1 Practical Guide For Diagnosis Treatment of People TB

Machine Translated by Google
Practical
guide
for diagnosis
treatment
and
of people
with
TB at the first
level of care
President of the Nation

Mr. Mauricio Macri
Minister of Health and Social

Development Dr. Carolina Stanley
Government Secretary for Health Prof.

Dr. Adolfo Rubinstein
Secretary of Health Promotion, Prevention and Risk Control Dr. Mario

Kaler
Undersecretary for Prevention and Control of Communicable

and Immunopreventable Diseases Dra. Miriam Inés Burgos
Director of AIDS, STDs, Hepatitis and Tuberculosis

Prof. Dra. Claudia Gabriela Rodriguez
Coordinator of the National Tuberculosis and Leprosy Control Program

Dra. Marcela Natiello
Team of the National Tuberculosis and Leprosy Program

Aldana Acuña Cynthia Araoz Lic. Luciana Acuña
Lic. Maia Chernomoretz

Lic. Sergio Ioannoy
PRACTICAL GUIDE
FOR DIAGNOSIS AND TREATMENT
OF PEOPLE WITH TB
AT THE FIRST LEVEL OF CARE
Practical Guide for the diagnosis and treatment of people with TB at the first level of care
Writing Dr.
Santiago Jiménez
Collaboration in the Writing Lic.

Marisela Núñez Team of the National
Program for the Control of Tuberculosis and Leprosy
Revision
Interdisciplinary Advisory Committee of the National Program for the Control of
Tuberculosis and Leprosy Dr. Diego Caiafa Dr. Laura Lagrutta Marcelo Vila PAHO/
WHO Argentina
Interdisciplinary Advisory Committee

Lic. Silvana Agüero, Instituto Vaccarezza/Network of Social Workers intervening in TBC
of AMBA Dr. Sergio Arias, INER, Instituto Coni Lic. Claudia Balenzano, Cesac 18/
Network of Social Workers intervening in TBC of AMBA
Dr. Raquel Sarobe, Buenos Aires Farm Province TB Program. Adriana

Domecq, Instituto Vaccarezza/Hospital Muñiz Dr. Alejandra Gaiano, Dir.
AIDS/SADI Dr. Norma Gonzalez, Hospital Elizalde/SAP Dr. Sandra
Inwentarz, Instituto Vaccarezza Dr. Pablo G. Montaner, Hospital Muñiz
Dr. Alfredo Moran, TB Program Mendoza Dr. Domingo Palmero,
Vaccarezza Institute/Muñiz Hospital Dr. Jorge Poliak, Former Penna
Hospital Dr. Bernardo Salvadores, Santa Fe TB Program Dr. Norberto
Símboli, ANLIS, Malbrán Institute Dr. Marisa Vescovo, Vaccarezza/H.
Muñiz Lic. Luciana Angueira, National TB Program/Network of Social
Workers intervening in TB of AMBA
Dr. Marcela Natiello, National TB Program / Vaccarezza Institute
Design: Andrés Venturino
The technical and financial contribution of the Pan American Health Organization/World
Health Organization (PAHO/WHO) for the development of this publication is gratefully
acknowledged. The points of view or opinions contained therein are those of the authors
and do not necessarily represent those of PAHO/WHO.
4
Index
Abbreviations 6
Introduction 8
TB situation in Argentina 13
Generalities fifteen
How do I confirm the diagnosis? What should I request? 19
What complementary studies are necessary? 25
How do I classify a patient with Tuberculosis? 27
How is the treatment? 30
How is the patient's medical follow-up? 39
What is a Latent Tuberculosis Infection?

How is your diagnosis and treatment? 41
How do I search for contacts? What do I do with them? 44
What should I take into account in special populations? 48
What can the health team do to put an end to

tuberculosis? 55
flowcharts 59
Annex: Nutrition and Tuberculosis 61
Bibliography 64
5
Abbreviations
3TC Lamivudine
AFB Acid alcohol resistant bacillus
BCG Bacillus Calmette and Guérin
BK smear microscopy
E ethambutol
EFV Efavirenz
FTC Emtricitabine
H Isoniazid
IP protease inhibitors
WHO World Health Organization

PDS Sensitivity test
PPD Purified Protein Derivative Skin Test
R Rifampicin
CNS Central nervous system
SNVS.2 National Health Surveillance System 2
Respiratory Symptomatic SR
ART Antiretroviral treatment
TB Tuberculosis
MDR-TB Multidrug-Resistant Tuberculosis
XDR TB Extensively Resistant Tuberculosis
ETB Extrapulmonary Tuberculosis

LTBI Latent Tuberculosis Infection
PTB Pulmonary Tuberculosis
TDF Tenofovir disoproxil fumarate

DOT Directly observed treatment
6
VDRL Venereal Disease Research Laboratory
HBV Hepatitis B Virus
HCV Hepatitis C Virus

HIV Human Immunodeficiency Virus
Z Pyrazinamide
7
Introduction
Tuberculosis (TB) continues to be a serious public health

problem in the region of the Americas and in the world, appearing as
the main cause of death from an infectious agent, even above HIV1.
It is estimated that in 2017 more than 10 million people

contracted TB and of these the greatest burden was borne by vulnerable
populations, affected by poverty, overcrowding, malnutrition and the
different barriers to access decent and effective health care2 ,3,4.
Every year 480,000 women and 140,000 boys and girls die with TB,
and there are 10 million orphans in the world due to this cause2.
Stopping this epidemic is possible if we achieve a paradigm

shift that takes into account all the underlying complexity behind the
pathology.
To this end, the World Health Organization (WHO) approved
the End TB Strategy in 2014 , the general objective of which is to end
the global epidemic by 2035. To do this, it is necessary to reduce the
incidence rate by 90%, 95% the absolute number of deaths (relative to
the 2015 baseline), and reaching 0% of patients whose households
experience catastrophic expenses due to illness.
The pillars of this strategy include:

Pillar 1. Comprehensive care and prevention focused on
the patient that guarantees, according to needs and
possibilities, timely access to diagnosis and effective
treatment, accompanied by educational, emotional and
financial support throughout the process.
8
Pillar 2. Bold policies and support systems focused on

social protection and poverty reduction, with special
attention to the needs of affected communities and
vulnerable populations.
Pillar 3. Innovation and intensified research to obtain

new diagnostic methods, medicines, vaccines and
innovative services5 .
The objective of this guide is to present up-to-date

information that helps health personnel, patients, and the
community to orient themselves in decisions about TB care and
prevention, without replacing the clinical criteria of acting
professionals, who must adapt the recommendations to each local
reality, according to the context in which they carry out their activity.
9
End TB Strategy
PILLAR 1. Comprehensive TB care and

prevention centered on the patient
Timely diagnosis of TB,

including universal access to
anti-TB drug susceptibility
testing and systematic screening
of contacts and high-risk groups.
Treatment of people with TB and

drug-resistant TB, with patient-
centred support.
Preventive treatment for

people at high risk and vaccination
against TB.
Collaborative TB/HIV activities,

and treatment of comorbidities.
10
PILLAR 2. Bold policies

and support systems
Political commitment, with

sufficient resources for TB care
and its prevention.
Participation of communities,
civil society organizations and
healthcare providers from the
public and private sectors.
Universal health coverage

policy, regulatory frameworks for
cases, vital records, quality and
rational use of medicines, and
infection control.
Social protection, poverty alleviation

and action on other determinants of
TB.
eleven
PILLAR 3. Innovation and

intensified research
Discovery, development
and rapid incorporation of new
tools, interventions and
strategies.
Research to optimize
application and impact and
encourage innovations
12
TB situation in
Argentina
13
14
General6,7
What is Tuberculosis (TB)?

