Transcript TB IN CHILDREN - Ministry of Health

Picture of
CPG Cover
TB IN CHILDREN &
PREGNANT WOMEN
by
Dr. Suryati Adnan &
Dr. Jumeah Shamsuddin
1
LEARNING OBJECTIVES
• To update current management of TB in
children & pregnant women
• To highlight latest antiTB regimens & dosages
in children
• To address evidence-based management of
BCG lymphadenitis
• To strengthen LTBI & contact management in
children
2
TB IN CHILDREN
• TB in children is increasing in Malaysia
• High risk of active disease in infants &
children under 5 years of age
• Active TB usually develops within 2 years of
infection but can be as short as a few weeks in
infants
TBIS, 2011; WHO, 2006
3
TB IN CHILDREN
• PTB & lymph node TB
- commonest presentations
• Most children with PTB are
sputum negative
4
COMMON CLINICAL PRESENTATIONS
OF TB IN CHILDREN
• Prolonged fever
• Failure to thrive
• Unresolved pneumonia
• Persistent lymphadenopathy
5
DIAGNOSTIC TESTS FOR ACTIVE TB
• AFB smear & culture from clinical specimens
• CXR - PTB, pleural, hilar LN disease
• TST (Mantoux test)
– compounded by false positive/negative
• Other relevant diagnostic procedures &
imagings for PTB & EPTB in children are similar
to adults
6
TST (MANTOUX TEST)
• False positive Mantoux
– BCG vaccination
– Non-TB mycobacterium infection
• False negative Mantoux
– Immunosuppression
7
RECOMMENDATION 18
• Children suspected of PTB should have
sputum examination, CXR & TST performed.
(Grade C)
– Gastric lavage/aspiration should be performed in
infants & children who are unable
to expectorate sputum. (Grade C)
8
TREATMENT FOR TB DISEASE IN CHILDREN
TB cases
New smear positive
PTB
New smear negative
PTB
Less severe EPTB
Severe concomitant
HIV disease
Severe form of EPTB
TB meningitis/
spine/bone
Regimen*
Intensive phase Continuation
phase
2HRZ
4HR
2HRZE
4HR
2HRZE
10HR
Remarks
Ethambutol can be
added in the
intensive phase of
suspected isoniazidresistance or
extensive pulmonary
disease cases.
WHO , 2010; WHO, 2006
9
TREATMENT FOR TB DISEASE IN CHILDREN
TB cases
Previously treated
smear positive PTB
including relapse &
treatment after
interruption
Regimen*
Intensive phase
Continuation
phase
3HRZE
5HRE
Treatment failure TB
MDR-TB
Individualised regimen
Remarks
All attempt should be
made to obtain culture
& sensitivity result. In
those highly suspicious
of MDR-TB, refer to
paediatrician with
experience in TB
management.
Refer to paediatrician
with experience in TB
management.
Refer to paediatrician
with experience in TB
management.
WHO , 2010; WHO, 2006
10
ANTITB DRUGS IN CHILDREN
Drug
Dose (range)
in mg/kg
10 (10 - 15)
Maximum
dose
300 mg
Rifampicin
15 (10 - 20)
600 mg
Pyrazinamide
35 (30 - 40)
2g
Ethambutol
20 (15 - 25)
1g
Isoniazid
Pyridoxine 5 - 10 mg daily need to be added if isoniazid is
prescribed.
11
RECOMMENDATION 19
• All children with TB should be given
standardised treatment regimens & dosages
according to the relevant diagnostic
categories. (Grade C)
12
LATENT TB INFECTION (LTBI)
IN CHILDREN
• LTBI: infected with M.tuberculosis but patient
is asymptomatic
• Active TB disease: Symptomatic TB infection
• Children younger than 5 years old with LTBI
has 10 - 20% risk of developing active TB
disease.
(Horsburgh C et al., N Engl J Med, 2004)
13
DIAGNOSTIC TESTS FOR
LTBI IN CHILDREN
• LTBI is suspected in children exposed to active
TB person
• For child contact: perform CXR & TST
• Sputum AFB smear is not required in
asymptomatic child being investigated for LTBI
• Symptomatic child: examine & investigate for
active TB & other diseases as indicated
14
INTERFERON GAMMA RELEASE
ASSAY (IGRA) IN CHILDREN
• The amount of Interferon Gamma (IFN-y)
released is correlated directly with age
(p<0.0001).
(Lighter J et al., Pediatrics. 2009)
• IGRA test is less likely to be positive in children
< 2 years of age.
• The sensitivity of both IGRAs & TST are
reduced in young or HIV-positive children.
(WHO, 2011)
15
RECOMMENDATION 20
• TST should be used as a standard test to
diagnose LTBI in children. (Grade C)
• IGRA should not be used as a replacement for
TST in diagnosing LTBI in children. (Grade C)
16
TREATMENT OF LTBI
IN CHILDREN
Active TB must be ruled out before starting LTBI
treatment.
