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Tuberculosis in the Hospital
J Rush Pierce Jr, MD, MPHAssociate Professor, Texas Tech University HSC Health Authority, Amarillo Bi-City-County health District
Texas Society of Infection Control PractitionersIntermediate Course, Amarillo, TexasOctober 20, 2006
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Disclosures Salaried by TTUHSC City of Amarillo Department of Public Health
provides approximately 30% salary support Consultant for Texas Dept. of Health and AIG
Annuity Insurance Company Some of Slides form CDC Teaching Library Received no financial compensation for
today’s talk
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Objectives of today's’ talk
List the major symptoms of active tuberculosis. Define latent tuberculosis and explain how it is
different than active tuberculosis. List conditions which facilitate the transmission
of tuberculosis. List activities which minimize transmission of
tuberculosis in hospitals. Explain the role of the Health Department in the
management of tuberculosis.
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An ICP Nightmare
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A 54 year-old homeless man comes to the ED with cough and fever. He is dirty, unshaven, appears undernourished, and smells of alcohol. After an 8 hour stay in the ED, he is discharged with amoxicillin for bronchitis. Social service arranges stay in a homeless shelter.
He returns one week later. He says he has been sick for several weeks with night sweats and cough that has at times produced bloody sputum. He has lost 20 pounds in two months.
The ED physician orders a CXR and the patient is admitted to the floor to the on-call physician.
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The patient is admitted to a semi-private room. The on-call physician orders a regular diet, oxygen, ceftriaxone and azithromycin.
The next day (hospital day 2), the radiologist reads the CXR and identifies a right upper lobe cavity. He dictates a report that goes to transcription.
The transcribed report arrives on the floor the following day (hospital day 3) and is filed by the clerk in the chart after the physician makes rounds.
The report is noted by the physician on hospital day 4. The physician orders sputum for AFB and a TB skin test, but fails to communicate concerns about the possibility of TB to the nursing staff.
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On hospital day 6, positive AFB smears are reported by the lab. The patient is placed in respiratory isolation and the ICP is contacted.
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Pertinent questions
What is tuberculosis? How is tuberculosis transmitted? What conditions facilitate the transmission of
tuberculosis? How is tuberculosis diagnosed? How is transmission of tuberculosis
prevented in hospitals?
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25 - 49
50 - 99
100 - 300
0 - 9
10 - 24
300 or more
No estimate
Rate per 100 000
Estimated TB incidence rates, 2000
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295
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Unusual qualities of Mycobacterium Slow growing (division time ~ once/day)
Symptoms subacute Laboratory isolation slow Long treatment necessary
Resistant to ordinary antibiotics Resistant to cellular enzymatic defense
mechanisms Unusual staining characteristics
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Sequencing the genome of M. tuberculosis
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Transmission of tuberculosis Spread by droplet nuclei
Expelled when person with infectious TB coughs, sneezes, speaks, or sings
Close contacts at highest risk of becoming infected
Transmission occurs from person with infectious TB disease (not latent TB infection)
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Transmission and Pathogenesis
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Conditions that facilitate the transmission of tuberculosis
Small closed spaces Lack of air movement Lack of light
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Consequences of infection with Consequences of infection with M. tuberculosisM. tuberculosis
95% 5%
Infection Immunity Reactivation disease
5%
Primary disease
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Types of Active Tuberculosis Lung Infections
PRIMARY
Recent infection Favors lower lobes Non-cavitary Less contagious Children > Adults
REACTIVATION
Remote infection Upper lobes Tends to cavitation More contagious Almost exclusively adults,
occasionally adolescents
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Active tuberculosis ling infection - History and physical examination
Weight loss Night sweats Hemoptysis
Signs of weight loss +/- fever Lung exam is usually
normal
HISTORY EXAM
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TB Skin Testing
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AFB smear
AFB (shown in red) are tubercle bacilli
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Chest Radiographin Active TB Lung Infection
Abnormalities often seen in upper lobe or superior segments of lower lobe
May have unusual appearance in HIV-positive persons
Cannot confirm diagnosis of TB
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Baseline Diagnostic Examinations for TB Tuberculin skin test Chest x-ray Sputum specimens (= 3 obtained 8-24 hours
apart) for AFB microscopy and mycobacterial cultures
Routine drug-susceptibility testing for INH, RIF, and EMB on initial positive culture
Counseling and testing for HIV infection
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Contact Investigation in the hospital Enlist the help of the Health Department Identify those at highest risk of transmission Test for acquisition of TB infection Consider preventive therapy (treatment of
latent infection) for those who have recently acquired TB infection
CQI review
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Factors to consider when deciding who is at highest risk Duration of exposure Place of exposure (closed room worse than
open area) Type of exposure (aerosol-inducing
procedures like HHN and bronchoscopy highest risk)
Immune system of exposed persons
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Who was exposed?
