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Louisiana Statistics

Drug Resistant TB Cases in Louisiana,1998-2018.pdf

Tuberculosis Control Program

HELPFUL INFORMATION

Blood Assay for Tuberculosis - Decision to implement Blood Assay for Tuberculosis (BAMT)/ Interferon Gamma Release Assay (IGRA).

Links

dhh.louisiana.gov › Center for Community and Preventive Health

TB Update Contemporary Topics in MTB 2010

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The Orleans Parish Triangle of TB

bermuda_triangle

Click here to see larger version of chart

To Be Informed Newsletter

To Be Informed is a newsletter/brochure in Vietnamese and English based on frequently asked questions by audience and participants of the TEACH Program. It is distributed to community venues and primary care clinics.

Fall/Winter

Discussion Points

Tuberculosis Synopsis Update

Definition : LTBI, “Chemoprophylaxis”
Targeted tuberculosis testing in high risk/high prevalence groups and “precision treatment” options
Three cut-off points for TST (tuberculin skin test) remain; However IGRA tests can substitute this test in certain circumstances
US Public health Strength of recommendation ABC
Quality of evidence I II III
Duration of LTBI Rx: 6- 9 months
Flexibility based on local public health considerations.

Recent Changes in Emphasis

Criteria for PPD TST (tuberculin skin test) positivity, by risk stratification
New definition of PPD TST (tuberculin skin test) converter: increase in 10 mm or more within a 2-year period.
Clinical monitoring
Lab monitoring in (a) HIV (b) pregnant (c) postpartum (d) Hx of liver disease
(e) Those who continue use of alcohol regularly. (f) Other medical conditions. For
cessation of Rx on the basis of LFTs recommended:
Rule of “FASTS” 5 times if asymptomatic; 3 times if symptomatic
Intermittent Rx must be DOPT
Rifabutin in place of Rifampin in HIV patients where PI's are used
In pregnant women with HIV or recent contact history or conversion, treatment should be started even in the first trimester.
In other lower risk pregnant patients, Rx can be deferred till after delivery
Options in INH resistant or PZA intolerant patients available
Immune-competent contacts of MDRTB with LTB, PZA/ETM or PZA/QUIN for
6 months.
Immune-compromised contacts of MDRTB…………Rx for 12 months

Teaching Bullets

Acid-fast
Obligate aerobe: Involvement of spleen/heart?
Intracellular
Replication time 15-20 hours
New Colonies generally do not appear after 6 weeks
99% Niacin-positive
Flouroscient stain more sensitive than CF stain ( Overall: low sensitivity with 10000 (10 X4) bact/cc. Quantitatively: Rare= 3-9/slide; few =>10/slide; numerous 1/oil
PCR: false positive
DNA probe: rapid but expensive for ID
Other AFB = Nocordia,Legionella Micadei
40-70 % of patients with MTB isolated on culture have positive smears
Culture = egg based or agar based
CXR: nodular= 10x2 -10x4; Cavitary=10x7-10x9
With treatment:
Within 15 days: TB bacilli decrease 2 log i.e. 10x6 to 10x4
Cough decreases in 40 % in 1 week and 65 % in 2 weeks
Drug regimens that do not include INH do not render the patient non infectious as rapidly
Operational implications regarding infectiousness should be modified depending upon living and working conditions.
Under standard conditions and humidity, 60% survive 3 hours and 30 % survive 9 hours
Rate of TB:
15/1000 close contacts
3/1000 - close contacts
Control:
BCG reduces the growth of organisms in macrophages
In low incidence areas---endogeneous infection—Rx LTB
In high incidence areas—exogeneous infection---TB control measures
PPD test:
48-72 hours -1 week. Plant Day 0 ; if not read in 7 days, replant 48-72 hours later
Booster/2 step

0	2 weeks	result
-	-	-
-	+	+ Booster Reaction, not conversion
+		+ Positive

PPDtest

Except in children, the size of the PPD TST (tuberculin skin test) reaction bears no relationship to the likelihood of active TB.
BCG induced reactions are smaller and tend to wane more quickly than reactions caused by naturally occurring infections
History of BCG generally ignored in the US
LTB: Treatment (Chemoprophylaxis)
80% reduction in incidence of active TB
50% less per year
Overall 60% reduction

PULM TB
35-80 % of patients have fever
11% have hyponatremia
Single early morning specimens have higher yield and lower rate of contamination than pooled specimens. Increase in yield between 3-5 specimens is low
Drug resistant mutants: ETH 10x4; INH/SM 10x6;RIF 10x8
8-16 % delinquent rates in 6 month DOT
INH induced hepatitis: 10/1000 ( 0.1-0.3-3%)
Retrobulbar neuritis with ETH: 15 % with 50mg/kg; 1-5% with 25mg/kg; <1% with 15mg/kg. Increased with renal dysfunction
50% of untreated TB patients die within 5 years
25% remain chronically ill with positive sputum cultures and infectious
25% resolve spontaneously
Steroids in TB: Cachexia,shock,ARDS,Pericardial disease
Lymphnode TB: Medical Rx after aspiration better outcome than surgical excision and Rx
Pleural TB: 30 % have no evidence of pulm lesions on CXR
Pl Fluid: 10 % eosinophils and 5 % mesothelial cells rules out TB
POTTS: Two adjacent vertebrae with IV disk ( lower thoracic and upper lumbar)
CSF : AFB smear 20% +, Culture 50-80%
TB peritonitis: Active TB uncommon; 50 % have MTB culture positive
GU TB: 50-70 % have old TB
50% of those with pericardial disease have pleural involvement

