Guidelines on

Tuberculosis
Ron Christian Neil T. Rodriguez, MD
Third Year Resident
Objectives

• To review the current guidelines of diagnosing and managing cases of tuberculosis in the
Philippines as per the National Tuberculosis Control Program Manual of Procedures
(NCP-MOP) 6th edition
Definition of Terms

• Active TB disease - a presumptive TB that is either bacteriologically confirmed or

clinically diagnosed by the attending physician
• Pulmonary TB (PTB) – refers to a case of tuberculosis involving the lung parenchyma. A
patient with both pulmonary and extra-pulmonary TB should be classified as a case of
pulmonary TB.
• Extra-pulmonary TB (EPTB) – refers to a case of tuberculosis involving organs other
than the lungs (e.g., larynx, pleura, lymph nodes, abdomen, genito-urinary tract, skin,
joints and bones, meninges).
Definition of Terms

• Bacteriologically confirmed TB (BCTB) – refers to a patient from whom a biological

specimen either sputum or non-sputum sample is positive for TB by smear microscopy,
culture or rapid diagnostic tests (such as Xpert MTB/RIF, Line Probe Assay for TB, TB
LAMP)
• Clinically diagnosed TB (CDTB) – refers to a patient wherein the criterion for
bacteriological confirmation is not fulfilled but diagnosis is made by the attending
physicians on the basis of clinical findings, X-ray abnormalities, suggestive histology
and/or other biochemistry or imaging tests
Definition of Terms

• New Case - refers to a patient who has never had treatment for TB or who has taken anti-
TB drugs for less than 1 month. Preventive treatment is not considered as previous TB
treatment
• Retreatment/Previously treated for TB - refers to a patient who had received 1 month or
more of anti-TB drugs in the past, and has contracted TB once more.
Systematic Screening for TB

• As per the NCP-MOP, systematic screening should be practiced in ALL healthcare

facilities
• Systematic screening – refers to the systematic identification of presumptive TB in a
predetermined target group, using examinations or other procedures that can be applied rapidly

• Symptom based screening is considered as the primary screening tool for systematic
screening, using the 4 cardinal symptoms of TB: at least two weeks duration of: cough,
unexplained fever, unexplained weight loss, and night sweats.
Systematic Screening for TB

• Another primary screening tool for TB is the use of chest radiography (Chest X-ray),
which is recommended to be done annually among all health facility consults
• Household members and close contacts of index patients should be screened for TB via
symptom-based and via chest x-ray
Systematic Screening for TB

• Presumptive pulmonary tuberculosis (TB) – refers to any person having: a) two weeks or
longer of any of the following - cough, unexplained fever, unexplained weight loss, night
sweats, or b) Chest X-ray finding suggestive of TB
• Presumptive Extrapulmonary TB - refers to anyone having signs and symptoms specific
to the suspected extra-pulmonary site with or without general constitutional signs and
symptoms such as unexplained fever or weight loss, night sweats, fatigue and loss of
appetite
Systematic Screening for TB

• In any age, presentation of the following may classify a patient as having extrapulmonary TB:
• Gibbus, especially of recent onset (resulting from vertebral TB/Pott’s disease);
• Non-painful enlarged cervical lymphadenopathy with or without fistula formation;
• Neck stiffness (or nuchal rigidity) and/or drowsiness suggestive of meningitis, with a sub-acute onset or raised
intracranial pressure;
• Pleural effusion;
• Pericardial effusion;
• Distended abdomen (i.e., hepatosplenomegaly) with ascites;
• Non-painful enlarged joint; and
• Signs of tuberculin hypersensitivity (e.g. phlyctenular conjunctivitis, erythema nodosum)
Systematic Screening for TB in Children

• As per the NCP-MOP, a child is defined as any individual aged below 15 years old
• A child presenting with at least one (1) of the three (3) main signs and symptoms
suggestive of TB is classified as presumptive TB. The three main signs are: at least 2
weeks of coughing/wheezing, unexplained fever, and unexplained weight loss or failure
to thrive
Systematic Screening for TB in Children

• If the child is a contact of a person known to have TB, the presence of fatigue, reduced
playfulness, decreased activity, not eating well or anorexia that lasted for 2 weeks or
more should also be considered and identify them as a presumptive TB.
• Chest xray screening is not routinely recommended in children, except if they are 5 years
old and above
Systematic Screening for TB in Children

• If the child is a contact of a person known to have TB, the presence of fatigue, reduced
playfulness, decreased activity, not eating well or anorexia that lasted for 2 weeks or
more should also be considered and identify them as a presumptive TB.
• Chest xray screening is not routinely recommended in children, except if they are 5 years
old and above
Diagnosing TB Cases

• Should an individual be considered as presumptive TB (or by history is considered multidrug resistant TB

(MDRTB)), the next step is to confirm it via the use of a rapid diagnostic test (RDT), such as the sputum
GeneXpert MTB/Rif
• The only contraindication to collecting sputum for bacteriological diagnosis of TB is massive hemoptysis which is
expectoration of large volumes of blood from the respiratory tract. Blood streaked sputum can still be examined

• If an extrapulmonary TB is considered, collection of the body fluids or biopsy sample for GeneXpert is
recommended
• Alternatives for GeneXpert (if it is unavailable), include the smear microscopy and the TB loop mediated
isothermal amplification (LAMP) test
• Unavailability of Xpert MTB/Rif test should not be a deterrent to diagnose TB disease bacteriologically
Diagnosing Extrapulmonary TB Cases
Diagnosing TB Cases

