Managing TB Cases in the Emergency Department
Infectivity of Patients on TB Therapy
||High Risk||3 consecutive respiratory specimens, including at least one early AM or induced sputum***, or BAL†††, collected at least 8 hours apart, are AFB smear negative.|
|Lower risk||No restriction|
|TB case or suspect on treatment for active TB
|TB case or suspect on treatment for TB
|TB case (or suspect on treatment for TB )|
-At increased risk for MDR-TB (see III.4)
|High or Lower risk|
|Known MDR-TB case (see IV.5)||High risk|
‡‡ See Risk Definitions, above|
§§ See Definition of Terms, above
****** If available, induced sputum is preferred.
†††††† If bronchoscopy is done, a post-bronchoscopic sputum specimen obtained at least 8 hours post bronchoscopy should be included as one of the 3 specimens.
‡‡‡ Note: A patient may be considered for placement in a lower risk setting without meeting these criteria if no previously unexposed persons will be present. (see Home Isolation, below)
§§§ The quality of sputum smear must be verified before smear negative status is confirmed, especially if cavitary disease is present
California Department of Public Health. California Tuberculosis Controllers Association, Page 10: http://ctca.org/fileLibrary/file_52.pdf
Initiate Prevention and Management Precautions |
Criteria for Initiating AII (Airborne Infection Isolation) Precautions
Airborne Infection Isolation (AII) precautions for inpatient settings for the Emergency Department include:
AII Policies and Practices
Discharging Patients with suspected or confirmed TB Home from the Emergency Department
Prior to discharging patients with TB home from the emergency department, all of the following criteria should be met:
In addition, the patient should be educated about outpatient TB care and treatment. Patients with TB who may be infectious should observe the following risk-reduction behaviors:
Finally, all TB cases should be reported to relevant Department of Health.
|Medication||Side Effects1||Criteria for Stopping Medications2|
1List is not an exhaustive all-inclusive list|
2Examples provided of potential urgent criteria that would justify medication cessation. Note that list is not an exhaustive all-inclusive list.
3Cure of TB and mortality benefit may justify loss of hearing.
For more information about TB medications and treatment, please refer to the Active Tuberculosis Treatment record of the Mayo Clinic Center for Tuberculosis Knowledge Base.
Criteria for Stopping Medications
Tuberculosis drugs should be stopped when the risk to the patient is offset by the benefit of the antituberculosis drug therapy. Do not stop a drug that will leave the patient at risk of TB treatment failure or relapse without first determining the drug poses a potential imminent threat to the patient’s life or health that offsets that risk. These decisions will often require review by a TB expert.
When an adverse TB drug reaction or toxicity is suspected in the ED, the provider should:
Grade 1 and 2 Toxicities (where alternative explanations may be likely contributors to the event):
TB therapy should be continued with modifications to other factors (addressing drug-drug interaction, ceasing other medications that could contribute, etc.)
Grade 3 and 4 toxicities (where TB therapy is a potential or likely contributor):
Note: All patients with active tuberculosis should be managed by a clinician with experience in tuberculosis management in conjunction with a local public health TB program.
Follow up with a TB Expert:
While the acute needs of patients in the ED are often paramount, immediate follow up after any changes is critical (within 24-48 hours). Due to the severity of TB disease, the duration of treatment, the risk of resistance with inappropriate or sub-optimal regimens, and the risk to public health for inappropriate management, extremely close care and follow-up with a TB expert is crucial.
Contact the Patient's TB Provider for
All patients with active tuberculosis should be managed by a clinician with experience in tuberculosis management in conjunction with a local public health TB program. For resources in your area, please see our State Resources page.