To treat or not, that is the question

Straydandelion · Nov 20, 2008

I haven't been in that situation, sorry, but just on the chance it could become active and IF you have never been vaccinated as some in European countries have which would be a false positive, I would take the medication. I see by former threads you are in nursing school, the possibility of spreading TB to those under your care could seriously affect your school and job also.

Elvish, BSN, DNP, RN, NP · Nov 20, 2008

Prior vaccination does not equal a +PPD. I have seen many many neg PPDs on people who received BCG vax either as children or as adults.

You might want to talk w/ your primary doc if you're unsure. I used to read PPDs for a living (community health ctr) and had many pts decide both ways. Good luck to ya.

TiredMD · Nov 20, 2008

This is an interesting treatment regimen. What country are you in? How prevalent is active Tb in your country, and what is the incidence of MDR Tb? Will you continue to have access to yearly screening if you don't accept treatment?

kellyc034 · Nov 20, 2008

One of my very best friends is from Latvia, was vaccinated with something over there and she tests positive for the PPD every time (though I completely agree with the previous post- not everyone that has been vaccinated gets positive PPD's).

She worked many years in hospitals, always tested positive, occ health sent her for chest x-ray, always came back clear, and that was the end of it.

Kelly

madwife2002, BSN, RN · Nov 20, 2008

I have a positive PPD but I dont have TB but I was vaccinated in the UK. Now I just have chest xray and questionairre

SaraO'Hara · Nov 20, 2008

I had a positive PPD and took the County Health Department's 6-month INH course. I have to have a CXR every four years, iirc (which doesn't come up till 2010).

racing-mom4, BSN, RN · Nov 20, 2008

Same thing happened to me, the Corp Med nurse requested I start on the treatment and I was against and my Dr agreed with me and wrote me a note stating I did not have to take it.

The tx is very hard on your liver--dont even think about drinking any alcohol while your on it (6mos was what they told me) and god forbid if your a typlical non compliant like me if you dont finish it is can cause resistance later on.

So now I just fill out a signs and symptoms sheet.

Roy Fokker, BSN, RN · Nov 20, 2008

This is an interesting treatment regimen. What country are you in? How prevalent is active Tb in your country, and what is the incidence of MDR Tb? Will you continue to have access to yearly screening if you don't accept treatment?

Hi Doc,

You bring up some interesting points. Can I throw a few questions at ya?

1. If a person comes from an area with fairly prevalent TB (let us assume India for example) but has negative PPD and CXR, what then?

2. If same person above has positive PPD but negative CXR, what then?

3. If same person as in question 1 has been advised by his/her PMD that they have "latent but not active TB", what then?

cheers,

cubangirl · Nov 20, 2008

This is an interesting treatment regimen. What country are you in? How prevalent is active Tb in your country, and what is the incidence of MDR Tb? Will you continue to have access to yearly screening if you don't accept treatment?

Well i live in the US, but my area has a big incidence of TB. So i was probably exposed to it. I also had the vaccine in my my country, but never tested positive before. So my two options are either the treatment of rifampin or xray once a year. :nurse:

heron, ASN, RN · Nov 20, 2008

My advice, treat it!!! We tend to take infections less seriously because we assume that abx will take care of it. Trust me ... Tb is nothing to fool with.

I'm not familiar with the latest CDC recs, but it might be worth it to check their site ... they're the experts, after all.

I have cared for ppl with Tb. Aside from the damage it can do to your lungs and the risk of spreading it to your family (cause you live with them, they have higher risk), many are also unaware that it can invade other body system.

I remember a young man who died of Tb meningitis. Wasn't pretty!

TiredMD · Nov 21, 2008

This is a bit outside my area, but what a nice chance to review the guidelines.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm

1. If a person comes from an area with fairly prevalent TB (let us assume India for example) but has negative PPD and CXR, what then?

Do nothing. Continue screening per guidelines, no prophylaxis is indicated.

2. If same person above has positive PPD but negative CXR, what then?
3. If same person as in question 1 has been advised by his/her PMD that they have "latent but not active TB", what then?

It's very interesting, because like you I was under the impression that a positive PPD was treated differently than "latent" Tb (as in evidence of old granulomas on chest xray, but no active infection). However, the CDC does not make such a distinction.

According to them, all that a chest xray with evidence of old infection does is change your cutoff of what constitutes a positive PPD.

Similarly, the location that the person immigrated from changes them from "low" to "moderate" risk status, and such changes the induration cutoff. From their guidelines:

"For persons who are at highest risk for developing active TB if they are infected with M. tuberculosis (i.e., persons with HIV infection, who are receiving immunosuppressive therapy, who have had recent close contact with persons with infectious TB, or who have abnormal chest radiographs consistent with prior TB), >5 mm of induration is considered positive. For other persons with an increased probability of recent infection or with other clinical conditions that increase the risk for progression to active TB, >10 mm of induration is considered positive. These include recent immigrants (i.e., within the last 5 yr) from high prevalence countries. . . "

The issue of which treatment for PPD convertors is also interesting to me. I asked where the OP was living because, personally, I had never heard of a 4mo rifampin regimen. I was quite wrong though, as it is one of the four recommended regimens, although the evidence for it is less strong than the standard 9mo of INH therapy.

The recommended treatment of immigrants from areas with high-prevalence of MDR Tb is pyrazinamide and ethambutol or pyrazinamide and a quinolone for 6--12 mo.

And for those commenting on the liver effects of Tb treatment, remember that it is primarily INH that causes that problem, not the rifampin regimen brought up by the OP. Hepatitis is a rare side effect of rifampin, but abnormal LFTs and impaired liver function are far more common with INH (and in absolute terms, not all that common anyway).