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NICE Guideline 2016- Active Tuberculosis

NICE Guideline 2016- Active Tuberculosis
In a person  infected with TB, the immune system cells  usually wall off the infection and cause the TB bacteria to go into an inactive form that causes no symptoms and is not contagious.

If the immune system is weakened, however, the infection becomes active, causing symptoms and contagious disease. About 3% to 5% of people develop active TB within a year of receiving positive diagnosis in a TB skin test or having evidence of a new infection. If the immune system becomes weakened for any reason, the infection can also become active, symptomatic and contagious.

What Are the Symptoms of Active TB?

Active TB begins with a bad cough (produces blood-tinged phlegm) that lasts 3 or more weeks and is accompanied by chest pain, fatigue, loss of appetite, weight loss, fever, chills and night sweating.

In January 2016, The National Institute for Health and Care Excellence (NICE). Tuberculosis. London (UK) published the Active Tuberculosis guideline as part of their guidance on Tuberculosis. Following are its recommendations:

Managing Active TB in All Age Groups

Standard Treatment

Once a diagnosis of active TB is made:

  • The clinician responsible for care should refer the person with TB to a clinician with training in, and experience of, the specialised care of people with TB.
  • The TB service should include specialised nurses and health visitors.
  • Active TB in children should be managed by a TB specialist (see recommendation under “Diagnosing Pulmonary (Including Laryngeal) TB in Children and Young People” above), and by paediatric trained nursing staff, where possible.

If these arrangements are not possible, seek advice from more specialised colleagues throughout the treatment period. [2016]

For people with active TB without central nervous system involvement, offer:

  • Isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2 months then
  • Isoniazid (with pyridoxine) and rifampicin for a further 4 months

Modify the treatment regimen according to drug susceptibility testing. [2016]

For people with active TB of the central nervous system, offer:

  • Isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2 months then
  • Isoniazid (with pyridoxine) and rifampicin for a further 10 months

Modify the treatment regimen according to drug susceptibility testing. [2016]

Test people with active spinal TB who have neurological signs or symptoms for central nervous system involvement (see recommendation under “Central Nervous System TB” above). Manage direct spinal cord involvement (for example, a spinal cord tuberculoma) as TB of the central nervous system. [2016]

For people with active spinal TB without central nervous system involvement, do not extend treatment beyond 6 months for residual effects (for example, persistent bending of the spine or vertebral loss). [2016]

Test people with disseminated (including miliary) TB who have neurological signs or symptoms for central nervous system involvement. If there is evidence of central nervous system involvement, treat as for TB of the central nervous system. [2016]

Treat active peripheral lymph node TB in people who have had an affected gland surgically removed with the standard recommended regimen. [new 2016]

For people with active TB of the lymph nodes, do not routinely extend treatment beyond 6 months for newly enlarged lymph nodes or sinus formation, or for residual enlargement of the lymph nodes or sinuses. [new 2016]

Dosing of Regimens

Use fixed-dose combination tablets as part of any TB treatment regimen. [2006]

Do not offer anti-TB treatment dosing regimens of fewer than 3 times per week. [2006, amended 2016]

Offer a daily dosing schedule to people with active pulmonary TB. [2006, amended 2016]

Consider a daily dosing schedule as first choice in people with active extra pulmonary TB. [2006, amended 2016]

Consider 3 times weekly dosing for people with active TB only if:

  • A risk assessment identifies a need for directly observed therapy and enhanced case management (see “Adherence, Treatment Completion and Follow-up” below) and
  • Daily directly observed therapy is not possible [2006, amended 2016]

People with Comorbidities or Coexisting Conditions

If the person has a comorbidity or coexisting condition such as:

  • HIV or
  • Severe liver disease, for example, Child-Pugh level B or C or
  • Stage 4 or 5 chronic kidney disease (a glomerular filtration rate of <30 ml/minute/ 1.73 m2) or
  • Diabetes or
  • Eye disease or impaired vision or
  • Pregnancy or breastfeeding or
  • A history of alcohol or substance misuse

Work with a specialist multidisciplinary team with experience of managing TB and the comorbidity or coexisting condition. [new 2016]

For people with HIV and active TB without central nervous system involvement, do not routinely extend treatment beyond 6 months. [new 2016]

For people with HIV and active TB with central nervous system involvement, do not routinely extend treatment beyond 12 months.[new 2016]

Take into account drug-to-drug interactions when co-prescribing anti retroviral and anti-TB drugs. [new 2016]

Adjunctive Corticosteroids

Central Nervous System TB

At the start of an anti-TB treatment regimen, offer people with active TB of the central nervous system dexamethasone or prednisolone, initially at a high dose with gradual withdrawal over 4 to 8 weeks. An example of a suitable regimen is listed in Table 12 in the original guideline document. [new 2016]

At the start of an anti-TB treatment regimen, offer children and young people with active TB of the central nervous system dexamethasone or prednisolone. This should initially be at a high dose with gradual withdrawal over 4 to 8 weeks in line with the British National Formulary for Children External Web Site Policy. [new 2016]

Pericardial TB

At the start of an anti-TB treatment regimen, offer adults with active pericardial TB oral prednisolone at a starting dose of 60 mg/day, gradually withdrawing it 2 to 3 weeks after starting treatment. [2016]

At the start of an anti-TB treatment regimen, offer children and young people with active pericardial TB oral prednisolone in line with the British National Formulary for Children External Web Site Policy. Gradually withdraw prednisolone 2 to 3 weeks after starting treatment. [2016]

Adjunctive Surgery

If surgery is indicated, the surgeon should fully explain what is involved to the person, either with or after consulting a TB specialist. Discuss the possible benefits and risks with the person and their family members or carers, as appropriate, so that they can make an informed decision. [new 2016]

Central Nervous System TB

Consider referring people with TB of the central nervous system for surgery as a therapeutic intervention only if there is evidence of raised intracranial pressure. [new 2016]

Spinal TB

Do not routinely refer people with spinal TB for surgery to eradicate the disease. [new 2016]

Consider referring people with spinal TB for surgery if there is spinal instability or evidence of spinal cord compression. [new 2016]

To read the full guideline click on the following link:

https://www.nice.org.uk/guidance/ng33/chapter/Recommendations#active-tb

Source: self
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