• Therapeutic regimens:
– Isoniazid: 6 months
– Isoniazid plus rifampicin : 3 months
WHO, 2006
Panickar JR et al., Eur Respir J, 2007
Spyridis NP et al ., Clin Infect Dis, 2007
17
RECOMMENDATION 21
• Non-HIV infected children with LTBI should be
treated with 6-month of isoniazid or 3-month
of isoniazid plus rifampicin. (Grade C)
18
MANAGEMENT OF CHILD TB CONTACT
CXR IN CHILD CONTACT
• CXR is important:– TST is not specific & sensitive enough
– Need to exclude active TB
– Suboptimal clinical assessment
– Some areas have high TB burden e.g. OA
population, immigrants etc.
• high degree of exposure
• language barrier
• CXR IS IMPORTANT TO EXCLUDE ACTIVE PTB
20
CXR IN CHILD CONTACT
• CXR can be omitted:If the health staff are able to exclude active
TB
• Adequate history & physical examination
• Considering the risk factors of
– severity of exposure
– age of the child
– disease burden in community
– logistics for follow-up for 2 years
21
BCG LYMPHADENITIS
• Develop 2 - 4 months after vaccination
• Usually self-limiting
• No evidence of benefit from medical therapy
– Erythromycin, isoniazid & rifampicin
• Suppuration can occur in 30 - 80%
• If LN >3 cm & fluctuant:
– needle aspiration
– surgical excision (if recurring)
Banani SA et al., Arch Dis Child, 1994
Goraya JS et al., Postgrad Med J, 2002
22
RECOMMENDATION 22
• Medical therapy should not be offered
routinely in BCG lymphadenitis. (Grade C)
23
CONGENITAL & PERINATAL TB
• Congenital TB is rare
• Active maternal TB during delivery: take
samples or biopsy for MTB culture & HPE
• Perinatal TB infection is suspected when infant
does not respond to standard treatment
Coulter JB et al., Ann Trop Paediatr, 2011
Whittaker et al., Early Hum Dev, 2008
Smith KC et al., Curr Opin Infect Dis, 2002
24
MANAGEMENT OF NEWBORNS
• Defer BCG at birth & perform full TB
investigations if:
– mother diagnosed <2 mths before delivery
or did not receive adequate treatment
– mother is sputum positive just before
delivery
– the newborn is symptomatic
• Treat as active TB if indicated
WHO, 1998
25
MANAGEMENT OF NEWBORNS
• INH as prophylaxis: 2 regimens
a) INH for 6 mths
b) INH for 3 mths & followed by mantoux
test:
o <5 mm - stop INH, give BCG
o ≥5 mm - complete INH for 6 mths, give BCG
• Any symptoms suggestive of TB disease:
repeat TB work up, treat as TB
26
PROPHYLAXIS FOR INFANTS OF
MATERNAL TB
RECOMMENDATION 23
• BCG should not be given to babies on
prophylactic TB treatment. (Grade C)
• Prophylactic TB treatment should be given to
babies born to mothers with active PTB except
those diagnosed more than 2 months before
delivery who have documented smear
negative before delivery. (Grade C)
28
TB IN PREGNANCY
& LACTATION
• Increased risk of maternal & perinatal
morbidity
• First-line antiTB drugs are safe in pregnancy &
breastfeeding
• Streptomycin: avoid during pregnancy
– risk of foetal ototoxicity
Ormerod P, Thorax, 2001
29
TB IN PREGNANCY
& LACTATION
• Breastfeeding should be continued
• Surgical mask should be used if the mother is
still infectious
• Pyridoxine should be given to mothers taking
isoniazid
• Infant-mother separation is considered if the
mother has MDR-TB or is non-compliant to
treatment
Ormerod P, Thorax, 2001
30
ORAL CONTRACEPTIVE PILLS
(OCPs) & ANTITB DRUGS
• Rifamycin (rifampicin & rifabutin) reduces the
efficacy of both combined oral contraceptives
& progesterone-only pills
• Alternative contraceptive method should be
used during & for 1 month after stopping
rifamycins
MOH NZ, 2010
31
RECOMMENDATION 24
• All women of child bearing age suspected of TB should be
asked about current or planned pregnancy. (Grade C)
• First-line antiTB drugs except streptomycin can safely be used
in pregnancy. (Grade C)
• First-line antiTB drugs can safely be used in breastfeeding.
(Grade C)
• Pyridoxine supplementation should be given to all pregnant &
breastfeeding women taking isoniazid. (Grade C)
• Patient on rifampicin should use alternative contraception
methods other than oral contraceptives & progesterone-only
pills. (Grade C)
32
TAKE HOME MESSAGES TB IN CHILDREN
• Children <5years old have high risk of
developing active TB disease.
• Defer BCG in newborns at risk of perinatal TB
until INH completed.
• TST & CXR should be performed in all child TB
contacts.
• BCG lymphadenitis does not require antibiotic.
33
TAKE HOME MESSAGES MATERNAL TB
• First-line antiTB drugs are safe in pregnancy
& lactation.
– Streptomycin must be avoided in pregnancy.
• Rifamycins reduce the efficacy of OCPs.
34
THANK YOU
[email protected]
[email protected]
[email protected]
35