| LTBI What is the risk of progression and in who? | 5-10% to active disease, 50% in the first 2 years: Risk of progression highest in: Children < 5, Immunocomprimised, Low BMI, Exposure to Active TB, CKD on dialysis, CXR changes, DM, ETOH, IVDU, Homeless, Smoker, Transplant recipient, Meds: TNF Remicaid. |
| What is Primary TB infection | Lower lobe disease seen in immunocomprimized: 90% goes to LTBI, 10% go to active TB and 5% stays in the lung or disseminates. (military TB) |
| What is Secondary TB? | Reactivation or new exposure. Upper lobe disease. Presents with constitutional sx: fever, night sweats, wt. loss, cough, pleuritic CP, and hemoptysis. Seen in immunocomprimized. |
| Where does extra pulmonary TB manifest? | Lymph nodes: 35% supraclavicular and post. cervial, painless and contender. GU: Uriary sx and cx neg pyuria, infertility due to genital organ involvement, Bone: Vertebral column (pott's dz), GI: ileum and cecum, Heart: constrictive pericarditis. |
| Who do you screen for TB? | Close contacts, HIV, Healthcare workers, Homeless,Immigrants < 5 yr, IVDU, prisoners and residents of NH. |
| How do you screen for TB | PPD: > 5 induration for HIV, Fibrotic changes on CXR, Recent contact with active case or immunocompromised. > 15 if no risk factors, and > 10 for all others and IGRA ( Interferron Gamma Release Assay) or Quantiferon TB Gold and TSPOT. Use this assay for pt who will not show for f/u. and for hx of BCG vaccine. |
| What is the next step in evaluation a + PPD? | Sputum x 3 ( 8-24 hours apart including am sample) for AFB smears and culture on each. NAAT done through Washington State Public Health Lab. or Expert testing on sputum X 2. ( this also give you rifampin resistance and done in few hours) Also check labs: baseline LFT, HIV, Hep panel. CXR with AP view. |
| How do you treat LTBI | 4 I's ( Isolation: at night and children < 4), ( intensive case finding-look for contacts), Immunization ( BCG), INH (90% effective) Qd or bid x 9-12 mo., 6 mo is 60% effective, or INH Rifampin once a week DOT x 3 mo 60% effective. |
| How do you screen close contacts of active cases? | Check PPD and again in 10 wks. |
| How do you treat active TB | Never begin treatment until active disease is r/o. Anything other than 7 days/ wk should by DOT by healthcare provider. DOT RIPE: Rifampin, INH, PZA, and Ethambutol x 2 mo, then INH and Rifampin x 4 mo. Repeat CXR at the end of treatment. If clear, then completely treated. |
| How do you monitor treatment? | Monitor monthly for clinical eval, culture and smears and side effects of medication., sx: anorexia n/v, dark urine, icterus, rash, parenthesis, fatigue, weakness, fever and RUQ pain, monthly LFT and CBC, |
| What are the side effects of Rifampin? | Hepatitis, thrombocytopenia, drug to drug interaction, colors secretions red. Stop treatment if LFT > 3x normal and symptomatic or > 5x normal and asymptomatic. |
| What are the side effects of INH? | Hepatitis, peripheral neuropathy prevented by taking B6 pyridoxine. |
| What are the side effects of PZA? | High UA levels with possible gout exacerbation |
| What are the side effects of ethambutol? | Optic neuritis. |
| How do you dx active TB? | CXR, 3 sputum samples for NAA, AFB and smear and cx.. If active TB confirmed, susceptibility testing for first line drugs should be done. |
| CAP Diagnostic criteria | New infiltrate on CXR, Temp > 38, WBC > 10 or bands > 15%. Sx of cough , dyspnea, RR> 30, hypoxia w/ sat < 90 and ascultatory findings. |
| CURB 65 management of CAP | Confusion, BUN > 20, RR > 30, BP < 90/60, Age >65 |
| CAP no comorbidities treatment | Azithromycin or Doxycycline |
| cap with comorbidities treatment | High dose Amox or Augmentin +Azithromycin or Doxy OR respiratory FQ ( levaquin or moxifloxacin) Treat for 5-10 days |