It is a curable disease caused by a bacterium called
Mycobacterium tuberculosis, also called Koch's bacillus. Due to its
resistance to discoloration in certain stains it is reported as BAAR (acid
alcohol resistant bacillus).
It is transmitted from person to person through the air, by
inhaling droplets containing the bacilli. These are usually eliminated
by the person with pulmonary tuberculosis by coughing, spitting,
sneezing or speaking7 .
How does the body react?

The inhaled bacilli enter the respiratory tract until they reach
the alveoli. There they are ingested by cells that are part of the non-
specific immune system (macrophages) that transport them to the local
ganglia. These nodes usually filter out foreign particles and prevent
the disease from developing. In certain circumstances the infection is
not contained at this level and spreads through the blood to any organ.
If the patient has preserved immunity, the lymphocytes enter the areas
of infection and, together with macrophages, organize themselves into
granulomas. Inside them, the bacteria remain alive but prevented from
multiplying or spreading, constituting a LATENT TUBERCULOSIS.
That is, the infection is present but controlled by the immune system.
If the immune system fails to organize the defensive barrier, the

bacilli replicate and ACTIVE TUBERCULOSIS develops.
The organ that is usually affected by this bacterium is the lung
(PULMONARY TUBERCULOSIS). However, the disease can also
take place in any other location where the bacteria have spread
(EXTRAPULMONARY TUBERCULOSIS)7 .
fifteen
What are the clinical manifestations?

LATENT TUBERCULOSIS INFECTION (LTBI)
People with latent ITB are not sick and have no symptoms. There
is no cough or expectoration, sputum smear and cultures are negative,
and chest X-ray is normal. They do not require respiratory isolation as
they cannot transmit the infection. They are usually diagnosed by a
positive tuberculin test (ppd).
Latent ITB does not constitute a case of tuberculosis.
Its treatment is considered in certain circumstances, to avoid the
development of the active form (see Diagnosis and Treatment of latent
ABI)7 .
ACTIVE TUBERCULOSIS (TB)
Depending on its anatomical location, it can be:

• Pulmonary tuberculosis
It is the most frequent. It comprises 85% of the cases. It is
characterized by cough and expectoration for more than 15
days, with or without hemoptysis, accompanied, in most cases,
by general symptoms such as weight loss, fever, night sweats,
and loss of appetite.
VERY IMPORTANT!
All patients with cough and expectoration greater than

15 days are defined as respiratory symptomatic (SR)
and should be studied to rule out pulmonary tuberculosis.
• Extrapulmonary tuberculosis
It usually manifests with constitutional symptoms (fever, weight
loss, and night sweats) accompanied by specific symptoms
related to the site of infection. It can involve any organ, although
nodal forms (large, asymmetric and sometimes painful
adenomegalia), pleural (pleural effusion with predominantly
lymphatic exudate) are more common.
16
focytic), meningeal (persistent headache, meningismus,

confusional syndrome), pericardial (pericardial effusion
with lymphocytic exudate) and others (osteoarticular,
abdominal, genitourinary, etc.).
Tuberculosis
no exposure latent ABI
(Disease)
Contact with the bacillus if there is progression
Latent ABI Tuberculosis
Symptoms None presents
infectivity No Yeah
bacilloscopy Negative Positive
Crop Negative Positive
tuberculin test Positive Positive
Treatment Isoniazid only (as prescribed) multiple drugs
How is the contagion?

Only the pulmonary and laryngeal forms are contagious. The
probability of transmission depends on the infectivity of the patient
(the more bacilli expelled, the greater the risk), on environmental
factors that favor the concentration of bacilli (closed, small places,
inadequate ventilation), on exposure (closer to and contact time, the
greater the risk) and the susceptibility of the host (nutritional status
and immunological status).
17
Although it is not very frequent, the contagion from a pregnant

woman to her child can occur through hematogenous dissemination
(congenital tuberculosis).
REMEMBER!
• Latent ITB and extrapulmonary active TB are not
infectious to other people. • In the form of
pulmonary TB, contagion is mainly through the air
and not by contact, shared surfaces or utensils7 .
• As long as treatment is not started, the patient
with pulmonary TB continues to infect
The best way to avoid contagion is for the

patient to start effective treatment.
In general, after 2 or 3 weeks, the amount of bacilli decreases

to 1% and the patient stops contagious8.
18
How do I confirm the

diagnosis of
Tuberculosis?
What should I request?7,9–12
An opportune diagnosis and an early initiation of treatment not

only reduce the risk of transmission but also the clinical, economic and
social sequelae of the disease.
The diagnosis is confirmed by identifying the causative agent, and

For this, bacteriological methods are essential.
Bacilloscopy (BK)
It is the direct observation through the microscope of sputum

samples (or other materials) after Ziehl-Neelsen staining.
It seeks to identify the presence of acid-fast bacilli (AFB). It is a simple,
inexpensive and fast technique. The results are in a few hours.
The sensitivity of sputum BK in pulmonary TB may

reach 80%.
In patients with HIV, in children and in extrapulmonary forms, it

can sometimes be negative (sensitivity = 65%), so culture of the sample
should always be requested.
Practical concepts for sputum examination
Two sputum samples should be collected. If possible on an empty

stomach and before brushing your teeth.
19
Samples from the nose and throat or saliva samples are not
suitable for analysis.
•First sample: it is collected the same day that you visit the
health facility (taken in well-ventilated environments or
outdoors). The patient receives a container to take a second
sample the next day.
•Second sample: it is picked up early at home and taken to the

health facility. The best sputum is the first in the morning.
A positive sputum smear makes the diagnosis of the

disease and allows the start of anti-TB treatment
immediately.
Once the case of Tuberculosis has been diagnosed, it is

necessary to notify it
Rapid molecular methods.

What is the Xpert® MTB/RIF?
It is a method that uses a nucleic acid amplification test and

detects the presence of a particular gene of the bacterium. Evidence
simultaneously the presence of M. tuberculosis and resistance to
Rifampicin.
Globally, it presents a sensitivity of 88% and a very high specificity

(99%).
The study is performed directly on the sputum sample or on

selected extrapulmonary samples (eg, CSF, lymph nodes).
Its great advantage is that the result is obtained in 2 hours and it

can detect up to 68% of active TB forms with copy-negative bacilli
(presence of very few bacilli).
If available, it is strongly recommended to use it as an initial

diagnostic method in children and adults suspected of having RESISTANT
TB (see below Risk groups for resistant TB), HIV ASSOCIATED TB and
MENINGEAL TB.
twenty
Crop
It is much more sensitive than smear microscopy and can increase diagnostic
confirmation by 30%. It allows the identification of mycobacteria and provides the
necessary isolation to carry out drug susceptibility tests.
The result usually takes between 2 and 8 weeks, depending on the growth of
the bacteria and the liquid or solid culture medium.
A culture should be requested for all samples with Tuberculosis.

