PUBLIC HEALTH
results in exposure of medical personnel and other community
members to TB. Early diagnosis helps to control the spread of
TB in our community by reducing transmission. It also results in
cost savings by preventing hospital admissions and readmission.
2. Obtain sputum sampling with Acid-Fast Bacilli (AFB) smears
and culture for tuberculosis PRIOR TO invasive testing
such as bronchoscopy or other testing that could potential-
ly increase the risk for spread of TB by inducing cough or
otherwise increasing aerosolization (1)
Studies show that induced sputum collection is more sensitive
than bronchoscopy.
The most sensitive sputum sample is post-bronchoscopy, so
please consider obtaining sputum testing post-bronchoscopy
in any individual in which TB is in the differential. (2)
If a patient is suspected of having tuberculosis, and sputum
sampling is not possible in your setting, please contact LMPHW
so we can quickly obtain patient samples in our office. (3)
3. If tuberculosis is suspected, isolate the individual to protect
your staff and other patients. The individual should remain
in isolation until rendered noninfectious, with three negative
AFB smears and two weeks of anti-tuberculin treatment.
4. Obtain appropriate evaluation prior to starting patients
on anti-tuberculosis medication. NEVER start a patient on
monotherapy, as resistance can easily develop to these med-
ications. With drug-resistant TB becoming more prevalent in
our community, it is imperative to obtain appropriate samples
(a minimum of three sputa samples with AFB smears) prior
to starting a patient on therapy for long-term management.
Mycobacteria tuberculosis (MTB) Polymerase Chain Reaction
(PCR) testing is recommended and can assist in earlier removal
from isolation within the hospital setting (4) With current
molecular testing techniques, we can quickly identify MTB
and test for Rifampin resistance.
Often, we can obtain these results prior to starting a patient
on therapy, and results may change the treatment recommen-
dations for the patient. This testing is available at many local
facilities, including the LMPHW laboratory, or at the Kentucky
State Public Health Laboratory with prior consultation with the
Kentucky TB Control Program. Again, let me emphasize, if TB
disease is in the differential diagnosis, never start a patient on
monotherapy with TB medications, including fluoroquinolones,
as resistance can easily develop to these medications, render-
ing future limitations in the treatment regimen or resulting in
potentially incurable disease.
5. We recommend that physicians with limited experience
in treating latent tuberculosis infection (LTBI), refer any
individual with a positive TB test (including TB skin test/
TST or Interferon Gamma Response Assay (IGRA), such as
TSpot or Quantiferon) to the LMPHW Regional TB Clinic
or to a qualified infectious disease specialist. An IGRA is rec-
ommended in individuals with prior Bacille Calmette-Guerin
(BCG) vaccination and in those individuals at high risk for TB.
Many misconceptions exist about false positive TST testing,
including in individuals with a history of BCG vaccination and
those with normal chest x-ray results—these findings do not
negate the need for LTBI treatment, and appropriate education
can be provided to the patient in these settings.
6. Refer all patients in which TB disease is suspected to LMPHW,
so appropriate testing and follow-up can be provided. By
Kentucky law, 902 KAR 20:020, the local health department
is required to participate in evaluation and treatment of all
patients diagnosed with tuberculosis.
The local health department should be informed of all cases
and suspected cases of tuberculosis within one (1) business day
in order to ensure that appropriate isolation procedures are
followed and that contact investigations are initiated according
to state and national guidelines (5). Contact investigations
are required for all tuberculosis cases and outcome reporting
to the CDC is required. Please contact LMPHW upon first
suspecting tuberculosis in a patient, and prior to hospital
discharge to establish a follow-up care plan.
Any time two (2) or more anti-tuberculosis drugs are prescribed
for a patient, the local or state health department must be noti-
fied by Epid 200 Form (6), which can be faxed to LMPHW (502)
574-8666 or KDPH (502) 564-3772. Please call (502) 574-6617
or (502) 574-5219 to confirm receipt of report.
7. Directly Observed Therapy (DOT) for tuberculosis antibac-
terial medications to treat active TB disease is the standard
of care in the United States. It should be administered by
the local health department (7). Appropriate dosage regimen
and documentation of these observed doses is required for all
individuals being treated for tuberculosis. Self-dosage is not
permitted for treatment of tuberculosis. At LMPHW Regional
TB Clinic, the resources are available to provide this standard
of care treatment to our community’s TB patients.
With patients whose TB disease is increasingly complex and
with expanding drug resistance, we need everyone’s help to keep
tuberculosis under control. Please do not hesitate to contact me or
the LMPHW Regional TB Clinic staff for assistance in TB-related
matters:
After hours, please contact the individual on-call at (502)
574-6617 and follow the prompts.
During normal business hours, please contact one of the
following individuals:
Susan Delph (Surveillance Nurse): (502) 574-5958
Amber Vittitoe (Case Manager): (502) 574-8053
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JULY 2019
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