Pneumonia & Tuberculosis
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Acute severe lower respiratory tract infection
Severe lower respiratory tract infections with HIV infection
ACUTE SEVERE LOWER RESPIRATORY TRACT INFECTION
Ill women with clinical evidence of pneumonia should be admitted to hospital. There is usually acute onset of fever, chest pain, & productive cough with typical chest signs on examination.
Investigations
- Chest X-ray
- FBC, U&E, ABG, blood culture, HIV test
- CD4 count if HIV positive
- Sputum GeneXpert & MCS (ignore if Bartlett score <1)
Treatment
- Give co-amoxiclav 1.2 g IV 8 hourly until the temperature has settled for 24 hours, followed by amoxycillin 1 g orally 8 hourly.
- For severe penicillin allergy, give azithromycin 500 mg daily orally
- For acutely ill women with severe pneumonia:
- Give ceftriaxone 2 g IV daily until apyrexial and stable for 24 hours
- Follow with amoxicillin/clavulanic acid 875/125 mg 12 hourly for 5 days
- AND azithromycin 500 mg daily for 5 days
- Attach a pulse oximeter, initially at least. If the oxygen saturation is <90%, give face mask oxygen. Consider ventilation in ICU if polymask oxygen is ineffective
- Clinical markers of severe pneumonia:
- evidence of multilobar pneumonia
- respiratory rate >30/minute
- cyanosis
- confusion
- systolic BP <90 mmHg
- renal dysfunction
- Call an internal medicine specialist for advice if the patient is extremely ill or problematic
SEVERE LOWER RESPIRATORY TRACT INFECTION WITH HIV INFECTION
Manage as above, but consider investigation & treatment for pneumocystis pneumonia (below) & investigate additionally for TB (below)
PNEUMOCYSTIS PNEUMONIA (PCP)
This presents with dry cough, tachypnoea, & hypoxaemia, usually in HIV infected patients with CD4 count <200/mm3, or in other categories of immunocompromised patients. There may be no clinical signs on chest examination, or bilateral symmetric signs. Chest x-ray usually shows symmetrical interstitial/ground-glass shadowing.
- Drug treatment is cotrimoxazole 80/400 mg in 4 divided doses for 3 weeks
- For women with weight <60 kg: 3 tablets 6 hourly
- For women with weight >60 kg: 4 tablets 6 hourly
For women with saturation <90%, add prednisone 40 mg orally 12 hourly for 5 days, then 40 mg daily for 5 days, then 20 mg daily for 10 days.
For patients who cannot swallow, give equivalent doses of cotrimoxazole IV, and hydrocortisone IV in a dose of 5 mg for 1 mg of prednsione.
TUBERCULOSIS
Typical history of pulmonary TB is cough for >2 weeks, weight loss or failure to gain weight in pregnancy, fever & night sweats, also dyspnoea, tiredness & haemoptysis. Chest X-ray may show cavitation, nodes, miliary pattern, or effusions. In immunocompromised patients, lower & mid-zone infiltrates without cavitation are frequent. Admit women with suspected TB to hospital for investigation. Seek expert help for complicated or atypical cases.
Essential investigations
- HIV test
- Chest X-ray
- Send 2 sputums, on different days, for TB microscopy & GeneXpert
- For HIV infected women, also send a separate sputum for TB culture
Drug treatment
- Start treatment when the diagnosis is confirmed. Start treatment empirically if TB is strongly suspected, especially if the woman is very ill
- Notify all cases started on treatment and arrange for continuation of treatment & transfer to the local clinic
- TB Treatment is usually given for 6 months
- HIV infected women not on ART should be planned for ART initiation two weeks after starting TB treatment
Starting regimen (intensive phase for 2 months):
- Weight <54 kg: RHZE 3 tablets with pyridoxine 25 mg daily
- Weight 55-70 kg: RHZE 4 tablets with pyridoxine 25 mg daily
- Weight >70 kg: RHZE 5 tablets with pyridoxine 25 mg daily
- R = rifampicin 150 mg
- H = isoniazid 75 mg
- Z = pyrazinamide 400 mg
- E = ethambutol 275 mg
The 4-month continuation phase consists of rifampicin and isoniazid only
If drug resistance is found on Gene Xpert, seek advice on alternative anti-TB drugs. Streptomycin is no longer used for TB treatment.
Extrapulmonary tuberculosis
Extrapulmonary TB is especially common in HIV infected women. TB pleural effusion is the most frequent form, & may diagnosed on pleural tapping (exudate, no evidence of malignancy) & treated as for pulmonary TB.
Other forms of extrapulmonary TB are TB meningitis (CSF examination), TB peritoneum (fluid tapping, and biopsy), TB lymphadenits (clinical or ultrasound/CT demonstration of lymphadenopathy with fine needle aspiration or biopsy), TB pericardium & vertebral TB. These may be treated with up to 9 months of TB treatment. TB meningitis needs additional corticosteroid treatment.