As it requires specific laboratory equipment and technical training, it may not be
accessible in all cases.
In all patients with a history of previous TB
In patients with clinical, epidemiological or radiological suspicion

of TB with two samples with negative bacilloscopy.
In forms of TB that can present with low numbers of bacilli:
•immunocompromised, especially HIV-positive or diabetic

At the time patients •extrapulmonary forms •pediatric patients
Who to
request of diagnosis
cultivation of
the sample In patients with increased risk of drug-resistant TB (see risk
in priority groups)
Presumed exposure to Mycobacterium bovis (rural worker or

worker in contact with animals or their products: undercooked
meat and offal, unpasteurized milk and milk derivatives)
In patients with sputum-positive BK at the end of the second

During the month of treatment or later
treatment
Patients who have a negative BK and who convert to
positive during treatment
Drug Susceptibility Testing (PSD)
These are tests that detect whether an antibiotic is effective in treating the
infection.
They can be carried out by conventional methods in solid media (such as the
method of proportions, which usually takes between 4 and 8
twenty-one
weeks) or in liquid media (such as the MGIT method, which usually

takes 2 weeks); or by rapid molecular methods (such as Xpert).
All patients with initial isolation of M. tuberculosis should be
tested for susceptibility at least to rifampicin (when a rapid test is
available) or at least to isoniazid and rifampicin (if using conventional
methods).
If an isolate resistant to rifampicin is detected, it should be
tested at least to fluoroquinolones and second-line injectables.
The result allows the correct choice of treatment and early
detection of resistant forms.
VERY IMPORTANT!
It is essential to request drug susceptibility tests in all
cases where resistance is suspected (see risk groups
for resistant TB).
Risk groups for resistant TB13

• Patients with a history of anti-tuberculosis treatment
(relapses, failures, loss to follow-up)
• Patients who remain smear-positive after 2 or 3 months of adequate
treatment with first-line drugs • Patients with a history of exposure
to confirmed drug-resistant bacilli
• Patients with exposure in institutions with the highest prevalence

of resistant TB (prisoners, health institutions, closed communities).
• Patients from areas with a high prevalence of resistant TB (Bolivia,

Peru, Ecuador, Africa, former Socialist Republics) • Patients with
HIV infection • Patients with a history of problematic substance use
(alcohol and other drugs) • Patients in street situation
22
Does the X-ray work?

Chest radiography is a very important complementary
element, since pulmonary forms are the most frequent. It is not very
specific and a suspicious reading requires microbiological studies to
confirm TB.
If possible, it is advisable to perform an X-ray at the beginning
of treatment, another before going to the consolidation phase to
assess the evolution of treatment, and another at the end to assess
sequelae.
The most commonly found radiological findings are:
Immunocompetent immunocompromised
cavitation Cavitation (rare)
Infiltrates in upper lobes Infiltrate in lower lobes
pleural effusion Pleural effusion (rare)
Consolidation diffuse interstitial infiltrate
Bilateral infiltrates normal chest X-ray
REMEMBER!
In severe immunodeficiency, radiological
findings are usually atypical, there may be
signs of hematogenous spread (diffuse
interstitial infiltrate or miliary pattern) and even present
a normal radiograph.
Typical radiological findings in a non-

immunocompromised patient
23
tuberculin test
This skin test reveals only contact with the bacillus, so it does not
constitute an element to diagnose disease under any circumstances.
Its usefulness is limited to forms of latent ABI (see below diagnosis

and treatment of latent tuberculosis).
24
What
complementary
studies are necessary?
Rp/
9 Complete blood count with platelets

9 Hepatogram
9 Blood glucose
9 Urea
9 Creatinine
9 Erythrocyte sedimentation rate
9 HIV serology
9 Serology for HBV/HCV
9 VDRL*
9 Chagas*
*Although syphilis and Chagas disease do not have a direct association with TB, it is
recommended to include them in the initial routine if possible, due to the epidemiological
situation in the country and the possibility of a cure.
25
Culture and drug susceptibility test (with priority given

to groups at risk of resistant TB)
chest X-ray
Serology for HIV to all patients diagnosed with TB
Baseline laboratory with glycemia (to assess dbt)

platelets, renal function, liver function (to monitor drug
toxicity)
HBV/HCV serology to patients with risk factors (for
monitoring of liver toxicity)
26
How is a patient
with Tuberculosis
classified?14
Tuberculosis is a notifiable disease.

Data collection is fundamental to quality patient care and to
all public health policy. The following definitions will be used:
case definitions
•Bacteriologically confirmed TB: presents a positive
biological sample by bacilloscopy, culture or rapid test (such
as Xpert MTB/RIF).
•Clinically diagnosed TB: TB that does not meet the criteria
for bacteriological confirmation, but has been diagnosed with
active TB by a physician based on X-ray abnormalities or
suggestive histology and extrapulmonary cases without
laboratory confirmation.
According to the anatomical location of the disease

• Pulmonary tuberculosis (TBP): compromises the lung
parenchyma and/or the tracheo-bronchial tree. Miliary TB is
classified as PTB because there are lesions in the lungs.
Intrathoracic adenopathies or tuberculous pleural effusion
without radiological changes in the lungs do not constitute a
case of pulmonary TB. A patient with pulmonary and
extrapulmonary TB should be classified as a PTB case.
• Extrapulmonary tuberculosis (TBE): involves other organs
than the lungs. Eg pleura, lymph nodes, abdomen,
genitourinary tract, bones and meninges.
27
Based on history of prior TB treatment

•New patients: have never been treated for TB or have received
anti-TB drugs for less than a month.
•Patients previously treated:
• Patients with relapse: they were declared cured or complete
treatment at the end of their last cycle and are now diagnosed
with a recurrent episode of TB. • Patients with treatment after
failure: declared as a failure at the end of their most recent
treatment.
• Patients treated after lost to follow-up: declared lost to follow-
up at the end of their most recent treatment.
• Other previously treated patients: those whose outcome after

the most recent treatment is unknown or undocumented.
New cases and relapses are incident TB

cases
By HIV status
•Patient with TB and HIV: have a positive result of the HIV test
carried out at the time of diagnosis of TB.
•Patient with TB and without HIV: any case that has a negative
result of the HIV test performed at the time of TB diagnosis. If
he is later found to have HIV, he must be reclassified.
•TB patient with unknown HIV status: any case that does not
have any HIV test results.
According to the result of the Treatment

• Cured: patient with pulmonary TB with confirmed bacteriology
at the start of treatment and who has a negative smear or culture
in the last month of treatment and on at least one previous
occasion.
28
• Complete treatment: completed treatment without evidence of

failure, but without evidence showing that smear microscopy or
sputum culture from the last month of treatment and on at least
one previous occasion were negative, because the tests were
not done, or because the results are not available.
•Treatment failure: sputum smear or culture positive at month 5

or later during treatment.
•Deceased: patient who dies for any reason before starting or
during the course of treatment.
•Lost to follow-up: did not start treatment or interrupted treatment

for 2 consecutive months or more.
•Not Evaluated: The treatment outcome has not been assigned.

Includes “transferred” cases and cases for which treatment
outcome is unknown.
Successful Treatment is the sum of cures

and complete treatments.
29
How is
the treatment
of Tuberculosis?7,8,15–17,27
Effective treatment manages to cure the disease and reduce

the transmission of the bacillus, therefore, it is essential not only for
the patient but also for the community.
In most situations it can be performed on an outpatient
basis at the first level of care, although the following situations may
require referrals to referral centers and hospitalization:
Severe or complicated clinical forms:

meningitis, severe hemoptysis, empyema,
disseminated forms, respiratory failure
Major adverse drug reactions
Comorbidities that are difficult to manage or that

put the patient's life at risk (transplant recipients,
When to refer
immunosuppressed patients, severe liver disease,
a patient chronic renal failure)
treatment failures
drug-resistant tuberculosis
front line
Failure to adhere (intolerance to the oral

route, social vulnerability, etc.)
30
What drugs do we have?

