Beruflich Dokumente
Kultur Dokumente
Abrahamian, DO,
FACEP
Associate Professor of Medicine, David
Geffen School of Medicine at UCLA, Los
Angeles, California; Director of
Education, Department of Emergency
Medicine, Olive View-UCLA Medical
Center, Los Angeles, California
WE-77
9/29/2010
8:00 AM - 8:50 AM
Mandalay Bay Convention Center
Tuberculosis
#1 cause of death from infectious diseases
in the world
~ 2 million TB-related deaths worldwide
~ 1/3 of world’s population is infected
~ 9 million new cases each year
~ 10-15 million infected in U.S.
MMWR. 2010;59(10):289-294.
MMWR. 2010;59(10):289-294.
1
MMWR. 2010;59(10):289-294.
2
Mycobacterium tuberculosis
Latent TB Infection
No symptoms
Can not spread TB to others
Positive TB skin test (usually)
Normal CXR & negative sputum
Risk of progressing to active TB
Active TB Disease
Typical symptoms:
Cough, weight loss, fatigue
Hemoptysis, night sweats
Can spread TB to others
Positive TB skin test (usually)
Positive CXR & sputum (usually)
3
Extrapulmonary TB
Lymphadenitis
Genitourinary
Sterile pyuria
Musculoskeletal
Pott’s disease of the spine
Meningitis
Subacute, cranial nerve signs
Lymphocytic pleocytosis
TB & HIV
Multidrug-Resistant (MDR) TB
Resistant to at least INH & rifampin
2008: 107 cases (1.1% of all culture + cases)
~ 8% resistance to INH reported in U.S.
High risk:
Prior Hx of TB (risk increases 4 fold)
Known exposure to MDR TB
Immigrant: Asia, Africa, S. America
Homeless
Prison
MMWR. 2010;59(10):289-294.
4
MDR TB in
Healthcare Workers
Extensively Drug-Resistant TB
(XDR TB)
MMWR. 2010;59(10):289-294.
5
Number of XDR TB - U.S., 1993-2006
MMWR. 2007;
56(11):250-253.
TB Transmission in ED
TB Infection Control
6
TB Isolation &
Suspicion of TB in ED
TB Dx Other Dx p
Isolation 5 (2-10) 21 (11-111) < .001
Therapy 12 (9-22) 128 (68-374) < .001
Isolation Room
Negative pressure
6 air exchanges per hour
Exhaust directly to outside
Need N-95 respirator
7
TB Infection Control in U.S. EDs
8
Isolation & Infection Control
Many unnecessary admissions to isolation
On average, only ~ 68% of TB patients are isolated
Instrument to predict which patients do NOT have TB
No TB Hx. or previous positive TB skin test result
Non-immigrant
Not homeless
Not recently incarcerated
No recent weight loss
No apical infiltrate or cavitary lesion on CXR
Moran GJ, et al. Ann Emerg Med. 2009;53:625-632.
9
Administering the Tuberculin
Skin Test
Tuberculin Reaction
10
Tuberculin Reaction
≥ 10 mm is classified as positive in:
Immigrants from high-prevalence countries
Injection drug users
Individual at high-risk congregate settings
Mycobacteriology laboratory personnel
High risk conditions (DM, CA, renal failure)
Children < 4 years of age
Children exposed to adults in high-risk
categories
Tuberculin Reaction
11
Chest Radiograph
12
Specimen Collection
Obtain 3 sputum specimens for
smear examination & culture
Persons unable to cough up sputum,
induce sputum, bronchoscopy or
gastric aspiration
Follow infection control precautions
during specimen collection
AFB Smear
Cultures
Use to confirm diagnosis
Culture all specimens, even if smear negative
Results in 4 to 14 days when liquid medium
systems used
Colonies of
M. tuberculosis
growing on media
13
TB Preventive Treatment
Treatment of Active TB
14
1st Line TB Drugs
Adult dose
Isoniazid 300 mg/d
Rifampin 600 mg/d
Pyrazinamide 25 mg/kg/d (max 2.5 gm)
Ethambutol 15-25 mg/kg/d
Streptomycin 15 mg/kg/d
Capreomycin Kanamycin
Ciprofloxacin Amikacin
Clofazimine Levofloxacin
Cycloserine Ofloxacin
Ethionamide Aminosalicylic acid
Rifabutin
Rifapentine
Linezolid
Imipenem
Amoxicillin/clavulanate
Macrolides
15
Treatment of Active TB
Common regimen:
INH, Rifampin, PZA, Ethambutol daily x 8 wks
Then INH + Rifampin for 18 weeks
(assuming organism is susceptible)
Longer duration of therapy for TB meningitis,
miliary TB, or bone/joint TB infection
Dexamethasone beneficial with TB meningitis
Response to Treatment
16
Period of Infectivity
17