Tuberculosis: 5 page review article: Management of Active Tuberculosis

Management of Active Tuberculosis
BETH POTTER, M.D., KIRSTEN RINDFLEISCH, M.D., University of Wisconsin Medical School, Madison, Wisconsin
CONNIE K. KRAUS, PHARM.D., University of Wisconsin School of Pharmacy, Madison, Wisconsin
Nearly one third of the world’s population is infected with Mycobacterium tuberculosis.1 More than one half of all infections occur in China, Southeast Asia, and the Indian subcontinent; the highest per capita incidence occurs in sub-Saharan Africa.2 In the United States, the incidence of active tuberculosis has decreased steadily since 1992.3 However, the rate of decline has slowed in the past two years.4 Some states and urban centers still report increases in infections, and disparities in incidence and morbidity persist among certain high-risk groups.
Screening and Primary Prevention
The U.S. Preventive Services Task Force5 recommends routine screening for tuberculosis in high-risk populations (Table 1 5). The goal of his recommendation
is to identify persons at significant risk for progressing to active disease. A validated riskassessment questionnaire may be used to identify children
who are likely to benefit from screening (Table 2 6). Primary prevention efforts have focused on the bacille Calmette-Guérin (BCG) vaccine, a live vaccine derived from an attenuated strain of Mycobacterium bovis.
Although BCG vaccine is used commonly in many parts of the world, few data support its effectiveness in reducing tuberculosisrelated morbidity and mortality in the general population. However, vaccination does reduce the occurrence of severe (e.g., meningeal) and disseminated forms of tuberculosis in young children. In the United States, vaccination may be considered for children
with continuous and unavoidable exposure to adults with inadequately treated or multidrug-resistant active disease.7 The decision to vaccinate should be made in consultation with local tuberculosis control programs.
Diagnosis
The diagnosis of active tuberculosis begins with a high index of suspicion for disease. A positive acid-fast bacillus (AFB) smear or positive culture for M. tuberculosis confirms active disease. However, if the suspicion for active disease is high enough, treatment should begin without waiting for a final diagnosis.
Although the overall incidence of tuberculosis has been declining in the United States, it remains an important public health concern, particularly among immigrants, homeless persons, and persons infected with human immunodeficiency virus. Patients who present with symptoms of active tuberculosis (e.g., cough, weight loss, or malaise with known exposure to the disease) should be evaluated. Three induced sputum samples for acid-fast bacillus smear and culture should be obtained from patients with findings of tuberculosis or suspicion for active disease.
If the patient has manifestations of extrapulmonary tuberculosis, smears and cultures should be obtained from these sites. Most patients with active tuberculosis should be treated initially with isoniazid, rifampin, pyrazinamide, and ethambutol for eight weeks, followed by 18 weeks of treatment with isoniazid and rifampin if needed. Repeat cultures should be performed after the initial eight-week treatment.
(Am Fam Physician 2005;72:2225-32, 2235. Copyright © 2005 American
Academy of Family Physicians.)
http://www.aafp.org/afp/2005/1201/p2225.pdf