First-line drugs are essential and form the basis of standard
treatment.
These are:
•Isoniazid (H)
•Rifampicin (R)
•Pyrazinamide (Z)
•Ethambutol (E)
The recommended doses are:
Drug Daily dose Maximum Dose Presentation Action
tab 100mg tab

Isoniazid (H) 5mg/kg 300mg BACTERICIDE
300mg
Rifampicin (R) 10mg/kg 600mg capsules 300 mg BACTERICIDAL
tab 250mg tab

Pyrazinamide (Z) 25-30 mg/kg 2,000mg BACTERICIDE
500mg
Ethambutol (E) 15-20mg/kg 1,600mg tab 400mg BACTERIOSTATIC
Rifabutin is a substitute drug for Rifampicin when it cannot be used

due to its interactions with other drugs (see Special Populations: TB and
HIV). It is considered a first-line drug.
Streptomycin (S), previously considered a first-line drug, is still

used in specific situations as part of the initial treatment (eg, for
hepatotoxicity due to first-line drugs), although with caution due to the
global increase in resistance to the drug. same.
Second-line drugs are reserved for special situations of intolerance,

adverse reactions to first-line drugs, or regimens for resistant TB.
• Fluoroquinolones: Levofloxacin, Moxifloxacin, Gatifloxacin •

Injectable Agents: Amikacin, Capreomycin, Kanamycin,
Streptomycin
• Other oral agents: Ethionamide, Prothionamide, Cycloserine,
Para-amino-salicylic acid (PAS), Terizidone, Linezolid, Clofa
zimin, Bedaquiline, Delamanid
31
What are drug associations?
They are first-line drug combinations formulated in a single

compound with fixed doses. They allow reducing prescription, dosage
and dispensing errors, as well as simplifying the number of tablets for
the patient, making treatment adherence easier.
• Double Association (HR): contains 150 mg of Isoniazid and

300 mg of Rifampicin.
• Triple combination (HRZ): contains 75 mg of Isoniazid, 150 mg
of Rifampicin and 400 mg Pyrazinamide • Quadruple
combination (HRZE): contains 75 mg of Isonia cida, 150 mg of
Rifampicin, 400 mg of Pyrazinamide and 275 mg of Ethambutol
intensive phase Second stage
Quadruple Association Quadruple Association Double Association (DA)
Duration 2 months 2 months 4 months
2 tablets TA + 2
< 40kg 2 tablets 1 AD tablet
tablets E
3 tablets TA + 3
Weight 40 – 55kg 3 tablets 2 tablets DA
tablets E
4 tablets TA + 4
> 55kg 4 tablets 2 tablets DA
tablets E
The treatment is free and is provided by

the National Program
What does the treatment consist of?

The standard treatment for patients with sensitive tuberculosis
consists of two phases:
32
Intensive phase (first phase)
The objective is to quickly reduce the number of active bacilli and thus
reduce the severity of the disease, preventing death and transmission.
It consists of two months of treatment with four drugs: Isoniazid,

Rifampicin and Pyrazinamide (powerful bactericidal association) plus Ethambutol
(helps prevent the emergence of resistant strains).
Consolidation phase (second phase)
Its objective is to eradicate the entire population of bacilli present in

the organism, which no longer has an intense replicative capacity, in order to
achieve a cure and prevent relapse of the disease.
It usually consists of four months of treatment with two drugs: Isoniazid
plus Rifampicin, although it can be extended according to certain circumstances
(see below).
The recommended regimen both in the intensive phase and

in the consolidation phase it is administered daily.
Treatment Codes
Very simple coding is used to quickly identify a treatment regimen.

It consists of a number representing the months, followed by the
abbreviations of the drugs used in each phase.
Standard TB Treatment: 2HRZE / 4HR
Initial phase of 2 months with H (Isoniazid), R (Rifampicin), Z

(Pyrazinamide) and E (Ethambutol) on a daily basis.
4-month continuation phase with H and R, on a daily basis.
In cases of relapse or new initiation of treatment after a

loss to follow-up, the recommended scheme also consists of 2HRZE / 4HR, with
initial culture and susceptibility tests essential, with subsequent modification of
the scheme in the event of resistance being reported.
The three-weekly administration strategy is not recommended for any of

the phases since it was associated with a higher risk
33
failure, relapse, and acquired resistance when sensitivity was unknown. If used
(only in the consolidation phase), it must be ensured that the patient does not lose
any of the stipulated doses and these must always be under supervised doses.
The isoniazid dose used in this case is 10 mg/kg/day (maximum = 900 mg). The
dose of rifampicin is not modified.
This strategy may affect the most vulnerable populations that present
higher risks of missing essential doses or of not correctly absorbing the medication
due to associated comorbidities.
What is the recommended

treatment time?
The recommended treatment is 6 months.
Intensive phase: always 2 months. Once it is finished, you must

request smear microscopy and control culture.
Consolidation phase: Susceptible forms of TB, both pulmonary and

extrapulmonary (pleural, nodal, pericardial TB) that do not carry a serious risk of
disability or mortality: 4 months of consolidation.
Total = 6 months (2HRZE 4HR)
In certain circumstances the treatment should be prolonged at the

expense of the second phase:
• Bone or joint TB: 7 months of consolidation. Total = 9
months (2HRZE 7HR)
• TB with CNS commitment: 10 months of consolidation.
Total = 12 months (2HRZE 10 HR)
• Treatments whose first phase could not include Pyrazinamide:
7 months of consolidation. Total = 9 months
• Patients with sensitive TB with extensive, cavitary lesions and positive
control culture at two months: 7 months of consolidation. Total = 9
months (2HRZE 7HR)
• Confirmed monoresistance to isoniazid: between 6 and 9 months of
RZE (a Fluorquinolone can be added) eg. 6 RZE-Lfx
3. 4
Patients presenting with cavitation on the initial radiograph and a

positive culture at the end of the first phase (two months) have a 22% relapse
rate compared with 2% for patients without any risk factors. This scenario justifies
extending the second phase under these circumstances (after a sensitivity test
that rules out resistance). If only one of the factors is present (cavitation or
positive culture at the second month), relapse rates are 6% and the decision to
prolong the second phase must be individualized16.
DO NOT FORGET!
In all patients with isoniazid it is necessary to supplement

with pyridoxine 25 mg/day (vitamin B6) if they are at risk of
polyneuropathies (pregnancy or lactation, patients with HIV,
diabetics, alcohol consumption, malnutrition and renal failure).
What is Directly Observed

Treatment (DOT)?
Directly observed treatment is the most efficient way.
cient to ensure adequate treatment. It is a strategy in which another person
observes and supervises the taking of the medication and in this way, through
close contact, can quickly identify suspensions, adverse effects and the need for
additional social support.
Supervision can take place in a health center (close to home), at the

workplace, in the community, or directly at home; and it must be carried out by
someone responsible, empathetic and accepted by the patient.
Ideally, the health team should organize and carry out this treatment
modality.
35
What adverse effects can be expected

from the drugs? How to proceed?
The vast majority complete their treatment without suffering
any adverse effect, however, they must be taken into account to
inform the patient and establish alarm guidelines, as well as ask
about them in each clinical control.
Some adverse effects are common, do not entail a risk
situation and allow the administration of the treatment to continue
(minor adverse effect).
Adverse effects drug probably

Recommended Handling
minors Responsible
Abdominal pain Isoniazid Give medication before bed

Nausea rifampicin or accompanied by small meals.
Anorexy Pyrazinamide If it continues and/or is
accompanied by persistent vomiting
or bleeding symptoms, consider it as
a major adverse effect and refer to rule
out hepatotoxicity.
Red or orange urine rifampicin Expected effect without clinical impact.

