<str<strong>on</strong>g>Guidel<strong>in</strong>es</str<strong>on</strong>g> <strong>on</strong> <strong>the</strong> Preventi<strong>on</strong> <strong>and</strong> C<strong>on</strong>trol <strong>of</strong> <strong>Tuberculosis</strong> <strong>in</strong> Irel<strong>and</strong> 2010HSE/HPSCAppendix 7: C<strong>on</strong>tact details for cl<strong>in</strong>ical <strong>and</strong> laboratory TB adviceRespiratory PhysiciansDr Tim McD<strong>on</strong>nell, St V<strong>in</strong>cent’s University Hospital, Dubl<strong>in</strong>Dr Brendan Keogh, Mater Misericordiae Hospital, Dubl<strong>in</strong>Dr Terry O C<strong>on</strong>nor, Mercy University Hospital, CorkDr JJ Gilmart<strong>in</strong>, University College Hospital, GalwayInfectious disease PhysiciansDr C. Flem<strong>in</strong>g, University College Hospital, GalwayDr Kar<strong>in</strong>a Butler, Our Lady’s Hospital, Cruml<strong>in</strong>, Dubl<strong>in</strong>C<strong>on</strong>sultant MicrobiologistsDr Margaret Hannan, Mater Misericordiae Hospital, Dubl<strong>in</strong>Dr Bartley Cryan, Cork University HospitalIrish Mycobacteria Reference LaboratoryMr Noel Gibb<strong>on</strong>s, Chief Medical Scientist, (01) 416 2963, ngibb<strong>on</strong>s@stjames.iePr<strong>of</strong> T Rogers, Cl<strong>in</strong>ical Director, (01) 896 2131, rodgerstr@tcd.ieDr J Keane, C<strong>on</strong>sultant Respiratory Physician, (01) 410 3920, jkeane@stjames.ieWebpage: www.stjames.ie/Departments/DepartmentsA-Z/I/IMRL/DepartmentOverview/or go to www.stjames.ie choose Lab services <strong>and</strong> <strong>the</strong>n Irish Mycobacteria Reference LaboratoryAntimicrobial Reference Laboratory,Department <strong>of</strong> Medical Microbiology,North Bristol NHS Trust,Southmead Hospital,Bristol BS10 5NB,United K<strong>in</strong>gdomThe Antimicrobial Reference Laboratory user manual may be found at www.bris.ac.uk/bcare/AssayBooklet.docResults <strong>and</strong> general <strong>in</strong>quiries: Tel. No: 00-44-117-959-5653Service EnquiriesPr<strong>of</strong> A. P. MacGowan, C<strong>on</strong>sultant Medical Microbiologist. C<strong>on</strong>tact teleph<strong>on</strong>e no: 0044- 117-959-5652Email address: alasdair.macgowan@nbt.nhs.ukDr. A. M. Lover<strong>in</strong>g, C<strong>on</strong>sultant Cl<strong>in</strong>ical Scientist. C<strong>on</strong>tact teleph<strong>on</strong>e no: 0044-117-959 5653Email address: <strong>and</strong>rew.lover<strong>in</strong>g@nbt.nhs.ukMr. H. A. Holt, Laboratory Manager. C<strong>on</strong>tact teleph<strong>on</strong>e no: 0044-117-959-5658Email address: alan.holt@nbt.nhs.uk-167-
<str<strong>on</strong>g>Guidel<strong>in</strong>es</str<strong>on</strong>g> <strong>on</strong> <strong>the</strong> Preventi<strong>on</strong> <strong>and</strong> C<strong>on</strong>trol <strong>of</strong> <strong>Tuberculosis</strong> <strong>in</strong> Irel<strong>and</strong> 2010HSE/HPSCAppendix 8: Internati<strong>on</strong>al St<strong>and</strong>ards for <strong>Tuberculosis</strong> CareIn 2006 <strong>the</strong> “Internati<strong>on</strong>al St<strong>and</strong>ards for <strong>Tuberculosis</strong> Care” were published to describe a widely acceptedlevel <strong>of</strong> care that all practiti<strong>on</strong>ers, public <strong>and</strong> private should seek to achieve <strong>in</strong> manag<strong>in</strong>g patients who haveor are suspected <strong>of</strong> hav<strong>in</strong>g tuberculosis. The st<strong>and</strong>ards are outl<strong>in</strong>ed below. The full document is available atwww.who.<strong>in</strong>t/tb/publicati<strong>on</strong>s/2006/istc_report.pdf.St<strong>and</strong>ards for DiagnosisSt<strong>and</strong>ard 1. All pers<strong>on</strong>s with o<strong>the</strong>rwise unexpla<strong>in</strong>ed productive cough last<strong>in</strong>g two to three weeks or moreshould be evaluated for tuberculosis.St<strong>and</strong>ard 2. All patients (adults, adolescents, <strong>and</strong> children who are capable <strong>of</strong> produc<strong>in</strong>g sputum)suspected <strong>of</strong> hav<strong>in</strong>g pulm<strong>on</strong>ary tuberculosis should have at least two <strong>and</strong> preferably three, sputumspecimens obta<strong>in</strong>ed for microscopic exam<strong>in</strong>ati<strong>on</strong>. When possible, at least <strong>on</strong>e early morn<strong>in</strong>g specimenshould be obta<strong>in</strong>ed.St<strong>and</strong>ard 3. For all patients (adults, adolescents, <strong>and</strong> children) suspected <strong>of</strong> hav<strong>in</strong>g extrapulm<strong>on</strong>arytuberculosis, appropriate specimens from <strong>the</strong> suspected sites <strong>of</strong> <strong>in</strong>volvement should