• If bacteriologic confirmation is not possible or is negative, evaluation by a physician

should be done to classify a patient as a case of clinically-diagnosed TB
• A TST or PPD (Mantoux) test should be used only as an adjuvant when there is doubt to
make clinical diagnosis of TB in children
• An induration of at least 10 mm regardless of BCG vaccination status or 5 mm in
immunocompromised children (e.g. severely malnourished) is considered a positive TST
reaction
Diagnosing TB Cases

• If considering extrapulmonary TB, this can be bacteriologically confirmed via the use of
a GeneXpert MTB/Rif
• If bodily fluid or biopsy cannot be obtained, it is recommended to start an antibiotic trial
and follow up after 1 to 2 weeks
• Extrapulmonary TB can be clinically confirmed based on signs and symptoms, imaging
studies, histology or other laboratory tests
Treatment of TB

• Patients who will undergo treatment are classified as either new cases or previously treated
cases/retreatment cases
• If a patient is considered as a Retreatment case, they may be further classified as follows:
• Relapse – previously treated for TB and declared cured or treatment completed, but is presently diagnosed
with active TB disease
• Treatment after Failure – previously treated for TB but failed most recent course based on a positive SM
follow-up at 5 months or later; or, a clinically-diagnosed TB patient who does not show clinical improvement
anytime during treatment
• Treatment After Lost to Follow-up – previously treated for TB but did not complete treatment and lost-to-
follow up for at least 2 months in most recent course
Treatment of TB

• If a patient is considered as a retreatment case, they may be further classified as follows:

• Previous Treatment Outcome Unknown – previously treated for TB but whose outcome in
the most recent course is unknown
• Patients with unknown previous TB Treatment History – patients who do not fit any of the
categories previously mentioned or previous treatment history is unknown (this group will be
considered as Previously Treated also)
Treatment of TB

• Once patient has completed the intensive phase, a sputum microscopy is requested at the
end of the 2nd month of medications to evaluate the need to continue current regimen or
shift to a drug resistant regimen
Treatment of TB
Treatment Outcomes
Preventive Treatment of TB

• Latent tuberculosis infection (LTBI): A state of persistent immune response to stimulation

by Mycobacterium tuberculosis antigens with no evidence of clinical manifestations of
active TB disease.
• No gold standard test for direct identification of Mycobacterium tuberculosis infection in
humans. The vast majority of infected people have no signs or symptoms of TB but are at risk
for active TB disease
Preventive Treatment of TB

• In cases of LTBI, preventive treatment should be done if they fall under the following conditions:
• People living with HIV aged one year and older (regardless of history of contact)
• All household contacts of bacteriologically-confirmed pulmonary TB
• Children less than 5 years old who are household contacts of clinically diagnosed pulmonary TB
• Close contacts of bacteriologically-confirmed pulmonary TB (outside the household)
• Other risk groups
• Patients receiving dialysis,
• Patients preparing for an organ or hematological transplantation
• Patients initiating anti-TNF treatment
• Patients with silicosis
Preventive Treatment of TB

• A TST can be done to evaluate if the individual in question can receive preventive treatment
or not
• The following eligible groups do not require TST. They may be offered TPT once active TB
is ruled out.
• People living with HIV aged 1 year or older
• Children less than 5 years old who are household contacts of bacteriologically-confirmed
pulmonary TB
• Individuals aged 5 years and older with other TB risk factors and who are household contacts of
bacteriologically confirmed pulmonary TB
Preventive Treatment of TB

• Perform TST in the following individuals. If TST is not available, it is not recommended to offer LTBI treatment
to these individuals.
• Children less than 5 years old who are household contacts of clinically diagnosed pulmonary TB
• Household contacts of bacteriologically-confirmed pulmonary TB case who are 5 years and older but with no other risk
factor for TB
• Close contacts of bacteriologically-confirmed pulmonary TB
• Other risk factors:
• Patients receiving dialysis,
• Patients preparing for an organ or hematological transplantation
• Patients initiating anti-TNF treatment
• Patients with silicosis
Preventive Treatment of TB

• Current preventive treatment regimens under the program is 6 months of Isoniazid (6H)
• Alternatives, if available, include:
• 3 months of isoniazid and rifapentine (3HP)  for pregnant women and for those age less than
2 years old OR
• 3 months of isoniazid and rifampicin (3HR)  preferred for children OR
• 4 months of isoniazid and rifampicin (4HR)  preferred for adults
Preventive Treatment of TB

• Baby born to mother with active TB disease

• Assess the newborn. If the newborn is not well, refer it to a specialist/pediatrician.
• If the newborn is well (absence of any signs or symptoms presumptive of TB), do not give
BCG first. Instead give TB preventive treatment. Give Pyridoxine at 5-10 mg/day.
Preventive treatment is not necessary if the mother has received more than 2 months of anti-
tuberculosis treatment and is not considered infectious.
• At the end of treatment, perform TST. If TST is negative or not available, give BCG.
• If the mother is taking anti-TB drugs, she can safely continue to breastfeed. Mother and
baby should stay together and the baby may be breastfed while on TB preventive treatment.
Reference

• National Tuberculosis Control Program Manual of Procedures 6 th edition

THANK YOU!