Reassure the patient
arthralgia Pyrazinamide non-steroidal anti-inflammatories
Drowsiness Isoniazid Give medication before going to bed.
Reassure the patient
Sensory neuropathy Isoniazid Supplement with pyridoxine

(tingling sensation or (50 – 75 mg/day)
numbness)
It is important to note that rifampicin interacts drug-wise with

many other drugs, including oral contraceptives, where it may
decrease its effectiveness.
Do not forget to recommend the use of other contraceptive methods
such as condoms or intrauterine devices while continuing anti-TB
treatment.
Another group of drugs with which it generates interactions

are dicoumarins and oral hypoglycemic agents. If used
simultaneously, stricter monitoring of the underlying pathology
should be considered.
36
When should I stop the

medications?
It is necessary before the occurrence of a major adverse effect.
Due to the seriousness of the situation, the drug under suspicion
should be withdrawn immediately and the patient referred for hospital
management or a change in regimen that does not consider including
the offending drug.
Major adverse effects Drugs likely responsible
Isoniazid / Rifampicin /
Rash with or without pruritus
Pyrazinamide / Streptomycin
Vertigo - Nystagmus –
Streptomycin
Tinnitus - Hearing loss
Visual disturbances (optic neuritis) ethambutol
severe hepatotoxicity Isoniazid Pyrazinamide Rifampicin
Severe thrombocytopenia, purpura, Hemolytic

rifampicin
anemia Renal failure
An infrequent but potentially fatal event is DRESS Syndrome.

(Drug Rash with Eosinophilia and Systemic Symptoms ). It is a severe
hypersensitivity reaction caused by drugs and characterized by skin
rash, hematological alterations (intense eosinophilia and atypical
lymphocytosis), associated with systemic symptoms such as fever and
multiple organ involvement, mainly hepatotoxicity.
Like any major adverse effect, it requires early suspicion, suspension

of all drugs, and urgent referral to a third level of care.
How do I manage hepatotoxicity?

Any anti-TB drug can cause hepatotoxicity, although it is more
common with isoniazid, pyrazinamide and rifampicin.
37
In the event of evidence of an increase in the level of

transaminases three times higher than the reference value accompanied
by symptoms (nausea, vomiting, abdominal pain), or a five-fold
increase in the absence of symptoms, it is necessary to discontinue
all drugs and closely evaluate to the patient.
Consider:
1. Investigate other causes of abnormal liver function

(viral hepatitis, pathology of the bile duct, alcohol
consumption, intake of other medications, etc.)
2. Wait until the symptoms have resolved and the

transaminase level has normalized before
sequentially reintroducing the medication with
liver test controls. The last drug administered
should be definitively discontinued if there was a
new increase in transaminases. Since
pyrazinamide is the most hepatotoxic drug, it is
left to be reintroduced last or not reintroduced if
the reaction was life-threatening.
CONSIDER
If clinical severity makes it necessary to maintain an anti-
TB scheme, remember that the drugs that can be used
without major liver compromise are Ethambutol,
Streptomycin and Levofloxacin.
38
How is
the patient's medical
follow-up?
If possible, monthly visits are recommended. In each of

them it is important to record the patient's weight (adjust the dose
accordingly), ask about the reappearance of symptoms, reinforce
adherence to treatment and pay attention to possible adverse
effects of the drugs.
Bacteriological control in patients with pulmonary TB
makes it possible to evaluate the response to treatment. It is done
as follows:
months of treatment
intensive phase Consolidation phase
1 month 2 months* 3 months 4 months 5 months 6 months
initial BK. BK end of phase If BK positive: bk end of
Initial crop. initial. Consider failure. treatment.
Sensitivity If positive, Perform culture If positive,

test to culture and PDS. consider failure.
drugs (PDS). and PDS. perform cultivation
and PDS.
*If the sputum smear (BK) is positive in the second month, the following possibilities
should be taken into account: poorly supervised initial phase and therefore poor
adherence to treatment, incorrect drug doses, presence of resistant TB. In patients
with extensive lung cavities and a large initial bacillary load, they may be dead
bacilli. It is essential to request a culture with a sensitivity test and a new BK every
month.
39
Control with chest X-ray can be useful at the beginning, when

moving to the consolidation phase and to evaluate the sequelae, once
the treatment has finished.
Before proceeding to the consolidation phase, clinical,

bacteriological and radiological evaluation must be ensured.
Molecular methods are NOT used to monitor or control treatment.
40
What is Latent
Tuberculosis Infection (LTBI)?
How is its diagnosis
and treatment?18
A latent tuberculosis infection (LTBI) is one produced by M.

tuberculosis, but effectively contained by the immune system,
without any evidence of clinical activity or disease.
It is generated by the persistent immune response in reaction to the
presence of antigens from the bacteria.
The patient does not present any symptoms and is not
contagious, however, up to 10% of them can, throughout their lives,
generate active TB. This risk of activation is caused by multiple
factors, the most important being the immunological state.
The diagnosis and treatment of an LTBI is essential
to avoid in some cases this progression to active forms.
How do I make the diagnosis?

It is done through the tuberculin test (Mantoux reaction). In
this test, a substance called PPD (Purified Protein Derivative) is
injected under the skin. In the majority of patients who have an
infection, the immune system recognizes this protein (which is
extracted from the bacillus) and produces a delayed hypersensitivity
reaction, which can be read as a raised skin, after 48-72 hours.
41
A positive value is considered if the elevation (and not the erythema) is greater
than 10 mm.
In patients with HIV and other immunocompromised

dera positive to a value greater than 5 mm.
incorrect reading correct reading
Tuberculin change is considered when a subject with a negative PPD becomes

positive in less than 2 years. This is estimated to represent a recent infection with M.
tuberculosis.
To diagnose an LTBI there must be no evidence of suspicious radiological

lesions in an active form, otherwise we can misdiagnose and treat pulmonary tuberculosis
with monotherapy (isoniazid), which can generate resistant forms, therefore, all patients
with a positive PPD should be evaluated with a chest X-ray and with sputum samples, if
respiratory symptoms are present.
Who should I diagnose and treat?

Not all patients develop an active form. The diagnosis and treatment of the
latent form (positive PPD) should be carried out systematically in those who present a
high risk of progressing to tuberculosis disease:
• Patients with HIV, regardless of their counts

of CD4.
• HIV-negative patients with some type of immunological compromise: anti-

TNF treatment, dialysis patients, patients preparing for a transplant, patients
with silicosis.
42
• Some contacts of an index case of pulmonary TB (see below

How do I find contacts?) • Under 20 years of age, regardless
of known prior exposure and regardless of some degree of
immunosuppression.*
The systematic search in patients in closed communities

(deprived of liberty), health workers and vulnerable populations
(patients living on the street, drug users) is not recommended unless
they are included in the previously mentioned populations.
What does the treatment consist of?

The treatment of choice is a daily dose of isoniazid (dose = 5
mg/kg in adults and 10 mg/kg in children. Maximum = 300 mg/day) for
6 months.
Alternatively, the following are also effective:
what else:
• Isoniazid plus rifampicin, taken daily, for 3

months
• Rifampicin alone, once daily, for 3-4 months • Rifapentine and

Isoniazid, weekly, for 3 months
REMEMBER!
It is essential for the treatment of an LTBI to have
excluded the presence of active disease.
* - This recommendation is based on the local epidemiological situation in Argentina,

which shows a sustained increase in TB cases in adolescents (Grade D. Expert
opinion)
43
How do I search
for contacts?
What do I do with them?17-19, 20
The overall objective of investigating contacts is:

• identify those who have previous active tuberculosis • identify
those candidates with latent ABI who require
treatment
• avoid infection
Who is considered an index case

and who a contact?
An index case is the patient on whom the investigation is
focused. They are usually the one who is initially identified with active
TB, although they are not necessarily the source of infection. Contact
is any person exposed to an index case.
Potentially any contact can acquire the infection and develop
the disease, however, as the risk is closely related to the intensity and
duration of exposure, contacts can be classified as:
•Intimate contacts (cohabitant): it is considered those people

who share the same space for one or more nights, or during
extended periods of the day (greater than 4 hours), in the
last three months from the identification of the index case or
from the onset of symptoms. Consider
in this group to the school contact
44
•Close or frequent contacts: that person who is not cohabiting, but shares
the same closed space (such as places of work, study or social meeting
rooms), during extended periods of the day, in the last few
three months.
• Sporadic contacts: those who occasionally have contact with the index
case (eg: public transport)
Investigation of intimate contacts and close contacts of all patients

with
Tuberculosis
What should I do?

