University of Pennsylvania Medical Center Guidelines for Antibiotic Use

TUBERCULOSIS GUIDELINES

I. TRIAGE OF PATIENTS TO PREVENT TUBERCULOSIS (TB) EXPOSURES

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 conditions.

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 tuberculosis.

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 clinical suspicion.

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 anti-tuberculous therapy.

In addition, admission to negative pressure room isolation should be considered in the following circumstances:

4. Known HIV infection and an undiagnosed cough or pulmonary condition.

5. Medical conditions predisposing to tuberculosis when admitted with cough and an undiagnosed pulmonary infiltrate.

IV. GUIDELINES FOR DISCONTINUING ISOLATION FOR TUBERCULOSIS

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 gain)

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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