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W. J. Fenton MD, FRCPC, FACP Clinical Professor of Medicine, U of S

TB 101 for Primary Care Providers. W. J. Fenton MD, FRCPC, FACP Clinical Professor of Medicine, U of S. Patient First. Patient First. TBC & partners have always put the patient first: Mobile clinics Try to be flexible concerning drug delivery Incentives if need be

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W. J. Fenton MD, FRCPC, FACP Clinical Professor of Medicine, U of S

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  1. TB 101 for Primary Care Providers W. J. Fenton MD, FRCPC, FACP Clinical Professor of Medicine, U of S

  2. Patient First

  3. Patient First TBC & partners have always put the patient first: • Mobile clinics • Try to be flexible concerning drug delivery • Incentives if need be In all we do collectively, we constantly should strive to make the patient first in our thinking and our actions.

  4. Think TB

  5. While you are thinking ….

  6. While you are thinking …. If you are dealing with TB – THINK HIV TBC tests for HIV in those we see with a positive TST age 14 and up If you are dealing with HIV – THINK TB

  7. Look for Early TB

  8. Look for Early TB • Cough 4/52 or more (If a smoker look for persistent change in cough of 4/52) • Unexplained fever of > 1/52 • Antibiotic resistant pneumonia (on CXR) May not be TB but check for it: sputum CXR

  9. Get Specimens

  10. Get Specimens Specimens help to: • Confirm/exclude diagnosis • Without a + culture the diagnosis remains presumptive • Identify the organism • Identify drug sensitivities

  11. Get Specimens • “If they are coughing get sputum” • do it now while they are in clinic • but also try to get some morning sputa • 3 AM sputa maximizes yield • Consider inducing the sputum if necessary • With Miliary TB may also consider urine, bone marrow • With very low CD4 count consider blood culture for TB

  12. Understand the Limitations of Radiology

  13. Understand the Limitations of Radiology • CXR & CT are crucial parts of TB evaluation BUT

  14. Understand the Limitations of Radiology • CXR & CT finding may suggest TB but do not prove it • e.g. recent case • Normal CXR does not exclude active TB • (Marciniuk Chest 1999;115:445-452) • TB has typical patterns but can look like anything on CXR

  15. Look at the Whole Picture

  16. Look at the Whole Picture As with any illness, look at the whole picture don’t just treat a test. history physical tests, CXR’s environment

  17. Focus of Contact Tracing

  18. Focus of Contact Tracing Primary TB – looking for someone who is coughing (looking for source) - age 15 & up Active smear + (culture +) TB – looking for spread - age <5 - HIV+, other immunosupression

  19. Never Monotherapy

  20. Never Monotherapy Why?

  21. Never Monotherapy Monotherapy will inevitably lead to drug resistance

  22. Why two drugs? • The organisms in a large active population e.g. cavity, will innately have some organism resistant to a drug. • The chance of an organism being resistant to two drugs is so small as to be non-existent . • When starting active treatment, want two drugs that the person has not been previously exposed to

  23. How treatment failure can occur

  24. Treatment Failure • Non-compliance • No drugs work if you don’t take them • Large rapidly growing population - selection of resistant organisms • Must have at least two drugs the organisms are sensitive to • Prescription error • Patient decides to delete one drug • Slow growing population - persistent organisms • Drugs not continued long enough • Long enough but not enough doses in the alotted time

  25. Where TB organisms live

  26. Location Vs Drug Effectiveness Activity on organisms CavityMacrophCaseum SM +++ 0 0 INH ++ + 0 RMP ++ + + EMB +/- +/- 0 PZA 0 ++ 0

  27. Activity of First-Line Drugs

  28. Why DOT?

  29. Why DOT? Cochrane Review trashed it!

  30. 407 cases of SAT, then switched to 581 of DOT, results are despite higher IV drug use, more homelessness and rising TB rates • DOT • Identifies compliance • issues quickly (audit) • Ensures drugs are taken together Weis et al NEJM 1994;330:1179-1184

  31. Active Disease Risks

  32. Active Disease Risk Untreated TB Infection 50% Pulm 30-40 M/M 10-20 20-30% Pulm 1-20 M/M 2-5 10% 1st yr, 2nd yr, 3-4, 5-10, 10+

  33. Infection Risks Can Stds P 184

  34. Active Disease Risks Untreated TB infection Compared with infected person with No risk factors & normal CXR 2-5x 20-30x100+x Granuloma on CXR (2) fibronodular on CXR (6-19) HIV infection (50-110) Smoke 1 ppd (2-3) TB infection within 2 yrs (!%) AIDS (110-170) infected age 0-4 (2.2-5) CA head & neck (16) <90% ideal wt (2-3) CRF on hemodialysis (10-25) DM (2-3.6) silicosis (30) TNF inhibitors (1.5-4) Transplantation (20-74) CS Rx (4.9) 20-30%

  35. Active TB Risk Factors

  36. Infection Risks Can Stds P 65

  37. TST Screening & BCG status Saskatchewan study comparing young kids who had or did not have neonatal BCG vaccination: At age 4 – no difference – TST 10 mm valid < age 4 - TST 15 mm valid TST < 15 “grey area” consider community & age risk Reid et al: Chest 2007;131;1806-1810

  38. Can doctors or nurses predict which patient will be compliant with medications use?

  39. NO!

  40. What is this?

  41. 6 months earlier

  42. Tuberculous Pleural Effusion * usually resolves spontaneously * active TB will develop in up to 60% * usually unilateral *more common in young men * DTH reaction to a few bacilli * smear negative fluid, culture positive in only 1/3 *pleural biopsy for diagnosis * Induced sputum may be positive

  43. How does HIV change TB Management

  44. How does HIV change TB Management • Test for HIV • All active TB cases • Contacts if at risk for HIV • Contacts if index cases is HIV-TB co-infection • TST • 5 mm is positive IN HIV+ PATIENT • Sensitivity decreases as CD4 count decreases

  45. How does HIV change TB Management • Active TB in HIV+ • May lack typical clinical & CXR features • More LN, pleural, meningeal, pericardial involvement • CXR may be normal • Aggressive sampling • Sputums even if CXR normal • Blood culture if CD4 <50-100 • If negative TST, consider repeat after ART & immune reconstitution

  46. How does HIV change TB Management • LTBI in HIV+ • Treat unless well documented previous treatment • ? Benefit of Rx in TST- or anergic HIV+ • HIV+ with recent infectious TB exposure – treat for LTBI regardless of TST status • High re-infection risk in HIV+ • Consider LTBI Rx for HIV+ TST-: • High epidemiologic risk • CXR features suggest past TB • Treat LTBI in pregnancy

  47. How does HIV change TB Management • Tx of TB in HIV+ • The good news – for fully sensitive TB the following are the same as in HIV- cases: • Cure rates • Clinical response rate • Culture conversion time • Relapse rates

  48. How does HIV change TB Management • Tx of TB in HIV+ • RMP (rifamycins) very important • BUT.. RMP interferes with some AR drugs • TB & HIV docs need to connect • Rx for 9/12 may be wiser than shorter courses • If CD4 <100 do not use RMP less than 3x/wk • Increased RMP resistance • ? Reduced absorption of RMP & EMB in HIV+ • DOT is standard • HIV+ may be more prone to INH neuropathy • B6 25 mg • Initiate ART early

  49. If you want things to happen(want service)

  50. If you want things to happen(want service) Phone Don’t just send a letter or requisition e.g. x-ray req’n

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