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/HPSCAll patients (adults, adolescents and children who are capable of producing sputum) suspected of havingpulmonary TB should ideally have three sputum specimens obtained for microscopic examination. Whenpossible at least one early morning specimen should be obtained. 25 The recommendations in chapter 4 onlaboratory diagnosis should be implemented in this regard.A sputum smear positive patient has a minimum of one sputum specimen positive for AFB by microscopy. 24The diagnosis of sputum smear negative pulmonary TB should be based on the following criteria:• At least three negative sputum smears (including at least one early morning specimen)• Chest X-ray findings consistent with TB and• Lack of response to a trial of broad-spectrum antimicrobial agents. 25As fluoroquinolones are active against M. tuberculosis complex and thus cause transient improvement inpersons with TB, they should be avoided. For such patients, if facilities for culture are available, sputumcultures should be obtained. In persons with known or suspected HIV infection, the diagnostic evaluationshould be expedited. 25An assessment of the likelihood of drug resistance based on history of prior treatment, exposure to apossible source case having drug-resistant organisms and the community prevalence of drug resistanceshould be obtained from all patients.In an era of increasing drug resistance every effort should be made to obtain bacteriological diagnosis inorder to obtain drug susceptibility data. This is also critical for obtaining molecular typing data essentialfor contact tracing and TB control programmes. For patients in whom drug resistance is considered tobe likely, culture and drug susceptibility testing for isoniazid, rifampicin, ethambutol, pyrazinamide andstreptomycin should be performed promptly. 25Where extrapulmonary TB is suspected, specimens from the suspected sites of involvement shouldbe obtained for microscopy, culture and histology. 25 The NICE guidelines suggest various site-specificinvestigations for the diagnosis of extrapulmonary TB (see table 5.1). 26CDC now recommends that NAAT should be performed on at least one respiratory specimen from eachpatient with signs and symptoms of pulmonary TB for whom a diagnosis of TB is being considered buthas not yet been established and for whom the test result would alter case management or TB controlactivities such as contact tracing. 158 All those wishing to undertake NAAT on suspected cases of pulmonaryTB should seek advice from the local consultant microbiologist (see chapter 4 on laboratory diagnosisof TB).-61-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCTable 5.1: Suggested site-specific investigations in the diagnosis of extrapulmonary TB 26Site Imaging Biopsy CultureLymph node Node Node or aspirateBone/jointPlain X-ray and CT scanMRISite of diseaseBiopsy or para-spinalabscessSite or joint fluidGastrointestinalUltrasoundCT abdomenOmentumBowelBiopsyAscitesGenitourinaryIntravenous urographyUltrasoundSite of diseaseEarly morning urineSite of diseaseEndometrial curettingsDisseminatedCT thoraxUltrasound abdomenLungLiverBone marrowBronchial washLiverBone marrowBloodCNSCT scanMRITuberculomaCerebrospinal fluid (CSF)Skin Site of disease Site of diseasePericardium Echocardiogram/MRI Pericardium Pericardial fluidCold/liverabscessUltrasound Site of disease Site of diseaseReproduced with kind permission from Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for itsControl. National Institute for Health and Clinical Excellence (2005) London: Available at www.nice.org.uk/CG33.ChildrenThe diagnosis of TB in children can be difficult because of non-specific symptoms and infrequentisolation of the organism. WHO recommends that diagnosis should be based on a careful history, clinicalexamination, and relevant investigations including tuberculin skin test, chest X-ray and sputum smearmicroscopy. 217 Caution should be used when interpreting chest X-ray changes in children (and particularlyso in very young children), as changes are less specific than in adults. The approach to be taken should bediscussed with the consultant radiologist.The diagnosis of intrathoracic (i.e. pulmonary, pleural and mediastinal or hilar lymph node) TB insymptomatic children with negative sputum smears should be based on the finding of chest X-rayabnormalities consistent with TB and either a history of exposure to an infectious case or evidence of TBinfection (positive TST). For such patients, if facilities for culture are available sputum specimens should beobtained (by expectoration, induced sputum or gastric washings) for culture (chapter 4). 255.2 Supervision of TB TreatmentRecommendation:Treatment of TB should be directed by a consultant respiratory physician/consultant ininfectious diseases with appropriate training in the management and treatment of TB.Drug-resistant TBTreatment of patients with drug-resistant TB is complicated. The drugs used are toxic and expensiveand the outcome is not always successful in inexperienced hands. Treatment should always be directedby a consultant respiratory physician/consultant in infectious disease with appropriate training in the-62-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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