INFECTIOUS DISEASES - PART 10 pot

Interpretation of TST Results in Previous Recipients of BCG Vaccine. Generally, interpretation of TST results in BCG recipients is the same as for people who have not received BCG vaccine. After BCG immunization, distinguishing between a positive TST result caused by M tuberculosis or M bovis infection and that caused by BCG can be difficult. Reactivity of the TST after receipt of BCG vaccine does not occur in some patients. The size of the TST reaction (ie, mm of induration) attributable to BCG immunization depends on many factors, including age at BCG immunization, quality and strain of BCG vaccine used, number of doses of BCG received, nutritional and immunologic status of the vaccine recipient, and frequency of TST administration. Tuberculosis disease should be suspected strongly in any symptomatic person with a positive TST result regardless of history of BCG immunization. When evaluating an asymptomatic child who has a positive TST result and who possibly received BCG, the result should not be attributed to BCG vaccine. Certain factors, such as documented receipt of multiple BCG immunizations (as evidenced by multiple BCG scars), decrease the likelihood that the positive TST result is attributable to LTBI. Evidence that increases the probability that a positive TST result is attributable to LTBI includes known contact with a person with contagious tuberculosis, a family history of tuberculosis disease, immigration from a country with a high prevalence of tuberculosis, a long interval (5 years) since neonatal BCG immunization, and a TST reaction 15 mm. Prompt clinical and radiographic evaluation of all children with a positive TST reaction is recommended. In most circumstances, a history of BCG will not account for the positive result. Chest radiographic findings of a granuloma, calcification, or adenopathy can be caused by M tuberculosis but not by BCG immunization. For the child with signs and symptoms consistent with abdominal tuberculosis and a history of ingestion of unpasteurized dairy products, a positive TST and a negative chest radiograph, abdominal imaging by computed tomography with contrast should be considered. Recommendations for TST Usage. The most reliable strategies for preventing LTBI and tuberculosis disease in children are based on thorough and expedient contact investigations rather than nonselective skin testing of large populations. Specific recommendations for TST use are given in Table 3.70 (p 683). All children need routine health care evaluations that include an assessment of their risk of exposure to tuberculosis. Only children deemed to have increased risk of contact with people with contagious tuberculosis or children with suspected tuberculosis disease should be considered for a TST. Household investigation is indicated whenever a TST result of a household member converts from negative to positive (indicating recent infection). Immunologic-Based Testing.* * Centers for Disease Control and Prevention. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR Recomm Rep. 2005;54(RR-15):49-55 QuantiFERON-TB Gold (QFT) is a test that measures interferon production from a person's white blood cells in response to stimulation with antigens from M tuberculosis. The sensitivity of QFT is similar to that of TST for detecting infection in people with untreated culture-confirmed tuberculosis. Although this test is approved by the FDA and recommended by the CDC for use in adults in all circumstances in which the TST is used, data are not available about its utility in children or adolescents. HIV Testing. Children with HIV are considered at high risk of tuberculosis, and an annual TST beginning at 3 to 12 months of age is recommended. Treatment (see Table 3.72, p 686): Specific Drugs. Antituberculosis drugs kill M tuberculosis and M bovis or inhibit multiplication of the organism, thereby arresting progression of LTBI and preventing most complications of early tuberculosis disease. Chemotherapy does not cause rapid disappearance of already caseous or granulomatous lesions (eg, mediastinal lymphadenitis). Dosage recommendations and the more commonly reported adverse reactions of major antituberculosis drugs are summarized in Tables 3.72 (p 686) and 3.73 (p 688). For treatment of tuberculosis disease, these drugs always must be used in combination to minimize emergence of drug-resistant strains. Isoniazid is bactericidal, rapidly absorbed, and well tolerated and penetrates into body fluids, including CSF. Isoniazid is metabolized in the liver and excreted primarily through the kidneys. Hepatotoxic effects are rare in children but can be life threatening. In children and adolescents given recommended doses, peripheral neuritis or seizures caused by inhibition of pyridoxine metabolism are rare, and most do not need pyridoxine supplements. Pyridoxine is recommended for exclusively breastfed infants and for children and adolescents on meat- and milk-deficient diets; children with nutritional deficiencies, including all symptomatic HIV-infected children; and pregnant adolescents and women. For infants and young children, isoniazid tablets can be pulverized. Rifampin is a bactericidal agent that is absorbed rapidly and penetrates into body fluids, including CSF. Rifampin is metabolized by the liver and can alter the pharmacokinetics and serum concentrations of many other drugs. Hepatotoxic effects, influenza-like symptoms, and pruritus may occur rarely. Rifampin is excreted in bile and urine and can cause orange urine, sweat, and tears and discoloration of soft contact lenses. Rifampin can make oral contraceptives ineffective, so other birth control methods should be adopted when rifampin is administered to sexually active adolescent women. For infants and young children, the contents of the capsules can be suspended in wild