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/HPSCMore detailed information regarding the operation of these rooms is available in the UK Department ofHealth’s document on “The prevention and control of tuberculosis in the United Kingdom: UK guidanceon the prevention and control of transmission of 1. HIV-related tuberculosis 2. drug-resistant, includingmultiple drug-resistant, tuberculosis, 1998”, “Hospital and community acquired infection and the builtenvironment-design and testing of infection control rooms. Journal of Hospital Infection 2007 published byWalker et al and HBN 04 Supplement 1. 231;234;235The design of airborne isolation rooms planned for new buildings or major refurbishments should be basedon the neutral pressure design, as detailed in HBN 04 Supplement 1 rather than a “switchable” negative/positive pressure design. 236It is important to note that no ventilation system will function correctly if the doors or windows are open.Sputum induction and aerosol-generating procedures• Sputum induction is used to obtain sputum when patients are unable to expectorate a specimen.The procedure uses sterile water or hypertonic saline to irritate the airway, increase secretions,promote coughing, and produce a specimen. It is also recommended for children as a preferredoption to gastric washings. 26 Sputum induction is classified as a high-risk procedure when performedon a person with suspected or known infectious TB. 26;229 There is a consensus in internationalbest practice guidelines that sputum induction should only be performed in an airborne isolationroom or if no such room is available a ventilated booth from which air is exhausted outside orHEPA filtered. 30;229 The committee agrees with this. These booths or local exhaust ventilation (LEV)systems must be maintained and regularly monitored to ensure they are working satisfactorily.• Aerosol-generating procedures such as the administration of medications by nebuliser onsuspected or confirmed cases of TB must be avoided in an open bay or in an unventilated areain all wards/departments. Treatment of an extrapulmonary TB open abscess or lesion whereaerosolisation of drainage fluid may occur should only be undertaken in an airborne isolationroom.Current international guidelinesThere are differing recommendations in the current international best practice guidelines on the typeof rooms suitable for patients with infectious TB. The CDC guidelines 229 recommend that all suspectedand confirmed TB cases be treated in negative pressure rooms while the NICE guidelines 26 advise a thatnegative pressure room is only required for suspected or confirmed MDR-TB cases. The NICE guidelinesfurther advise that while single rooms without specific ventilation systems can be used for non-MDR-TBpatients no immunosuppressed patients should be on the ward.Recommendation:Patients with known or suspected pulmonary or laryngeal TB should be admitted to anairborne isolation room (negative pressure isolation room with an ante room or a neutralpressure design as outlined in HBN 04 supplement 1). Hospitals need to have a riskassessment process to ensure the appropriate provision of isolation facilities (see figure 6.1).Availability of isolation roomsA study in 2003 reported that only 14% of Irish hospitals had an isolation room suitable for AirbornePrecautions. 237 While the available number of rooms may have increased with recent new builds andrefurbishments in Irish hospitals, it is likely that some hospitals have an insufficient number of isolationrooms with a ventilation system to isolate all known or suspected infectious TB cases.Hospitals should prioritise the building of airborne isolation rooms. New buildings or major renovations inacute general hospitals should have a minimum of one airborne isolation room to 150 beds or one to 75beds for regional/tertiary hospitals. Critical care and accident and emergency units should have at least oneairborne isolation room. 236-77-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCRisk assessment for all confirmed or suspected pulmonary or laryngeal TB cases. 26Recommendation:All patients with suspected or known pulmonary or laryngeal TB must have a risk assessmentfor MDR-TB.Risk factors for MDR-TB include the following:• A history of prior TB treatment (especially incomplete treatment) and/or prior TB treatmentfailure• Contact with a known case of MDR-TB• Birth in a foreign country, particular a high incidence country for MDR-TB (Lithuania, Estonia,Latvia, Uzbekistan, Kazakhstan, China ( Henan & Liaoning provinces) Tomsk Oblast (RussianFederation) and Ecuador) (refer to www.who.int/tb/publications/mdr_surveillance/en/index.htmlfor latest information on countries with high incidence of MDR-TB)• HIV infectionRecommendation:Patients with suspected or confirmed MDR-TB must be admitted to an airborne isolation room(negative pressure isolation room with an ante room or a neutral pressure design as outlined inHBN 04 supplement 1). (This may require transferring the patient to another institution wherethe facilities, together with a physician experienced in the management of complex drugresistantcases are available).See figure 6.1 for risk assessment for patient placement if a sufficient number of airborne isolation roomsare not available.-78-
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25-27 Middle Gardiner Street Dublin
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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