Identify contacts
The index case should be questioned and the name, surname, age, and
address of all intimate contacts should be identified. It is for them that the investigation
should begin, ideally within the first week.
An active home visit by the health team is recommended to verify the

information and interview the contacts, in addition to evaluating the structural
conditions of the home and the social condition of the cohabitants.
Once the evaluation is finished, the contacts continue

close.
Prioritize contacts
Priorities should be established in the evaluation of contacts according to

the probability of having an undiagnosed form of TB, or of presenting a high risk of
developing the disease.
All contacts with the presence of TB symptoms should be evaluated

as a priority,
Children and children under 19 years of age, pregnant

women, patients with HIV or with other immunosuppression
and contacts with a form of MDR/XDR TB
Four. Five
clinical evaluation
The objective is to be able to rule out active tuberculosis. Therefore, all

contacts should be questioned for symptoms of TB (cough, fever, night sweats
or weight loss) and if present, continue with diagnostic studies that confirm or
rule out the disease (see How do I confirm the diagnosis of Tuberculosis ? ?).
In contacts with no suspected disease, the possibility of infection should

be evaluated (usually through a tuberculin test and a chest X-ray) to identify
those who would benefit from treatment (see Diagnosis and Treatment of Latent
BTI) .
What contact should I treat?

The treatment of contacts is aimed at reducing the risk of developing
an active form of tuberculosis. It is essential before starting treatment to have
ruled out the presence of active disease.
They should be treated to:
Children and adolescents under 19 years of age
They are especially vulnerable and have a high risk of developing severe
forms of the disease. It is a priority indication for treatment.
• All children and children under 5 years of age, regardless of the result
of the tuberculin test, since, as they present a still immature immune
system, they do not always generate a positive reaction.
• All children and adolescents between the ages of 5 and 19 with a PPD
positive
In asymptomatic children and adolescents from 5 to 19 years of age,

with negative PPD, intimate or close contact with smear-positive patients, the
initiation of treatment with isoniazid should be considered and then discontinued
once tuberculin shift has been ruled out in the control of the third month if they
have ceased their exposure for more than two months.
Dose: Isoniazid 10 mg/kg (maximum = 300 mg) once daily for

6 months. (Under two years: Isoniazid 15 mg/kg)
46
HIV patients
HIV infection is the factor that most impacts the progression

to active forms of tuberculosis, as well as the development of
disseminated and severe forms. Therefore, this population is
considered especially vulnerable and should be treated regardless of
the result of the tuberculin test.
Dose: Isoniazid 300 mg once daily for at least 6 months,

and may be extended to 9 months.
Contacts with tuberculin shift

Contacts with a recently positive tuberculin test (tuberculin
shift) have a higher risk of developing the active form of the disease
in the following 2 years. Treatment with isoniazid 300 mg taken daily
for 6 months is considered.
All contacts, regardless of whether they were treated or

not, must have alarm patterns at the appearance of any
symptom that leads to suspicion of active tuberculosis.
There is currently no strong evidence indicating a benefit in

treating MDR/XDR TB contacts, so research should focus on ruling
out the presence of disease. However, for some household contacts,
preventive treatment could be considered based on individualized risk
assessment (especially in high-risk contacts) and with solid clinical
justification as directed by a specialist.
47
What should I take

into account in special
populations?12,15,16,21
Pregnancy and lactation

The same standard treatment with first-line drugs is recommended.
Despite the fact that they all cross the placenta, no teratogenic effects
have been shown, with the exception of aminoglycosides, which can cause
fetal ototoxicity and for this reason should not be used.
Breastfeeding should continue and the baby should not be separated.

The small concentration of drug that passes into breast milk is not toxic to
the nursing infant. The mother should use a mask to breastfeed, if she has a
positive sputum smear.
The newborn should be vaccinated with BCG and start

chemoprophylaxis, after ruling out the active form. Do not forget to
supplement with pyridoxine 25 mg/day to all pregnant and lactating women
under treatment with isoniazid.
HIV infection
Tuberculosis represents the cause of death of one in three people
with AIDS in the world; and coinfection 26% of all TB deaths. Both diseases
are mutually related, enhancing the negative effects: TB accelerates the
progression of HIV infection to AIDS and, with it, to death; and
48
HIV infection causes decreased immunity, worsening the evolution

and mortality of tuberculosis.
This is why it is essential to establish integrated TB/HIV services.
Tuberculosis should be actively sought in all patients

diagnosed with HIV.
HIV testing should be performed on all patients suspected
or diagnosed with tuberculosis.
TB/HIV coinfection presents some peculiarities that must be

taken into account:
•Clinical: the pulmonary form is also the most frequent form

in people with HIV, however, chronic cough and hemoptysis
may not be present due to less inflammatory capacity and
less cavitation. Symptoms may be subtle and limited to fever
associated with impregnation syndrome (weight loss and
sweating).
•Diagnosis: serial smear microscopy continues to be useful to
establish the diagnosis, but it has low sensitivity (67%),
therefore, all suspected TB cases must also have culture
and drug susceptibility tests. If available, Xpert® MTB/RIF
should be used as the initial diagnostic test of choice in
patients with HIV.
• Treatment: the same drugs and the same doses are used. It
is essential, whenever possible, to include rifampicin in the
regimen. In patients under effective antiretroviral treatment
(ART), a 6-month regimen is recommended over a regimen
of 8 months or more, except for extensive pulmonary, bone,
articular, and CNS forms.
49
Antiretroviral treatment (ART) should be started within the

first 8 weeks from the start of anti-TB treatment. In case of
severe immunosuppression (CD4 count < 50/mm3), ART
should be received within a maximum period of 2 weeks
from the start of anti-TB treatment.
Key concepts for Take into account the interactions of rifampicin with
patients antiretroviral treatment, especially with protease inhibitors

TB/HIV (PIs).
Start joint prophylaxis with trimethoprim/sulfamethoxazole

(TMP/SMX or cotrimoxazole) 1 tablet of 160/800 mg/day orally
until ensuring a CD4 count greater than 200/mm3.
The recommended first-line ART scheme* is: EFV

+ FTC (or 3TC) + TDF
EFV = Efavirenz; FTC=FT

FTC= Emtricitabine; 3TC = Lamivudine; TDF = Tenofovir
*Take into account that the regimens containing Efavirenz (of choice due to the
significant absence of interactions with Rifampicin) present a primary resistance greater
than 10% in our country, so a baseline resistance test for HIV or strict monitoring to
diagnose a viral failure early.
If a baseline resistance test is not available or if clinical

urgency does not allow waiting for its result, the use of integrase
inhibitors such as Raltegravir 400 mg every 12 hours or Dolutegravir
50 mg every 12 hours should be considered, substituting Efavirenz.
Rifampicin is a potent inducer of cytochrome P-450, it

decreases the plasma concentrations of doses of protease inhibitors
(Atazanavir/Ritonavir/Daru navir/Lopinavir) by 75-90%, so they
should not be used together with these antiretrovirals. .
If these ARVs must be included, the recommended option is

the replacement of rifampicin by rifabutin. The dose is 150 mg once
daily in the presence of IP.
Childhood tuberculosis22–25
Children represent a particularly vulnerable population with a
higher risk of developing severe and/or disseminated forms.
fifty
days, associated with high morbidity and mortality; mainly children