cherry-flavored syrup or sprinkled on semisoft foods (eg, applesauce). Mycobacterium tuberculosis resistant to rifampin is uncommon in the United States. Rifabutin is a suitable alternative to rifampin in children with HIV on highly active antiretroviral therapy that proscribes the use of rifampin; however, experience in children is limited. Major toxicities of rifabutin include leukopenia, gastrointestinal tract upset, polyarthralgias, rash, increased transaminase concentrations, and skin and secretion discoloration (pseudojaundice). Anterior uveitis has been reported among children receiving rifabutin as prophylaxis or as part of a combination regimen for treatment, usually when administered at high doses. Rifabutin also increases hepatic metabolism of many drugs but is a less potent inducer of cytochrome P450 enzymes than rifampin and has fewer problematic drug interactions than rifampin. However, adjustments in dose of rifabutin and the coadministered antiretroviral drugs may be necessary for certain combinations. Pyrazinamide attains therapeutic CSF concentrations, is detectable in macrophages, is administered orally, and is metabolized by the liver. Administration of pyrazinamide with isoniazid and rifampin allows for 6-month regimens in patients with drug-susceptible tuberculosis. Mycobacterium bovis intrinsically is resistant to pyrazinamide, precluding 6-month therapy for this pathogen. In doses of 30 mg/kg per day or less, pyrazinamide seldom has hepatotoxic effects and is well tolerated by children. Some adolescents and many adults develop arthralgia and hyperuricemia because of inhibition of uric acid excretion. Pyrazinamide must be used with caution in people with underlying liver disease. Ethambutol is well absorbed after oral administration, diffuses well into tissues, and is excreted in urine. However, concentrations in the cerebrospinal fluid are low. At 15 mg/kg per day, ethambutol is bacteriostatic only, and its primary therapeutic role is to prevent emergence of drug resistance. A dose of 25 mg/kg per day is necessary for bactericidal activity. Because ethambutol can cause reversible or irreversible optic neuritis, recipients should be monitored monthly for visual acuity and red-green color discrimination. Use of ethambutol in young children whose visual acuity cannot be monitored requires consideration of risks and benefits. However, ethambutol-associated optic neuritis exceedingly is rare in children with normal renal function. Streptomycin is administered intramuscularly but is available only on a limited basis. When streptomycin is not available, kanamycin, amikacin, or capreomycin are alternatives that can be prescribed for the initial 4 to 8 weeks of therapy. The less commonly used (eg, "second-line") antituberculosis drugs, their doses, and adverse effects are listed in Table 3.74 (p 689). These drugs have limited usefulness because of decreased effectiveness and greater toxicity and should be used only in consultation with a specialist. Ethionamide is an orally administered antituberculosis drug that is well tolerated by children, achieves therapeutic CSF concentrations, and may be useful for treatment of people with meningitis or drug-resistant tuberculosis. Fluoroquinolones have antituberculosis activity and can be used in special circumstances. Because some fluoroquinolones are approved by the FDA for use only in people 18 years of age and older, their use in younger patients necessitates careful assessment of the potential risks and benefits (see Antimicrobial Agents and Related Therapy, p 735). Occasionally, a patient cannot tolerate oral medications. Isoniazid, rifampin, streptomycin and related drugs, and fluoroquinolones can be administered parenterally. Therapy for LTBI. Isoniazid given to adults who have LTBI (eg, no clinical or radiographic abnormalities suggesting tuberculosis disease) provides substantial protection (54%-88%) against development of tuberculosis disease for at least 20 years. Among children, efficacy approaches 100% with appropriate adherence to therapy. All infants, children, and adolescents who have a positive TST result but no evidence of tuberculosis disease and who never have received antituberculosis therapy should receive isoniazid unless resistance to isoniazid is suspected (ie, known exposure to a person with isoniazid-resistant tuberculosis) or a specific contraindication exists. Isoniazid in this circumstance is therapeutic and prevents development of disease. A physical examination and chest radiograph should be obtained at the time isoniazid therapy is initiated to exclude tuberculosis disease; if the radiograph is normal, the child remains asymptomatic, and treatment is completed, radiography should not be repeated. Duration of Therapy for LTBI. For infants, children, and adolescents, the recommended duration of isoniazid therapy is 9 months. Isoniazid is given daily in a single dose. When adherence with daily therapy with isoniazid cannot be ensured, twice-a-week DOT can be considered. Therapy for Contacts of Patients With Isoniazid-Resistant M tuberculosis. The incidence of isoniazid resistance among M tuberculosis isolates from US patients is approximately 9%. Risk factors for drug resistance are listed in Table 3.75. However, most experts recommend that isoniazid be used to treat LTBI in children unless the child has had contact with a person known to have isoniazid-resistant tuberculosis. If the source case is found to have isoniazid-resistant, rifampin-susceptible organisms, isoniazid should be discontinued and rifampin should be given for a total course of 6 months. The effectiveness and safety of a 2-month course of rifampin and pyrazinamide for treatment of LTBI in children is not known. Further, the 2-month regimen has been found to cause severe hepatotoxicity in adults and is not recommended for