tuberculosis infection control in drug resistant tuberculosis

Infection control in drug-resistant tuberculosis

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Pathway last updated: 06 March 2015. To see details of any updates to this pathway since its launch,visit: About this Pathway. For information on the NICE guidance used to create this path, see:Sources.Copyright NICE 2015. All rights reserved

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Infection control in drug-resistant tuberculosis NICE Pathways

Tuberculosis pathwayCopyright NICE 2015.

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1 Person with suspected or known drug-resistant tuberculosis

No additional information

2 Care for people with multidrug-resistant (MDR) tuberculosis

Discuss the options for organising care for people with MDR TB with clinicians who specialise inthis. Seek the views of the patient and take them into account, and consider shared care.

3 Infection control for suspected or known MDR tuberculosis

For patients with suspected or known infectious MDR TB who are admitted to hospital, admitthem to a negative-pressure room. If none is available locally, transfer the patient to a hospitalthat has these facilities and a clinician experienced in managing complex drug-resistant cases.Carry out care in the negative-pressure room until the patient is found to be non-infectious ornon-resistant, and ideally until cultures are negative.

Staff and visitors should wear FFP3 masks1 during contact with a patient with suspected orknown MDR TB while the patient is considered infectious.

Before the decision is made to discharge a patient with suspected or known MDR TB fromhospital, agree secure arrangements for the supervision and administration of all anti-TBtherapy with the patient and carers.

Discuss the decision to discharge a patient with suspected or known MDR TB with the infectioncontrol team, the local microbiologist, the local TB service, and the consultant in communicabledisease control.

Negative-pressure rooms used for infection control in MDR TB should meet the standards of theInterdepartmental Working Group on Tuberculosis2, and should be clearly identified for staff, forexample by a standard sign. Such labelling should be kept up to date.


1 European standard EN149:2001; masks should meet the standards in 'Respiratory protective equipment at work:

a practical guide HSG53' published by the Health and Safety Executive (2005). Available from www.hse.gov.uk.2 The Interdepartmental Working Group on Tuberculosis (1998) The prevention and control of tuberculosis in the

United Kingdom: UK guidance on the prevention and control of transmission of 1. HIV-related tuberculosis 2. drug-


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http://www.hse.gov.uk/pubns/books/hsg53.htm

4 Treatment for non-MDR drug-resistant tuberculosis

Patients with drug-resistant TB, other than MDR, should be under the care of a specialistphysician with appropriate experience in managing such cases. First-choice drug treatment isdetailed below.

Recommended drug regimens for non-MDR drug-resistant TB

Drug resistance1 Initial phase,2 Continuation phase,

S 2RHZE 4RH

H known before treatment 2RZSE 7RE

H found after starting treatment 2RZE 10RE

Z 2RHE 7RH

E 2RHZ 4RH

R (only if confirmed isolated resistance) 2HZE 16HE

S+H 2RZE 10RE

Other Individualised


resistant, including multiple drug-resistant, tuberculosis. London: Department of Health. Available from

www.dh.gov.uk.1 Abbreviations: E, ethambutol; H, isoniazid; R, rifampicin; S, streptomycin.

2 Drug regimens are often abbreviated to the number of months a phase of treatment lasts, followed by letters for

the drugs adminstered in that phase.


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http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006196

Glossary

BCG

Bacille Calmette-Gurin

Case management

Case management involves follow-up of a suspected or confirmed TB case. It requires acollaborative, multidisciplinary approach and should start as soon as possible after a suspectedcase is discovered.

Case manager

Standard and enhanced case management is overseen by a case manager who will usually bea specialist TB nurse or (in low-incidence areas) a nurse with responsibilities which include TB.Dependent upon the person's particular circumstances and needs, case management can alsobe provided by appropriately trained and supported non-clinical members of the TB multi-disciplinary team.

Close contact

Can include a boyfriend or girlfriend and frequent visitors to the home of the index case, inaddition to household contacts

Cohort review

A systematic appraisal of the way every case of TB has been managed in a given locality interms of treatment completion rates and contact investigations over a specified time period.

DOT

Directly observed therapy.

Directly observed therapy

Directly observed therapy (DOT) is when a trained health professional, or responsible layperson supported by a trained health professional, provides the prescribed medication andobserves the person swallowing every dose.



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Dual strategy

A Mantoux test followed by an interferon-gamma test if the Mantoux is positive.

Enablers

'Enablers' are methods of helping someone to overcome barriers to completing diagnosticinvestigations and TB treatment. Examples of barriers that may need to be overcome include:transport, housing, nutrition and immigration status.

Enhanced case management

Enhanced case management (ECM) is provided when someone has clinically or sociallycomplex needs. It commences as soon as TB is suspected. As part of ECM, the need fordirectly observed treatment (DOT) is considered, in conjunction with a package of supportivecare tailored to the person's needs.

Hard-to-reach children

Groups of children identified as potentially hard-to-reach or treat include:

unaccompanied minorsthose whose parents are hard-to-reach, including vulnerable migrantsthose whose parents are in prison or who abuse substancesthose from traveller communitieslooked-after children.

Hard-to-reach groups

In this pathway, the term hard-to-reach groups is used to mean groups of adults, young peopleand children from any ethnic background, regardless of migration status. They are 'hard toreach' if their social circumstances, language, culture or lifestyle, or those of their parents orcarers, make it difficult to:

recognise the clinical onset of TBaccess diagnostic and treatment servicesself-administer treatment (or, in the case of children, have treatment administered by aparent or carer)attend regular appointments for clinical follow-up.



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High incidence

A high-incidence country or area has more than 40 cases of TB per 100,000 people per year.The Health Protection Agency lists high incidence countries and areas of the UK at its website.

