Transcript TSICPTBintheHospital..

Tuberculosis in the Hospital
J Rush Pierce Jr, MD, MPH
Associate Professor, Texas Tech University HSC
Health Authority, Amarillo Bi-City-County health District
Texas Society of Infection Control Practitioners
Intermediate Course, Amarillo, Texas
October 20, 2006
Disclosures
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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
Objectives of today's’ talk
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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.
An ICP Nightmare
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.
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.
On hospital day 6, positive AFB smears are
reported by the lab. The patient is placed in
respiratory isolation and the ICP is contacted.
Pertinent questions
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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?
Estimated TB incidence rates, 2000
Rate per 100 000
0-9
10 - 24
25 - 49
50 - 99
100 - 300
300 or more
No estimate
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
Unusual qualities of Mycobacterium
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Slow growing (division time ~ once/day)
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Symptoms subacute
Laboratory isolation slow
Long treatment necessary
Resistant to ordinary antibiotics
Resistant to cellular enzymatic defense
mechanisms
Unusual staining characteristics
Sequencing the genome of M. tuberculosis
Transmission of tuberculosis
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Spread by droplet nuclei
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Expelled when person with infectious TB
coughs, sneezes, speaks, or sings
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Close contacts at highest risk of becoming
infected
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Transmission occurs from person with
infectious TB disease (not latent TB infection)
Transmission and Pathogenesis
Conditions that facilitate the
transmission of tuberculosis
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Small closed spaces
Lack of air movement
Lack of light
Consequences of infection with
M. tuberculosis
95%
Infection
5%
Immunity
5%
Primary disease
Reactivation disease
Types of Active Tuberculosis Lung
Infections
PRIMARY
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Recent infection
Favors lower lobes
Non-cavitary
Less contagious
Children > Adults
REACTIVATION
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Remote infection
Upper lobes
Tends to cavitation
More contagious
Almost exclusively adults,
occasionally adolescents
Active tuberculosis ling infection History and physical examination
HISTORY
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Weight loss
Night sweats
Hemoptysis
EXAM
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Signs of weight loss
+/- fever
Lung exam is usually
normal
TB Skin Testing
AFB smear
AFB (shown in red) are tubercle bacilli
Chest Radiograph
in Active TB Lung Infection
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Abnormalities often
seen in upper lobe or
superior segments of
lower lobe
May have unusual
appearance in HIVpositive persons
Cannot confirm
diagnosis of TB
Baseline Diagnostic Examinations
for TB
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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
Contact Investigation in the hospital
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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
Factors to consider when deciding
who is at highest risk
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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
Who was exposed?
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Staff (nursing, physician, respiratory therapy,
physicians, social service, dietary, admitting
office, housekeeping, etc.)
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Patients
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Visitors
How do you know who was
exposed?
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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
Contact investigation
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Baseline testing
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Rationale
How to do this
Repeat testing
Assess positive reactors for active disease
Offer positive reactors preventive therapy
(treatment of latent tuberculosis
Testing for TB Infection
The Tuberculin Skin Test
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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
Reading the Tuberculin Skin Test
Read reaction 48-72 hours after
injection
Measure only induration
Record reaction in millimeters
What is the booster
phenomena and what is a
two step tuberculin test?
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
Two-Step Testing
Use two-step testing for initial skin testing of adults who
will be retested periodically
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If first test positive, consider the person infected
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If first test negative, give second test 1-3 weeks later
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If second test positive, consider person previously
infected
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If second test negative, consider person
uninfected
How does BCG vaccine affect
the tuberculin test?
BCG Vaccination and
Tuberculin Skin Testing
• TST not contraindicated for BCG-vaccinated
persons
• DX and RX for LTBI considered for any BCGvaccinated 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
Consequences of infection with
M. tuberculosis
95%
Infection
5%
Immunity
5%
Primary disease
Reactivation disease
Persons at Higher Risk of Developing
TB Disease once Infected
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HIV infected
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Recently infected
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Persons with certain medical conditions
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Persons who inject illicit drugs
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History of inadequately treated TB
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
Conditions That Increase the Risk of
Progression to TB Disease (cont.)
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Cancer of the head and neck
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Hematologic and reticuloendothelial diseases
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End-stage renal disease
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Intestinal bypass or gastrectomy
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Chronic malabsorption syndromes
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Low body weight (10% or more below the ideal)
Candidates for Treatment of LTBI
Positive skin test result at least 5 mm
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HIV-positive persons
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Recent contacts of a TB case
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Persons with fibrotic changes on chest
radiograph consistent with old TB
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Patients with organ transplants and other
immunosuppressed patients
Candidates for Rx of LTBI (cont.)
Positive skin test result at least 10 mm
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Recent arrivals from high-prevalence countries
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Injection drug users
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Residents/employees of congregate settings
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Mycobacteriology laboratory personnel
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Persons with certain clinical conditions
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Children < 4 years of age, or children and
adolescents exposed to adults in high-risk
categories
Candidates for Rx of LTBI (cont.)
Positive skin test result at least 15 mm
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Persons with no known risk factors for TB
may be considered
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Targeted skin testing programs should only
be conducted among high-risk groups
Decreasing transmission in hospitals
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High index of suspicion
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ED staff
Nursing staff
Physicians
Early reporting of suspicions
Early isolation
Get to know your Health Dept
Policies
Questions and/or comments