under 5 years of age.
The development of the disease usually occurs within two years
from the primary infection, which is why the burden of childhood TB
reflects recent and continuous transmission within a population and
very possibly within the family or intimate nucleus.
The clinical presentation, diagnosis and treatment present
some peculiarities of their own.
•Clinical: Pulmonary TB is the most frequent form in children.
Its common manifestations are inadequate weight loss or
progress, fever, cough, and fatigue with decreased activity
level. Respiratory symptoms may be few and involve findings
due to lymph node compression of the airway (cough and
wheezing). Extrapulmonary forms can compromise any
organ (pleura, lymph nodes, CNS) and can be up to 30% of
childhood forms.
In young and immunosuppressed children, the disseminated

form predominates, with pulmonary foci, meningeal forms,
and abdominal forms with the presence of lymph nodes,
thickening of the intestinal walls, and ascitic fluid.
REMEMBER!
In young children and infants, the probability that the
contagion has been within the home is very high. Finding
the source of contagion is of great help for diagnosis.
•Diagnosis:
•Chest x-ray: request front and profile. In primary
tuberculosis, intrathoracic lymphadenopathy is frequently
seen. In progression, they may be accompanied by
atelectasis, areas of consolidation with or without pleural
effusion, multifocal consolidation, bronchopneumonia, or
miliary forms. The typical radiological forms, with
involvement in the upper lung fields and areas of cavitation,
are usually seen in older children and adolescents.
51
• Tuberculin test: the tuberculin change reveals a recent

infection. Positivity criteria are similar to adults (>5 mm in
immunocompromised children; >10 mm in immunocompetent
children). •Microbiological diagnosis: the disease in
children is usually paucibacillary, so direct examination and
culture should be requested. In children who can
expectorate, the sample should be serial sputum.
To obtain bronchopulmonary secretions from young children

without the ability to expectorate, samples of gastric contents (5–10
mL) should be used through a nasogastric tube.
It should be done in the morning with 3 or 4 hours of fasting.
If available, the Xpert technique is recommended as initial
diagnosis in children with suspected resistant TB or in HIV-associated
cases.
All pediatric samples must always be cultured
•Treatment: consists of two phases (intensive and

consolidation) and the same drugs are used as in the adult
population. The recommended doses are as follows:
Drug Dose and range (mg/kg) maximum dose
Isoniazid 10 (7-15) 300mg
rifampicin 15 (10-20) 600mg
Pyrazinamide 35 (30-40)
ethambutol 20 (15-25)
In children under 2 years of age (rapid acetylators) it is

recommended to use the isoniazid dose in the higher range (15 mg/kg/
day) to ensure adequate blood levels.
52
clinical forms Intensive Phase Consolidation Phase
• Pulmonary TB with negative sputum smear •
Peripheral nodal TB • Intrathoracic lymphadenitis 2 HRZE+ 4HR
• Pulmonary TB with positive bacilloscopy •
Extensive lung lesions • Severe extrapulmonary

2HRZE 4HR*
(except meningeal or osteoarticular forms)
•TB with meningeal or osteoarticular involvement 2HRZE 10HR
+ Some recommendations omit ethambutol during the initial phase of treatment as

long as the following categories are met: Non-cavitary forms, smear-negative and HIV-
negative; and with the presence of bacilli with confirmed sensitivity to all first-line
drugs.
*In patients with extensive lung lesions and poor evolution, miliary forms, and/or
patients with HIV or other immunodeficiency, consider extending the continuation
phase from 7 to 10 months with daily HR.
DO NOT FORGET!
Rule out coinfection with HIV in all pediatric

patients diagnosed with TB, as well as investigate the
presence of TB in all children with HIV infection.
The National Program has associations of dispersible drugs for

children:
• Double association: Rifampicin 75 mg / Isoniazid 50 mg •
Triple association: Rifampicin 75 mg / Isoniazid 50 mg /
Pyrazinamide 150mg
They need to add between 5-10 ml of water and must be ingested

within a period of no more than 10 minutes after being prepared.
53
Resistant tuberculosis. When should

I suspect it?
They are forms of TB caused by organisms that are resistant
to the drugs commonly used to treat the disease. They are transmitted
in the same way as the sensitive forms and are not more infectious
than these, however, they constitute a major public health problem
since the lack of recognition and timely effective treatment allows the
advance of the disease and contagion persistent.
Multi-resistant TB (MDR) is that caused by organisms

resistant to the most effective anti-TB drugs: Isoniazid and Rifampicin
together.
Extensively resistant TB (XDR) is that with resistance to
isoniazid and rifampicin, plus a fluoroquinolone with antituberculosis
action and at least one second-line injectable drug (Kanamycin,
Amikacin or Capreomycin).
Resistance can develop primarily, that is, by direct infection by
resistant bacilli; or secondarily, when resistance is generated during
treatment because the patient does not follow the appropriate regimen
(incorrect intakes and doses, irregular intakes, dropouts, prescription
errors, etc.).
It is essential to suspect and diagnose these forms of resistant
TB in time to avoid serious complications and transmission to third
parties (see table Risk groups for resistant TB). The treatment must
be carried out in a reference center.
54
What can the

health team do
to end
Tuberculosis?5,10,26
Ensure dignified care and

real access to health
TB predominantly affects the most vulnerable populations,
including people with low economic resources, ethnic minorities,
migrants, people deprived of their liberty and HIV patients. Not only
do they bear the brunt of the disease, but tuberculosis itself is a
factor in impoverishment due to the catastrophic expenses that it
entails.
Discrimination, mistreatment and criminalization of these

susceptible populations constitute a real barrier to the health
system. The team must overcome this barrier and ensure dignified
and quality care.
55
Conduct an active search in

populations at higher risk
The number of patients with an underdiagnosis of tuberculosis
can be very high in some settings, especially in populations that do not
correctly access health services, due to their situation of extreme
vulnerability or their social complexity.
An active search strategy can be decisive for timely diagnosis and
treatment.
In addition to the contacts of an index case, active search is
recommended in the following risk populations: patients with HIV,
diabetes, treatment with immunosuppressants (corticoids, biologicals,
etc.), patients exposed to silica, patients deprived of liberty , untreated
patients who have fibrotic lesions on radiography, homeless patients,
migrants, indigenous populations and in patients with problematic drug
use.
Actively search for tuberculosis in any patient with a cough

and expectoration for more than 15 days, even if the
consultation with the health system is not for these symptoms.
Ensure vaccine coverage

BCG
BCG (Bacillus Calmette and Guérin) vaccine consists of live and
attenuated bacilli. It has been shown to prevent severe forms of TB,
particularly meningitis and miliary TB, both of which are associated with
high mortality in infants and young children. That is why it should be part
of the childhood vaccination scheme.
The health team must ensure the application of BCG in the

newborn, before discharge from the maternity ward or, failing that, during
the first week of life; and to verify the application of this vaccine in the first
health control of the newborn, to apply it in case it has not been carried
out.
56
Children not vaccinated in the maternity hospital, with delayed

schedules, should receive a dose up to and including the age of 6 years.
It is common for a nodule to form at the application site that can,
in some cases ulcerate and then heal in three months, without the need
for any specific treatment other than cleaning the area. That the scar or
nodule is not generated does not mean that the child is not protected.
Revaccination of children and adolescents is not recommended,

nor is vaccination in adults, since the preventive efficacy against
pulmonary TB is only around 50%.
There is a high risk of disseminated BCG disease in

infants infected with HIV or in those suffering from some
form of immunosuppression, so the vaccine is
contraindicated in these settings.
Ensure patient care and

support to achieve complete
treatment
Failure to complete a treatment correctly can lead to increased
infectivity, poorer outcomes, and drug resistance.
That is why adherence is a critical factor. However, it is not an easy
task (neither for the patient nor for the health personnel) and there are
many who discontinue their treatment or do it erratically if they do not
have adequate support.
It is essential in this new global strategy to end tuberculosis to
establish care and support systems focused on the specific needs of
the patient (material, emotional and educational).
The health team should assess the need to implement an ODT

strategy (see above). Although it continues to be the recommended
strategy, systematic reviews and experiences show that there is no
single effective approach for all cases and conditions. Consequently,
the interventions
57
Instructions to facilitate adherence must be adjusted to each particular

situation, taking into account the cultural and social context of each
individual, each family and each community; and they must be
approached in an interdisciplinary and multisectoral manner, generating
bold and creative policies in the face of each identified barrier.
Study and treat all contacts and

forms of latent TB in risk groups
Avoiding the development of an active form of tuberculosis

may be an essential component in eliminating and ending the disease.
For specific guidelines, see How to handle contacts? and

