Treatment of latent tuberculosis – tuberculosis prophylaxis.
A latent tuberculosis infection (LTBI) is an infection with M. tuberculosis without clinical, bacteriological or radiological evidence of active tuberculosis.
The main indications for screening for LTBI are:
1. source and contact investigation
2. contact groups of at-risk populations
3. prior to immunosuppression and in immunocompromised individuals
The tuberculin skin test (TST) and the interferon-gamma release assay (IGRA) are tests for detecting infection with the M. tuberculosis complex.
Interpretation of the TST and IGRA for the diagnosis of LTBI is complex, and depends on age and immune status. For this we refer to the Tuberculosis Handbook.
Indication for treatment of latent tuberculosis:
1. A positive Mantoux or IGRA that is likely due to a recently (< 2 years earlier) acquired infection, e.g. after recent contact with a known infectious source or with TB risk groups, or after recent travel to an area with high tuberculosis prevalence.
2. Contact with infectious TB in a child < 5 years (until a Mantoux conversion is excluded), and a positive Mantoux in a child < 5 years.
3. Patients at risk with conditions or diseases associated with an increased risk of developing active TB:
positive Mantoux or IGRA in severe impairment of cellular immunity: - HIV infection (CD4 count <500 mm3); - anti-rejection therapy after transplantation; - treatment with high-dose corticosteroids (>15 mg/day prednisolone for at least 4 weeks); - treatment with anti-TNF-α agents.
Treatment
The following preferred order for preventive TB treatment is advised: - 3 months isoniazid and rifampicin (3HR) daily* - 4 months rifampicin (4R) daily* - 6-9 months isoniazid (6-9H) daily if rifampicin is contraindicated
*3HR and 4R are equivalent treatment regimens.
Dosage adults: 300 mg isoniazid and 600 mg rifampicin once daily
For all pregnant women, monthly monitoring of transaminases is recommended during pregnancy and for the first 3 months postpartum.
Treatment in impaired cellular immunity
No distinction is made between treatment for persons with normal immunity and for persons with HIV, persons who will receive anti‑TNF medication or other immunosuppressants, or persons who will undergo organ transplantation.
Preferably, initiation of TNF‑α blocking agents should be delayed until preventive treatment is completed. If earlier initiation is necessary, it is advised to start only after at least one to two months of preventive LTBI treatment.
Treatment of fibrotic lesions
Persons with fibrotic residual lesions are preferably treated with 3 months isoniazid and rifampicin (3HR).
If radiological abnormalities diminish during treatment, treatment for active tuberculosis should nevertheless be considered, for example with 9HR.
Policy for LTBI caused by a multidrug-resistant strain
Consult an expert.
Consult the tuberculosis coordinator if necessary (Dr Magis-Escurra, pulmonologist; Prof van Crevel, infectious diseases physician) regarding indication, choice and/or monitoring
Treatment notes
Addition of vitamin B6 (pyridoxine) 20 mg once daily (10 mg for children <1 year) p.o. to isoniazid is indicated for pregnant women, breastfeeding women, elderly patients and patients with diabetes, renal impairment, malnutrition, HIV or epilepsy, and for children with a history of convulsions.
For rifampicin: check the consequences of any interactions when starting and stopping rifampicin
Treatment of latent tuberculosis – tuberculosis prophylaxis.
A latent tuberculosis infection (LTBI) is an infection with M. tuberculosis without clinical, bacteriological or radiological evidence of active tuberculosis.
The main indications for screening for LTBI are:
1. source and contact investigation
2. contact groups of at-risk populations
3. prior to immunosuppression and in immunocompromised individuals
The tuberculin skin test (TST) and the interferon-gamma release assay (IGRA) are tests for detecting infection with the M. tuberculosis complex.
Interpretation of the TST and IGRA for the diagnosis of LTBI is complex, and depends on age and immune status. For this we refer to the Tuberculosis Handbook.
Indication for treatment of latent tuberculosis:
1. A positive Mantoux or IGRA that is likely due to a recently (< 2 years earlier) acquired infection, e.g. after recent contact with a known infectious source or with TB risk groups, or after recent travel to an area with high tuberculosis prevalence.
2. Contact with infectious TB in a child < 5 years (until a Mantoux conversion is excluded), and a positive Mantoux in a child < 5 years.
3. Patients at risk with conditions or diseases associated with an increased risk of developing active TB:
positive Mantoux or IGRA in severe impairment of cellular immunity:
- HIV infection (CD4 count <500 mm3);
- anti-rejection therapy after transplantation;
- treatment with high-dose corticosteroids (>15 mg/day prednisolone for at least 4 weeks);
- treatment with anti-TNF-α agents.
Treatment
The following preferred order for preventive TB treatment is advised:
- 3 months isoniazid and rifampicin (3HR) daily*
- 4 months rifampicin (4R) daily*
- 6-9 months isoniazid (6-9H) daily if rifampicin is contraindicated
*3HR and 4R are equivalent treatment regimens.
Dosage adults: 300 mg isoniazid and 600 mg rifampicin once daily
For all pregnant women, monthly monitoring of transaminases is recommended during pregnancy and for the first 3 months postpartum.
Treatment in impaired cellular immunity
No distinction is made between treatment for persons with normal immunity and for persons with HIV, persons who will receive anti‑TNF medication or other immunosuppressants, or persons who will undergo organ transplantation.
Preferably, initiation of TNF‑α blocking agents should be delayed until preventive treatment is completed. If earlier initiation is necessary, it is advised to start only after at least one to two months of preventive LTBI treatment.
Treatment of fibrotic lesions
Persons with fibrotic residual lesions are preferably treated with 3 months isoniazid and rifampicin (3HR).
If radiological abnormalities diminish during treatment, treatment for active tuberculosis should nevertheless be considered, for example with 9HR.
Policy for LTBI caused by a multidrug-resistant strain
Consult an expert.
Consult the tuberculosis coordinator if necessary (Dr Magis-Escurra, pulmonologist; Prof van Crevel, infectious diseases physician) regarding indication, choice and/or monitoring
Treatment notes
For rifampicin: check the consequences of any interactions when starting and stopping rifampicin