High-incidence country

A high-incidence country or area has more than 40 cases of TB per 100,000 people per year.The Health Protection Agency lists high incidence countries and areas of the UK at its website.

HIV

Human immunodeficiency virus

Homelessness

For the purposes of TB control, a broad and inclusive definition of homelessness has beenadopted which incorporates overcrowded and substandard accommodation. It includes people:

who share an enclosed air space with individuals at high risk of undetected activepulmonary tuberculosis (that is, those with a history of rough sleeping, hostel residence orsubstance misuse)without the means to securely store prescribed medicationwithout private space in which to self-administer TB treatmentwithout secure accommodation in which to rest and recuperate in safety and dignity for thefull duration of planned treatment.

Household contact

A person sharing a bedroom, kitchen, bathroom or sitting room with the index case.

Immigration removal centre

Immigration removal centres are private or prison-run holding centres for migrants waiting to beaccepted by, or deported from, the UK. Immigration removal centres are also known asimmigration detention centres and pre-departure accommodation.

Incident cases

The number of new cases of TB treated per year.



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'Inform and advise' information

Advice on the risks and symptoms of TB, usually given in a standard letter.

Interferon-gamma release assays

A blood test carried out after, at the same time as, or instead of the Mantoux test. If the result ispositive, more tests are undertaken to see if the person has TB.

Latent TB

Latent TB infection means someone is infected with mycobacteria of the M. tuberculosiscomplex, where the bacteria are alive but not currently causing active TB.

Lost to follow-up

People are defined as 'lost to follow-up' if they:

cannot be contacted within 10 working days of their first missed outpatient appointment (ifthey are on self-administered treatment)cannot be contacted within 10 working days of their first missed DOT appointment (if theyare on daily or three times per week DOT).

MDR

Multidrug-resistant

Medical hold

A process to ensure prisoners are not transferred until they are medically fit enough.

Multidisciplinary TB teams

A team of professionals with a mix of skills to meet the needs of someone with TB who also hascomplex physical and psychosocial issues (that is, someone who is hard-to-reach). The teamwill meet regularly to plan, implement and evaluate a care pathway. Specific members shouldbe able to meet to deal with urgent issues. Team members will include a social worker,voluntary sector and local housing representatives, TB lead physician and nurse, a casemanager, a peer supporter/advocate and a psychiatrist.



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Multidisciplinary tuberculosis (MDTB) team

A team of professionals with a mix of skills to meet the needs of someone with TB who also hascomplex physical and psychosocial issues (that is, someone who is hard-to-reach). The teamwill meet regularly to plan, implement and evaluate a care pathway. Specific members shouldbe able to meet to deal with urgent issues. Team members will include a social worker,voluntary sector and local housing representatives, TB lead physician and nurse, a casemanager, a peer supporter/advocate and a psychiatrist.

New entrant

A person who has recently arrived in or returned to the UK from a high-incidence country.

Peers

Peers are members of the target population who may have experienced TB. They are often in agood position to help convey, with empathy, the need for screening or treatment. They may berecruited and supported to communicate health messages, assist with contact investigations orscreening and to offer people support while they are being tested or treated.

Prison

Where the term 'prison' is used it applies to any of Her Majesty's prison establishments,including young offender institutions.

Rapid access

In the context of TB services, rapid access refers to timely support from a specialist team.

Respiratory TB

Tuberculosis affecting the lungs, pleural cavity, mediastinal lymph nodes or larynx

Standard recommended regimen

The '6-month, four-drug initial regimen' of 2 months of isoniazid, rifampicin, pyrazinamide andethambutol, followed by 4 months of isoniazid and rifampicin



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Substance misuse

Substance misuse is defined as intoxication by or regular excessive consumption of and/ordependence on psychoactive substances, leading to social, psychological, physical or legalproblems. It includes problematic use of both legal and illegal drugs.

TB

Tuberculosis

TB prevention and control

TB prevention and control comprises:

active case-finding (contact investigations and screening of high-risk groups)awareness-raising activitiesdiagnostic and treatment servicesstandard and enhanced case management (including the provision of directly observedtherapy)finding those lost to follow-up and encouraging them back into treatmentidentification and management of latent infectionimmunisationincident and outbreak controlcohort reviewmonitoring and evaluationthe gathering of surveillance and outcome data.

Triage

Triage is the process by which people are classified according to the type and urgency of theirsymptoms/condition/situation. The aim is to get someone in need to the right place at the righttime to see an appropriately skilled person/team.

Vulnerable migrants

Vulnerable migrants may include undocumented migrants and those with no recourse to publicfunds. Some refugees, asylum seekers and new entrants to the country may also fall into thiscategory.



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Sources

Tuberculosis (2011) NICE clinical guideline 117

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after carefulconsideration of the evidence available. Those working in the NHS, local authorities, the widerpublic, voluntary and community sectors and the private sector should take it into account whencarrying out their professional, managerial or voluntary duties. Implementation of this guidanceis the responsibility of local commissioners and/or providers. Commissioners and providers arereminded that it is their responsibility to implement the guidance, in their local context, in light oftheir duties to avoid unlawful discrimination and to have regard to promoting equality ofopportunity. Nothing in this guidance should be interpreted in a way which would be inconsistentwith compliance with those duties.

Copyright

Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICEcopyright material can be downloaded for private research and study, and may be reproducedfor educational and not-for-profit purposes. No reproduction by or for commercial organisations,or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE

National Institute for Health and Care ExcellenceLevel 1A, City TowerPiccadilly PlazaManchesterM1 4BT

www.nice.org.uk

[email protected]

0845 003 7781



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tuberculosis infection control in drug resistant tuberculosis

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