University of Pennsylvania Medical
Center Guidelines for Antibiotic Use
I. TRIAGE OF PATIENTS TO PREVENT TUBERCULOSIS (TB)
1. Staff member should be aware of the presence of
cough in patients entering the hospital through the Admissions
Office, Emergency Department, clinics, and practices.
2. If cough is not identified by questioning or
evaluation, proceed with appropriate workup for patient.
3. If patient has a productive cough of more than two
weeks duration, a mask should be placed on the patient. Patients at
particular risk of tuberculosis include those on immunosuppressive
medications (e.g. cyclosporine, steroids), HIV infected persons,
persons born in countries with high endemic rates of TB, alcoholics
and those with kidney failure, pulmonary disease and other
4. If circumstances in the Emergency Department permit,
the patient should be brought into the ED or
Walk-in Clinic for more careful evaluation. If an
isolation room is available, the suspect patient should be placed in
a closed room and all health care workers entering the room should
wear TB masks. This recommendation is not meant to subvert the
triage of more critically ill patients.
5. Patients identified as suspect for tuberculosis at
sites other than the Walk-in Clinic or Emergency Department should be
evaluated at those sites to the extent that it is feasible before
referral for admission or Emergency Room evaluation.
6. If after more thorough evaluation Tb is a persistent
concern the patient should have a chest X-ray performed as soon as
possible and if appropriate be admitted to a negative pressure room
for Airborne Precautions in the hospital.
7. Precautions may be discontinued if, after more
thorough evaluation the patient is thought not likely to have
II. OBTAINING ACID FAST BACILLUS SMEARS
Stained smears of sputum specimens to detect the
presence of acid fast bacilli (AFB) are useful diagnostic tools in
the management of tuberculosis. Patients with tuberculosis who have
negative sputum smears for AFB are less contagious than patients with
positive smears. Sputum AFB smears are performed daily by the
Clinical Microbiology Laboratory. Specimens received before 10:00
A.M. will be processed on the same day. There is no need for the
Microbiology Laboratory to perform AFB smears after hours in order to
make a judgement about the need for TB isolation. If tuberculosis is
suspected on clinical grounds, a single AFB smear should not be used
to influence the decision to isolate the patient.
III. GUIDELINES FOR PATIENTS WHO SHOULD BE ADMITTED TO
NEGATIVE PRESSURE ROOMS FOR TUBERCULOSIS ISOLATION
The following are guidelines for clinical practice in
the management of patients suspected of having tuberculosis.
Isolation of a patient for tuberculosis should always be based on
Patients must be admitted to negative pressure room
isolation under the following circumstances:
1. Cough and a chest X-ray film suggestive of
tuberculosis (for example, apical infiltrate, cavitary lesion,
miliary pattern, or mediastinal adenopathy.
2. Positive acid fast smear.
3. Known multi-drug resistant tuberculosis when
admitted or re-admitted. This applies to patients admitted for
non-pulmonary conditions and to those who have received
In addition, admission to negative pressure room
isolation should be considered in the following circumstances:
4. Known HIV infection and an undiagnosed cough or
5. Medical conditions predisposing to tuberculosis when
admitted with cough and an undiagnosed pulmonary infiltrate.
IV. GUIDELINES FOR DISCONTINUING ISOLATION FOR
Isolation should not be discontinued after an
arbitrary number of days in isolation while on treatment.
Discontinuation of isolation should be based on evidence of response
to therapy as outlined below.
1. Patients not known to have tuberculosis but admitted
to rule out tuberculosis would be kept in negative pressure isolation
until there are three negative AFB smears.
2. Patients with known tuberculosis should be kept in
negative pressure room isolation until they have had the following
evidence of response to anti-tuberculous therapy (there should be
evidence of response in each category):
A. Clinical improvement:
1. Decreased cough
2. Decrease in maximum daily temperature
3. Resolution of night sweats
4. Improved general health (improved appetite, weight
B. Patients with TB should be kept in negative pressure
room isolation until there are no organisms on smear.
V. WHAT TO DO IN THE EVENT OF AN EXPOSURE
If you believe you have been exposed to tuberculosis in
the course of your duties at the hospital, you should discuss this
with your supervisor for possible referral to the Occupational Health
Service for screening. The Infection Control Office investigates
every case of tuberculosis in the Hospital to determine if there have
been any unprotected exposures. In instances of unprotected exposure,
the exposed individuals are identified by the Infection Control Staff
and instructed to report to Occupational Health for testing.
Individuals who become infected with tuberculosis (develop a positive
skin test reaction) following an exposure are not able to
transmit tuberculosis unless they develop an active case of TB.
Students who are exposed in the Hospital in the course of their
duties should be evaluated in the Student Health Office (x 2850).
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