Treatment
A multidisciplinary, patient-centered approach involving the patient, providers, and public health officials is required to accomplish the following treatment goals: eradicating Mycobacterium infection, eliminating the risk of transmission, avoiding the disease, and preventing drug resistance.8
Infectious disease consultation is mandatory in all HIV-positive and suspected or confirmed multidrug-resistant cases. Directly observed therapy is an essential component of APTB treatment to ensure compliance in many situations.
Admission and discharge
Admission to a hospital is not required unless a patient meets criteria for admission independent of APTB diagnosis, or proper risk stratification and assessment cannot be completed in a timely manner. A patient with suspected APTB should be placed in airborne isolation. All staff should wear N95 disposable masks or respirators while inside the patient’s room.9
Discharge considerations are listed below:
- Inform the department of health (DOH).
- Establish proper isolation precautions to minimize exposure.
- Ensure ability to stay at home until DOH and physician determines noninfectivity.
- Educate the patient about length of therapy, directly observed therapy, side effects and importance of compliance.
- Coordinate discharge with the DOH.
- Make sure proper follow-up is scheduled.
Back to the case
Our patient was placed on airborne respiratory isolation immediately upon admission and sputum was sent for AFB. Sputum smear was positive for AFB as well as a positive nucleic acid testing for Mycobacterium tuberculosis. HIV antibody testing was negative. Once the sputum AFB was determined to be positive, the department of health was informed. He was started on the intensive phase of therapy with pyrazinamide, rifampin, ethambutol, and isoniazid along with pyridoxine. He tolerated his medications well and had no immediate reactions. His family and close contacts were screened and advised to be tested.
The patient was discharged after proper follow-up with primary care doctor was scheduled. The department of health arranged for directly observed therapy. He received information about the importance of taking all of his medications and staying at home except for medical visits until the DOH had deemed him to be noninfectious.
Bottom line
APTB in the hospital is an uncommon but serious problem in certain populations. It requires a high index of suspicion and a multidisciplinary approach for effective treatment and prevention of transmission.
Dr. Syam Mallampalli
Dr. Satyananta Velidi
Dr. Malachi Courtney
Dr. Mallampalli is an attending physician in hospital medicine at Geisinger in Danville, Pa., and clinical assistant professor at Temple University, Philadelphia. Dr. Velidi is an attending physician in hospital medicine at Geisinger. Dr. Courtney is associate director of the department of hospital medicine at Geisinger.
References
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3. Medrano BA et al. A missed tuberculosis diagnosis resulting in hospital transmission. Infect Control Hosp Epidemiol. 2014 May;35(5):534-7.
4. Kelly AM et al. Delayed tuberculosis diagnosis and costs of contact investigations for hospital exposure: New York City, 2010-2014. Am J Infect Control. 2017 May 1;45(5):483-6.
5. Lewinsohn DM et al. Official ATS/IDSA/CDC Clinical Practice Guidelines: Diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan;64:111-5.
6. Mazurek GH et al. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR Recomm Rep. 2005 Dec 16;54(RR-15):49-55.
7. CDC. Trends in tuberculosis – United States, 2010. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):333-7.
8. Jensen PA et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-17):1-141.
9. Siegel JD et al and the Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164.