Diagnosis and Treatment of Latent TB.
Notify, record and report all

data
Data reporting and recording are a fundamental component of
individual patient and community care. They are necessary for global
and regional monitoring of the disease, and also to constantly evaluate
programmatic efforts in order to plan policies and strategies that lead
to ending tuberculosis.
Notification must be made at the time of diagnosis and at the

time of completion of treatment. It should also include the patient's
serological status with respect to HIV and drug sensitivity (if culture
was performed).
The notification and registration of data is mandatory

and is carried out through the SNVS.2 computer system.
58
flowcharts
contact study
Investigate intimate contacts first and then close contacts of all TB patients
Identifies the contacts Record name, surname,

age and address
Prioritize contacts study with priority
• Cohabitants •
Pregnant women •
Children and minors under 19 years of age

• Patients with HIV or with another
immunosuppression
• Contacts of a form of
MDR/XDR-TB
• Contacts with symptoms of
clinical evaluation active TB
Absence of symptoms
If there are symptoms of TB
(no suspicion of active TB)
Request PPD test rule out disease

(diagnoses infection (If TB is diagnosed,
Request chest X- treatment with 4 drugs)
ray (reduces active disease)
Isoniazid treatment
positive PPD Regardless of the PPD result

Contacts with tuberculin shift
Children and children under 19 years of age Children under 5 years
Immunocompromised patients HIV patients
59
SUSPECTED TUBERCULOSIS
Respiratory symptomatic: cough and expectoration for more than 15 days

Other symptoms: weight loss, fever, night sweats, hemoptysis
REQUEST BACILLOSCOPY: 2 samples
POSITIVE BACILLOSCOPY NEGATIVE BACILLOSCOPY
TB diagnosis Clinical
POSITIVE
suspicion continues
• Chest X-ray • Cultures

NEW CASE
• Xpert
• Complementary tests • Clinical
judgment
Suspected
resistant tuberculosis
Case previously treated
Consider GeneXpert NEGATIVE
Indispensable
consider others
diagnoses
sample culture
Drug sensitivity tests
TREATMENT
• Notify the case of tuberculosis. •

Request HIV serology and complementary studies. • Indicate
treatment with patient-centered support. • Evaluate contacts and treat
when appropriate. • Assess the patient at least once a month. • Request a
bacilloscopy or culture to control the treatment. • Redens treatment based on
outcome and sensitivity, if applicable.
60
Exhibit
Food and Tuberculosis
Nutrition plays a fundamental role in people suffering from tuberculosis.
The nutritional needs of the patient with TB are highly variable, they
depend on the disease process, the age of the patient and the previous nutritional
status.
Most TB patients are hyporexic, have altered sense of taste, and suffer
from muscle weakness.
prevent malnutrition
Objectives
Regain or maintain ideal weight
of nutritional
treatment Improve infection-related immune function
Meet individual nutritional needs
Management is individual and the objectives must be adapted to

each case.
Nutritional treatment should contribute to solving the problems of weight

loss, diarrhoea, appetite, nausea, and specific micronutrient deficiency disorders.
The Food Plan constitutes an important basis in the work

treatment, it must be:
Adequate in calories:
• Malnourished patients 30 to 40 kcal/kg ideal weight •

Asymptomatic patients 30 to 35 kcal/kg ideal weight
Rich in proteins: 15 to 30% of the Total Caloric Value.
61
An intake of 1.2 to 1.5 g/kg is recommended. ideal weight; 75 to

100 gr. per day is enough.
• Rich in complex carbohydrates, vitamins and minerals. • Split:
4 main meals (breakfast, lunch, snack and dinner) and 2 daily
snacks (mid-morning and mid-afternoon)
• Easy digestion, simple preparations. •

Preparations with high caloric density (in little volume).
lumen, high calories)
Food selection:
• Dairy: preferably skimmed, milk 500 to 750
ml per day.
• Egg: average 3 units per week and one boiled egg white daily.
• Lean meats (beef, chicken, fish) 1 serving per day. • Assorted

vegetables: raw and cooked, 1 serving in the al
lunch and 1 portion at dinner. •
Assorted fruits: 3 units per day •
Preferably whole grains: 1 serving per day. • Legumes: 1
portion 3 to 4 times a week. • Safe water: 8 glasses per day.
Forms of preparation allowed: boiled, steamed, baked

no, grill, grilled, NOT FRIED.
Adequate nutritional intake, during tuberculosis treatment and
recovery, is necessary to fully restore nutritional status during and after
treatment.
62
Lic. Marisela Nuñez

Nutritionist MN 2594
63
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President of the Nation

Minister of Health and Social

Government Secretary for Health Prof.

Secretary of Health Promotion, Prevention and Risk Control Dr. Mario

Undersecretary for Prevention and Control of Communicable

Director of AIDS, STDs, Hepatitis and Tuberculosis

Coordinator of the National Tuberculosis and Leprosy Control Program

Team of the National Tuberculosis and Leprosy Program

Lic. Maia Chernomoretz

Collaboration in the Writing Lic.

Interdisciplinary Advisory Committee

Dr. Raquel Sarobe, Buenos Aires Farm Province TB Program. Adriana

Dr. Marcela Natiello, National TB Program / Vaccarezza Institute

Design: Andrés Venturino

How do I confirm the diagnosis? What should I request? 19

What complementary studies are necessary? 25

How do I classify a patient with Tuberculosis? 27

How is the treatment? 30

How is the patient's medical follow-up? 39

What is a Latent Tuberculosis Infection?

How do I search for contacts? What do I do with them? 44

What should I take into account in special populations? 48

What can the health team do to put an end to

Annex: Nutrition and Tuberculosis 61

AFB Acid alcohol resistant bacillus

BCG Bacillus Calmette and Guérin

WHO World Health Organization

PPD Purified Protein Derivative Skin Test

SNVS.2 National Health Surveillance System 2

MDR-TB Multidrug-Resistant Tuberculosis

XDR TB Extensively Resistant Tuberculosis

ETB Extrapulmonary Tuberculosis

PTB Pulmonary Tuberculosis

TDF Tenofovir disoproxil fumarate

VDRL Venereal Disease Research Laboratory

HBV Hepatitis B Virus

HCV Hepatitis C Virus

Tuberculosis (TB) continues to be a serious public health

It is estimated that in 2017 more than 10 million people

Stopping this epidemic is possible if we achieve a paradigm

The pillars of this strategy include:

Pillar 2. Bold policies and support systems focused on

Pillar 3. Innovation and intensified research to obtain

The objective of this guide is to present up-to-date

PILLAR 1. Comprehensive TB care and

Timely diagnosis of TB,

Treatment of people with TB and

Preventive treatment for

Collaborative TB/HIV activities,

PILLAR 2. Bold policies

Political commitment, with

Universal health coverage

Social protection, poverty alleviation

PILLAR 3. Innovation and

What is Tuberculosis (TB)?

How does the body react?