tb mx child_women

7/27/2019 TB Mx Child_women

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TB IN CHILDREN &PREGNANT WOMEN

byDr. Suryati Adnan

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Picture of CPG Cover


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Development group members

Dr. Suryati AdnanConsultant Infectious Disease Paediatrician

Hospital Sultan Hj Ahmad Shah, Pahang

Dr. Jeyaseelan P. NachiappanSenior Consultant Infectious

Disease PaediatricianHospital Teluk Intan, Perak Dr. Jumeah ShamsuddinMaternal-Fetal Medicine SpecialistDEMC Specialist Hospital, Selangor


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CONTENTS

Update on current management of TB inchildren & pregnant women

Latest antiTB regimens & dosages in children

Evidence-based management of BCGlymphadenitis

LTBI & contact management in children

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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 ininfants

TBIS, 2011; WHO 2006 4


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TB IN CHILDREN

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PTB & lymph node TB- commonest presentations

Most children with PTB aresputum negative


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COMMON CLINICAL PRESENTATIONSOF TB IN CHILDREN

Prolonged fever

Failure to thrive

Unresolved pneumonia

Persistent lymphadenopathy

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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 andimagings for PTB and EPTB in children aresimilar to adults

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TST (MANTOUX TEST)

False positive Mantoux BCG vaccination Non-TB mycobacterium infection

False negative Mantoux Immunosuppression

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RECOMMENDATION 18

Children suspected of PTB should havesputum examination, CXR & TST performed.(Grade C)

Gastric lavage/aspiration should be performed ininfants & children who are unableto expectorate sputum. (Grade C)

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TREATMENT FOR TB DISEASE IN CHILDREN

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TB cases

Regimen *

Remarks Intensive phase Continuationphase

New smear positivePTBNew smear negativePTBLess severe EPTB

2HRZ 4HR Ethambutol can beadded in theintensive phase of suspected isoniazid-resistance orextensive pulmonarydisease cases.

Severe concomitantHIV disease

2HRZE 4HR

Severe form of EPTBTB meningitis/spine/bone

2HRZE 10HR

WHO , 2010; WHO, 2006


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TREATMENT FOR TB DISEASE IN CHILDREN

11WHO , 2010; WHO, 2006

TB cases Regimen *

Remarks Intensive phase Continuationphase

Previously treatedsmear positive PTBincluding relapse andtreatment after

interruption

3HRZE 5HRE All attempt should bemade to obtain culture& sensitivity result. Inthose highly suspicious

of MDR-TB, refer topaediatrician withexperience in TBmanagement.

Treatment failure TB Refer to paediatrician

with experience in TBmanagement.

MDR-TB Individualised regimen Refer to paediatricianwith experience in TBmanagement.


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ANTI-TB DRUGS IN CHILDREN

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Drug Dose (range)in mg/kg

Maximumdose

Isoniazid 10 (10 - 15) 300 mg

Rifampicin 15 (10 - 20) 600 mg

Pyrazinamide 35 (30 - 40) 2 g

Ethambutol 20 (15 - 25) 1 g

Pyridoxine 5 - 10 mg daily need to be added if isoniazid isprescribed.


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LATENT TB INFECTION (LTBI)IN CHILDREN

LTBI : infected with M.tuberculosis but patientis asymptomatic.

Active TB disease : Symptomatic TB infection.

Children younger than 5 years old with LTBIhas 10 - 20% risk of developing active TBdisease. (Horsburgh CR Jr, 2004)

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DIAGNOSTIC TESTS FORLTBI IN CHILDREN

LTBI is suspected in children exposed to activeTB person

For child contact: perform CXR & TST Sputum AFB smear is not required in

asymptomatic child being investigated for LTBI

Symptomatic child: examine & investigate foractive TB & other diseases as indicated

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INTERFERON GAMMARELEASE ASSAY IN CHILDREN

The amount of Interferon Gamma (IFN-y)released is correlated directly with age(p


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RECOMMENDATION 20

TST should be used as a standard test todiagnose LTBI in children. (Grade C)

IGRA should not be used as a replacement forTST in diagnosing LTBI in children. (Grade C)

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TREATMENT OF LTBIIN CHILDREN

Therapeutic regimens: Isoniazid: 6 months Isoniazid plus rifampicin : 3 months

WHO,2006Panickar JR et al., Eur Respir J., 2007Spyridis NP et al ., Clin Infect Dis., 2007.

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Active TB must be ruled out before starting LTBItreatment.


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RECOMMENDATION 21

Non-HIV infected children with LTBI should betreated with 6-month of isoniazid or 3-monthof isoniazid plus rifampicin. (Grade C)

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MANAGEMENT OF CHILD TB CONTACT


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BCG LYMPHADENITIS

Develop 2 - 4 months after vaccination Usually self-limiting No evidence of benefit from medical therapy.

Erythromycin, isoniazid and 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., 1994Goraya JS et al., Postgrad Med J., 2002 21


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RECOMMENDATION 22

Medical therapy should not be offeredroutinely in BCG lymphadenitis. (Grade C)

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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., 2011Whittaker et al., Early Hum Dev., 2008Smith KC et al., Curr Opin Infect Dis., 2002

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MANAGEMENT OF NEWBORNS

INH as prophylaxis: 2 regimensa) INH for 6 mthsb) INH for 3 mths & followed by mantoux

test:o


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PROPHYLAXIS FOR INFANTS OFMATERNAL TB


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RECOMMENDATION 23

BCG should not be given to babies onprophylactic TB treatment. (Grade C)

Prophylactic TB treatment should be given tobabies born to mothers with active PTB exceptthose diagnosed more than 2 months before

delivery who have documented smearnegative before delivery. (Grade C)

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TB IN PREGNANCY& LACTATION

Increased risk of maternal & perinatalmorbidity

First-line antiTB drugs are safe in pregnancy &breastfeeding

Streptomycin: avoid during pregnancy risk of foetal ototoxicity

Ormerod P, Thorax, 2001

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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 totreatment

Ormerod P, Thorax, 200129


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ORAL CONTRACEPTIVE PILLS& ANTITB DRUGS

Rifamycin (rifampicin & rifabutin) reduces theefficacy of both combined oral contraceptives& progesterone-only pills

Alternative contraceptive method should beused during & for 1 month after stopping

rifamycinsNZMoH; 2010

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RECOMMENDATION 24

All women of child bearing age suspected of TB should beasked 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

and breastfeeding women taking isoniazid. (Grade C)

Patient on rifampicin should use alternative contraceptionmethods other than oral contraceptives and progesterone-only pills. (Grade C)

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TAKE HOME MESSAGES -TB IN CHILDREN

Children


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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.

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THANK YOU

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