (section 5.1).5.3 Treatment of TB should be directed by a consultant respiratory physician/consultant in infectiousdiseases with appropriate training in the management and treatment of TB (section 5.2).-xi-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC5.4 There should be active case management with a dedicated case manager or health careprofessional who liaises with and follows the patient during the entire treatment course to monitorand enhance adherence (section 5.3).5.5 More widespread establishment of combined clinics attended by both respiratory physiciansand public health doctors for the diagnosis and treatment of TB (and LTBI) and the evaluationof contacts is recommended. Such clinics should be appropriately staffed with medical, nursing,pharmacy, administrative staff and medically qualified interpreters and should be integrated withthe hospital system (section 5.3).5.6 Isoniazid and rifampicin, with pyrazinamide and ethambutol for the initial two months (intensivephase), followed by isoniazid and rifampicin for a further four months (continuation phase)is recommended in patients with sensitive strains of tuberculosis and where there are nocontraindications (section 5.4).5.7 Six months of chemotherapy is usually adequate for the treatment of active disease caused bysensitive strains. However, it should be extended to nine months for the following patients:5.7.1 Patients with drug-susceptible pulmonary TB with initial cavitation on chest X-ray andwhose sputum cultures remain positive after the intensive phase ( i.e. the first two monthsof treatment)5.7.2 Other patients who are still culture positive at two months regardless of chest X-ray results5.7.3 Patients whose treatment regimen did not include pyrazinamide in the intensive phase orwhose organism is resistant to pyrazinamide5.7.4 Patients being treated with once weekly isoniazid and rifampicin whose sputum cultureremains positive after the two month intensive phase of treatment (section 5.4).5.8 Follow-up sputum specimens for smear and culture should be obtained monthly in patients withdrug-susceptible pulmonary disease. Requests for more frequent testing should only be undertakenfollowing discussion between the treating physician and consultant microbiologist. For patients withisoniazid- and rifampicin-susceptible TB there is no need to examine sputum monthly once cultureconversion is documented (i.e. two negative cultures taken at least two to four weeks apart). It isrecommended that identification and sensitivities are repeated in cases who are still culture positiveat ≥ two months (section 5.4).5.9 To enhance compliance and to minimise potential problems from the development of drugresistance, it is strongly recommended that only combination tablets should be used wheneverpossible (section 5.4).5.10 It is recommended that the supraregional TB centre at St James’s Hospital and a number of regionalcentres should have a small number of non-acute beds available to facilitate the inpatient care ofpatients who are non-compliant or have drug-resistant TB (section 5.5).5.11 Prioritising the establishment of a structured national DOT programme is recommended for moreeffective management and control of TB (section 5.6).6 Infection Prevention and Control6.1 Patients with known or suspected pulmonary or laryngeal TB should be admitted to an airborneisolation room (negative pressure isolation room with an ante room or a neutral pressure design asoutlined in HBN 04 supplement 1). Hospitals need to have a risk assessment process to ensure theappropriate provision of isolation facilities (section 6.5).-xii-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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