Quantiferon TB Gold/TB Spot Test
Gamma Interferon necessary for activation of microbicidal mechanism in macrophages
Nitric Oxide: Microbicidal and bacteriostatic
Murine macrophages which produce NO both inhibit growth and kill virulent human TB bacilli in vitro when activated by TNF alpha and gamma interferon
Cytokines and lymphokines have the ability to organize granulomas and wall of infection, decrease bacillary load and restrict the mobility of infected macrophages and hence spread of infection
In immune-deficiency individuals, decreased TNF causes lack of granuloma formation and hence unrestricted spread.
Caseation necrosis and cavitation is due to killing of TB bacilli with cytokines and T lymphocytes
MMWR - TIGRA TB Tests June 2010 Update
NTM/MOTT

Who Dat Mott 2011 PowerPoint Presentation

Of all Mycobacteria isolated in 41state labs
65% NTM
21% MAC
5% Mycobacterium kansasii (MyKS)
MAC in HIV :serotype 4-8
Rx of MAC in non immune compromised host: 50 % successful with 20 % relapse
Mycobacterium kansasii (MyKS)
Colonization less frequent than MAC
53 % of those from whom MyKS isolated truly had invasive disease
Same criteria of dx
35-40% have no significant lung disease
Rapid growers
beaded gram positive rods on gram stain
MyCh/Mfort: Sternal osteomyelitis, mediastinitis,pericarditis,vascular inv, aspiration pneumonitis
MAC-PD Management Strategy & NTM Summary

For more information regarding NTM/MOTT, please click on the following link: Nontuberculosis Mycobacteria Info & Research

Contemporary Topics in MTB 2010 through the Wemore TB Clinic Tour

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TB & HIV: Quadruple Jeopardy

tb_hiv

Atypical TB/NTM/MOTT : Background

Although most non-tuberculosis mycobacterium (NTM) are isolated from water, soil, and the environment and essentially may be ubiquitous, nevertheless, they may be hither to an under appreciated source of lung disease. NTM has been recognized as human pathogens as far back as 1950, and were prevalent in a distinct epidemiological setting in elderly white males, with an underlying chronic lung disease. Some forms of NTM's, specifically Mycobacterium avium-complex (MAC) are a frequent cause of opportunistic infection in immune compromised hosts and have been recognized more in the HIV population. However, NTM can also occur in immunosenescent individuals and even normal hosts, and not infrequently seen in geriatric population. Clinicians in the community have been aware of this increasing problem, but have been limited by the poor correlation that exists between bacteriological diagnosis of infection, and its clinical and radiological manifestation. This perpetuates an empiric and albeit challenging approach towards its treatment and management. Further, NTM infections in the form of MAC, M.Kansasii, M. Chelonei and M. Gordonoe to name a few, may not only co-exist with other infections, but require specific and different treatment regimes for variable durations. Since the advent of HIV in the 1980's, more attention has been paid to NTM infection. Recent reports of increasing incidents of this infection in middle-aged non-smoking females, with no underlying lung disease or no obvious immune deficiency state bring this problem to the attention of the public at large and the medical community in particular. National surveys in the early 80's indicated that about 33% of all mycobacterium isolates in clinical laboratories were due to NTM, and a later survey confirmed this observation. This data does not include patients with HIV and disseminated NTM disease, and neither does it factor the changing epidemiology of the infection as we see it today. In one suburban community survey in Virginia during the period of 1990-1992, twenty out of twenty-one cases of mycobacterium disease were due to NTM, and 80% of these were due to MAC. Being not a reportable disease, these are estimates based on indirect evidence. It is our observation also, that infection with NTM's represents a poorly recognized cause of lung infection in middle-aged and elderly patients in the community in Louisiana and the tri-state area.

Clinical information

X-ray findings in pulmonary tuberculosis with and without HIV infection has been described well. However, x-ray evidence of Atypical TB is non specific with pulmonary nodules and signs of scarring. All efforts to distinguish between colonization, persistent infection, and infection causing disease require a comprehensive correlation between clinical condition, bacteriological data, x-ray evidence, and progression of disease. This is not only a clinical challenge for the physician but a source of uncertainty for the patient and the family. The treatment protocols for such patients, once a need for treatment is determined, necessitates a long term multi-drug therapy plan, with substantial patient costs and increased morbidity both due to the disease, as well as, due to drug related side effects.

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School of Medicine

Tuberculosis | LSU Wetmore Foundation