Tuberculosis, Pulmonary

Description

Medicine treatment

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A15.0-3/A15.7-8/A16.0-2/A16.4/A16.7-9 + (B20.0)

Notifiable medical condition

Tuberculosis (TB) treatment guidelines are updated regularly. This STG should be read in conjunction with the most recent National Tuberculosis Control Programme guidelines.

DESCRIPTION

• A chronic, granulomatous infection of the lungs caused by M. tuberculosis.
• Pulmonary tuberculosis is a serious health problem in South Africa, and is exacerbated by HIV and multidrug resistant tuberculosis (MDR-TB).

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Diagnosis

• Molecular tests (TB nucleic acid amplification tests, TB-NAAT) are used for the diagnosis of M. tuberculosis and the identification of drug resistant organisms.
• While some TB-NAAT assays test for both rifampicin and isoniazid resistance, Xpert® MTB/RIF Ultra, a type of TB-NAAT, only tests for rifampicin resistance. Refer to PHC EML Pulmonary TB in adults for guidance on sputum sampling and interpretation of results relating to TB-NAAT assays.
• The diagnosis of pulmonary TB in adults is made on a positive TB-NAAT on sputum. In some patients, especially HIV-infected patients, TB-NAAT is not an adequate ‘rule out’ test.
• PLHIV who have features of TB but are TB-NAAT negative require further investigation and may need empiric anti-tuberculosis therapy while awaiting TB cultures.

Patients who have previously completed TB treatment (especially within the last 2 years) may still test TB-NAAT positive in the absence of active disease. TB should be confirmed on culture in this setting.

• All patients who are TB-NAAT positive require further sputum to be sent for AFB to allow for monitoring of treatment. TB-NAAT should not be used for monitoring.
• All TB patients must be screened for HIV. PLHIV with concomitant TB are eligible for cotrimoxazole prophylaxis, regardless of CD4 count.

Sputum induction with nebulised sodium chloride 5% should be attempted for patients unable to spontaneously produce sputum. A wide bore needle (e.g. 18G) aspiration for TB-NAAT should be done in patients with suspected TB lymphadenitis.

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Urine lipoarabinomannan (LAM) is a good “rule-in” diagnostic test for:

1. PLHIV with CD4 ≤200 cells/μL who have signs and symptoms of pulmonary and/or extrapulmonary TB, and
2. PLHIV who are seriously ill.

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MEDICINE TREATMENT

All patients with active TB who are TB-NAAT positive and rifampicin sensitive should receive intensive phase therapy for 2 months and 4 months of continuation phase treatment (see table below). Patients who are at risk of having resistant TB (e.g. previous episode of TB treatment, prisoners, and health care workers) should have sputum sent to exclude INH mono resistance if the particular TB-NAAT test in use for pulmonary specimens does not already test for this.

National tuberculosis control programme guidelines

Fixed dose drug combinations available:

RH – 150/75 mg	RH – 300/150 mg
RHZE – 150/75/400/275 mg
R – Rifampicin Z – Pyrazinamide	H – Isoniazid (INH) E – Ethambutol

Treatment for known or presumed drug sensitive TB

Pre-treatment body weight	Two months initial phase	Four months continuation phase
	RHZE  (150/75/400/275)	RH  (150/75)	RH  (300/150)
30–37 kg	2 tablets	2 tablets	-
38–54 kg	3 tablets	3 tablets	-
55–70 kg	4 tablets	-	2 tablets
71 kg and over	5 tablets	-	2 tablets

INH may result in the development of a peripheral neuropathy due to drug-induced pyridoxine deficiency. Prophylactic pyridoxine supplementation is recommended in patients on INH that are at high risk of peripheral neuropathy (e.g. HIV, diabetes, alcoholics).

• Pyridoxine 25 mg, oral, daily for duration of INH-containing TB therapy.

Close contacts of TB patients (particularly children <5 years of age) should be screened and managed as per National TB Guidelines.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024

Chapter 16: Respiratory Disorders _16.9 Tuberculosis, Pulmonary