Staff (nursing, physician, respiratory therapy, physicians, social service, dietary, admitting office, housekeeping, etc.)
Patients
Visitors
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How do you know who was exposed?
Review of duty hours and work days of staff Post notices to staff Review patient room assignments With help of Health Department, interview
patient Letters to visitors, public notices
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Contact investigation
Baseline testing Rationale How to do this
Repeat testing Assess positive reactors for active disease Offer positive reactors preventive therapy
(treatment of latent tuberculosis
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Testing for TB Infection
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The Tuberculin Skin Test
Inject intradermally 0.1 ml of 5TU PPD tuberculin
Produce wheal 6 mm to 10 mm in diameter
Follow universal precautions for infection control
No contraindication in pregnancy
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Reading the Tuberculin Skin Test
•Read reaction 48-72 hours after injection
•Measure only induration
•Record reaction in millimeters
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What is the booster phenomena and what is a two step tuberculin test?
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Boosting
•Some people with LTBI may have negative skin test reaction when tested years after infection
•Initial skin test may stimulate (boost) ability to react to tuberculin
•Positive reactions to subsequent tests may be misinterpreted as a new infection
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Two-Step Testing
Use two-step testing for initial skin testing of adults who will be retested periodically
• If first test positive, consider the person infected
• If first test negative, give second test 1-3 weeks later
• If second test positive, consider person previously infected
• If second test negative, consider person uninfected
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How does BCG vaccine affect the tuberculin test?
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BCG Vaccination and Tuberculin Skin Testing
• TST not contraindicated for BCG-vaccinated persons
• DX and RX for LTBI considered for any BCG-vaccinated person whose skin test reaction is >10 mm, if any of these circumstances are present:
-contact with another person with infectious TB- Was born or has resided in a high TB prevalence country- Is continually exposed to populations where TB prevalence is high
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Consequences of infection with Consequences of infection with M. tuberculosisM. tuberculosis
95% 5%
Infection Immunity Reactivation disease
5%
Primary disease
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Persons at Higher Risk of Developing TB Disease once Infected
•HIV infected
•Recently infected
•Persons with certain medical conditions
•Persons who inject illicit drugs
•History of inadequately treated TB
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Conditions That Increase the Risk of Progression to TB Disease
•HIV infection
•Substance abuse
•Recent infection •Chest x-ray findings suggestive of
previous TB
•Diabetes mellitus
•Silicosis
•Prolonged corticosteriod therapy
•Other immunosuppressive therapy
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Conditions That Increase the Risk of Progression to TB Disease (cont.)
•Cancer of the head and neck
•Hematologic and reticuloendothelial diseases
•End-stage renal disease
•Intestinal bypass or gastrectomy
•Chronic malabsorption syndromes
•Low body weight (10% or more below the ideal)
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Candidates for Treatment of LTBI
Positive skin test result at least 5 mm
• HIV-positive persons • Recent contacts of a TB case
• Persons with fibrotic changes on chest radiograph consistent with old TB
• Patients with organ transplants and other immunosuppressed patients
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Candidates for Rx of LTBI (cont.)
Positive skin test result at least 10 mm
• Recent arrivals from high-prevalence countries
• Injection drug users
• Residents/employees of congregate settings
• Mycobacteriology laboratory personnel
• Persons with certain clinical conditions
• Children < 4 years of age, or children and adolescents exposed to adults in high-risk categories
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Candidates for Rx of LTBI (cont.)
Positive skin test result at least 15 mm
• Persons with no known risk factors for TB may be considered
• Targeted skin testing programs should only be conducted among high-risk groups
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Decreasing transmission in hospitals High index of suspicion
ED staff Nursing staff Physicians
Early reporting of suspicions Early isolation Get to know your Health Dept Policies
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Questions and/or comments