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• Young children are at a higher risk of progression to TB disease and• The paediatric population has more years to potentially develop TB disease.The Pediatric Tuberculosis Collaborative Group also recommended:• TB disease should be excluded by chest X-ray and examination before initiating treatment for LTBI• That the regimen for treatment of LTBI in children and adolescents should be isoniazid either dailyor twice weekly for nine months and• That if the source case is isoniazid resistant, rifampicin should be used daily for six months.The collaborative group recommendations were based on clinical trials, which showed that treatmentof LTBI in children with isoniazid therapy reduces the risk of progression to active disease. 34 The onlypublished efficacy trials of treatment of LTBI in children are for isoniazid alone with a recommendedregimen for treatment of LTBI in HIV non-infected children of a nine month course of isoniazid daily ortwice weekly by DOT.Based on a review of the evidence and guidance in the international literature and by consensus of theNational TB Advisory Committee, the following are recommended treatment regimens for LTBI in children:Recommendation:The recommended treatment regimens for LTBI in children are:(i) Isoniazid for a minimum of six months with an optimum duration of nine monthsor(ii) Rifampicin for six monthsor(iii) A combination of rifampicin and isoniazid for a duration of four months.Physicians experienced in the management of children with LTBI should supervise treatment.3.5 Treatment of Multidrug-Resistant or XDR LTBIA source case can be sputum smear positive for MDR-TB or XDR-TB and therefore contacts have to bemanaged in the appropriate manner. The WHO recommends that close contacts of MDR-TB or XDR-TB patients should receive careful clinical follow-up for a period of at least two years. If active diseasedevelops, prompt initiation of treatment with a regimen designed to treat MDR-TB or XDR-TB isrecommended. On the basis of currently available evidence, WHO does not recommend the universal useof second-line drugs for chemoprophylaxis in MDR-TB or XDR-TB contacts. 107 It is also recommended thatthe management and follow-up of contacts aged
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC3.6 Pre-treatment EvaluationThe pre-treatment evaluation (figure 3.1) of persons who are targeted for treatment of LTBI provides anopportunity for healthcare providers to:• Establish a rapport with the patient• Discuss details of the patient’s risk of TB• Emphasise the benefits of treatment and the importance of adherence to the drug regimen• Review possible adverse effects of the regimen, including interactions with other drugs, and• Establish an optimal follow up plan.The evaluation should include an interview conducted in the patient’s primary language with the assistanceof qualified medical interpreters, if necessary.The patient history should document:• Risk factors for TB• Prior treatment for TB or LTBI• Pre-existing medical conditions that may be contraindications to treatment or are associated withan increased risk for adverse effects from treatment and• Current and previous drug therapy, with particular attention to previous adverse reactions to drugsand to current drugs which may interact with LTBI treatment e.g.o Isoniazid: interacts with antacids (decrease absorption of isoniazid)o Phenytoin and carbamezapine (isoniazid decreases metabolism of these drugs henceleading to increased blood levels); and corticosteroids (concentration of isoniazid possiblyreduced by corticosteroids)o Rifampicin: causes reduced levels of many drugs including warfarin, methadone, oralcontraceptive pill, oral hypoglycaemic agents, theophylline, ketoconazole, dapsone, PIsand NNRTIs) (figure 3.1). 77Recommendation:Clinicians may choose to undertake baseline liver function tests (LFTs) for all patients agedover 14 years at the start of treatment for LTBI. However, this is not universally obligatory.However, baseline LFTs should be done on the following persons prior to commencing therapy for LTBI:1. Everyone over the age of 35 years2. All HIV-infected persons3. Pregnant or post-partum women (up to 2-3 months postpartum)4. Those with a history of hepatitis, liver disease or heavy alcohol ingestion5. Injecting drug users6. Those on treatment with other potential hepatotoxic agents.All patients prescribed a rifampicin-containing regime should have a baseline full blood count andplatelets. 52;77Patients with baseline transaminases of more than three times the upper limit of normal (ULN) ‡ ‡ 2should have the ALT and bilirubin retested. Screening for viral or other causes of hepatitis including alcoholand hepatotoxic drugs should also be undertaken. In this situation, the decision to treat LTBI or more likelyto defer treatment should be carefully made on a case-by-case basis weighing the risk of progression to TBdisease against the risk of isoniazid or rifampicin drug induced liver injury (DILI). Factors influencing the risk2 ‡ ‡ The upper limit of normal (ULN) used should be that of the laboratory performing the assay.-34-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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