be obta<strong>in</strong>ed formicroscopy <strong>and</strong>, where facilities <strong>and</strong> resources are available, for culture <strong>and</strong> histopathological exam<strong>in</strong>ati<strong>on</strong>.St<strong>and</strong>ard 4. All pers<strong>on</strong>s with chest radiographic f<strong>in</strong>d<strong>in</strong>gs suggestive <strong>of</strong> tuberculosis should have sputumspecimens submitted for microbiological exam<strong>in</strong>ati<strong>on</strong>.St<strong>and</strong>ard 5. The diagnosis <strong>of</strong> sputum smear-negative pulm<strong>on</strong>ary tuberculosis should be based <strong>on</strong> <strong>the</strong>follow<strong>in</strong>g criteria: at least three negative sputum smears (<strong>in</strong>clud<strong>in</strong>g at least <strong>on</strong>e early morn<strong>in</strong>g specimen),chest radiography f<strong>in</strong>d<strong>in</strong>gs c<strong>on</strong>sistent with tuberculosis <strong>and</strong> lack <strong>of</strong> resp<strong>on</strong>se to a trial <strong>of</strong> broad spectrumantimicrobial agents. (Note: Because <strong>the</strong> fluoroqu<strong>in</strong>ol<strong>on</strong>es are active aga<strong>in</strong>st M. tuberculosis complex <strong>and</strong>thus may cause transient improvement <strong>in</strong> pers<strong>on</strong>s with tuberculosis, <strong>the</strong>y should be avoided.) For suchpatients, if facilities for culture are available, sputum cultures should be obta<strong>in</strong>ed. In pers<strong>on</strong>s with known orsuspected HIV <strong>in</strong>fecti<strong>on</strong>, <strong>the</strong> diagnostic evaluati<strong>on</strong> should be expedited.St<strong>and</strong>ards for TreatmentSt<strong>and</strong>ard 6. The diagnosis <strong>of</strong> <strong>in</strong>trathoracic (i.e. pulm<strong>on</strong>ary, pleural, <strong>and</strong> mediast<strong>in</strong>al orhilar lymph node) tuberculosis <strong>in</strong> symptomatic children with negative sputum smears should be based <strong>on</strong><strong>the</strong> f<strong>in</strong>d<strong>in</strong>g <strong>of</strong> chest radiographic abnormalities c<strong>on</strong>sistent with tuberculosis <strong>and</strong> ei<strong>the</strong>r a history <strong>of</strong> exposureto an <strong>in</strong>fectious case or evidence <strong>of</strong> tuberculosis <strong>in</strong>fecti<strong>on</strong> (positive TST or <strong>in</strong>terfer<strong>on</strong> gamma releaseassay). For such patients, if facilities for culture are available, sputum specimens should be obta<strong>in</strong>ed (byexpectorati<strong>on</strong>, gastric wash<strong>in</strong>gs, or <strong>in</strong>duced sputum) for culture.St<strong>and</strong>ard 7. Any practiti<strong>on</strong>er treat<strong>in</strong>g a patient for tuberculosis is assum<strong>in</strong>g an importantpublic health resp<strong>on</strong>sibility. To fulfill this resp<strong>on</strong>sibility <strong>the</strong> practiti<strong>on</strong>er must not <strong>on</strong>ly prescribe anappropriate regimen but, also, be capable <strong>of</strong> assess<strong>in</strong>g <strong>the</strong> adherence <strong>of</strong> <strong>the</strong> patient to <strong>the</strong> regimen <strong>and</strong>address<strong>in</strong>g poor adherence when it occurs. By so do<strong>in</strong>g, <strong>the</strong> provider will be able to ensure adherence to<strong>the</strong> regimen until treatment is completed.St<strong>and</strong>ard 8. All patients (<strong>in</strong>clud<strong>in</strong>g those with HIV <strong>in</strong>fecti<strong>on</strong>) who have not been treatedpreviously should receive an <strong>in</strong>ternati<strong>on</strong>ally accepted first-l<strong>in</strong>e treatment regimen us<strong>in</strong>g drugs <strong>of</strong> knownbioavailability. The <strong>in</strong>itial phase should c<strong>on</strong>sist <strong>of</strong> two m<strong>on</strong>ths <strong>of</strong> is<strong>on</strong>iazid, rifampic<strong>in</strong>, pyraz<strong>in</strong>amide, <strong>and</strong>ethambutol. The preferred c<strong>on</strong>t<strong>in</strong>uati<strong>on</strong> phase c<strong>on</strong>sists <strong>of</strong> is<strong>on</strong>iazid <strong>and</strong> rifampic<strong>in</strong> given for four m<strong>on</strong>ths.Is<strong>on</strong>iazid <strong>and</strong> ethambutol given for six m<strong>on</strong>ths is an alternative c<strong>on</strong>t<strong>in</strong>uati<strong>on</strong> phase regimen that may beused when adherence cannot be assessed, but it is associated with a higher rate <strong>of</strong> failure <strong>and</strong>-168-
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