children. Optimal therapy for children with LTBI caused by organisms with resistance to isoniazid and rifampin is not known. In these circumstances, multidrug regimens have been used. Drugs to consider include pyrazinamide, a fluoroquinolone, and ethambutol, depending on susceptibility of the isolate. Consultation with a tuberculosis specialist is indicated. Treatment of Tuberculosis Disease. The goal of treatment is to achieve sterilization of the tuberculous lesion in the shortest possible time. Achievement of this goal minimizes the possibility of development of resistant organisms. The major problem limiting successful treatment is poor adherence to prescribed treatment regimens. The use of DOT decreases the rates of relapse, treatment failures, and drug resistance; therefore, DOT is recommended strongly for treatment of children and adolescents with tuberculosis disease in the United States. For M tuberculosis disease, a 6-month regimen consisting of isoniazid, rifampin, and pyrazinamide for the first 2 months and isoniazid and rifampin for the remaining 4 months is recommended for treatment of drug- susceptible pulmonary disease, pulmonary disease with hilar adenopathy, and hilar adenopathy disease in infants, children, and adolescents. If the chest radiograph shows a cavitary lesion or lesions and sputum remains culture positive after 2 months of therapy, the duration of therapy should be extended to 9 months. For children with hilar adenopathy in whom drug resistance is not a consideration, a 6-month regimen of only isoniazid and rifampin is considered adequate by some experts. When drug resistance is possible (see Table 3.75, p 690), initial therapy should include a fourth drug, either ethambutol or an aminoglycoside, until drug susceptibility results are available. If an isolate from the pediatric case under treatment is not available, drug susceptibilities can be inferred by the drug susceptibility pattern of isolates from the adult source case. If this information is not available, local endemic rates of single and multiple drug resistance can be helpful. Data may not be available for foreign-born children or in circumstances of international travel. If this information is not available, a 4-drug initial regimen is recommended. In the 6-month regimen with triple-drug therapy, isoniazid, rifampin, and pyrazinamide are given once a day for the first 2 weeks. Between 2 weeks and 2 months of treatment, isoniazid, rifampin, and pyrazinamide can be given daily or twice a week by DOT. After the initial 2-month period, a DOT regimen of isoniazid and rifampin given twice a week is acceptable (see Table 3.72, p 686, for doses). Several alternative regimens with differing durations of daily therapy and total therapy have been used successfully in adults and children. These alternative regimens should be prescribed and managed by a specialist in tuberculosis. Therapy for M bovis disease. Controlled clinical trials for the treatment of M bovis disease have not been conducted. Treatment recommendations for M bovis disease in adults and children are based on results from treatment trials for M tuberculosis disease. Although all strains of M bovis are pyrazinamide- resistant, multidrug-resistant strains are rare. As knowledge of culture and susceptibility results rarely are available for children with M bovis disease, initial therapy should include 3 or 4 drugs appropriate for M tuberculosis disease. For isoniazid- and rifampin-susceptible strains, a total treatment course of at least 9 to 12 months is recommended. Therapy for Drug-Resistant Tuberculosis Disease. Drug resistance is most common in the following: (1) people born in areas such as Russia and the former Soviet Union, Asia, Africa, and Latin America; (2) people previously treated for tuberculosis disease; and (3) contacts, especially children, with tuberculosis disease whose source case is a person from one of these groups (see also Table 3.75, p 690). Most cases of pulmonary tuberculosis in children that are caused by an isoniazid-resistant but rifampin-susceptible strain of M tuberculosis can be treated with a 6-month regimen of rifampin, pyrazinamide, and ethambutol. For cases of multidrug-resistant tuberculosis disease, the treatment regimen should include at least 4 antituberculosis drugs to which the organism is susceptible. In cases of tuberculosis with isoniazid- and rifampin-resistant strains, 6-month drug regimens are not recommended. Twelve to 24 months of therapy usually is necessary for cure. Twice- and thrice-a-week regimens also are not recommended for drug-resistant disease; daily DOT is critical to cure children with drug-resistant tuberculosis disease and to prevent emergence of further resistance. Extrapulmonary M tuberculosis. In general, extrapulmonary tuberculosiswith the exception of meningitiscan be treated with the same regimens as used for pulmonary tuberculosis. For suspected drug-susceptible tuberculous meningitis, daily treatment with isoniazid, rifampin, pyrazinamide, and streptomycin or another aminoglycoside or ethionamide should be initiated. When susceptibility to all drugs is established, the aminoglycoside or ethionamide can be discontinued. Pyrazinamide is given for a total of 2 months and isoniazid and rifampin are given for a total of 9 to 12 months. Isoniazid and rifampin can be given daily or twice a week after the first 2 months of treatment. For life-threatening tuberculosis, 4 drugs are given initially because of the possibility of drug resistance and the severe consequences of treatment failure (see Therapy for Drug-Resistant Tuberculosis Disease, p 691). Corticosteroids. The evidence supporting adjuvant treatment with corticosteroids for children with tuberculosis disease is incomplete. Corticosteroids are indicated for children with tuberculous meningitis, because they decrease rates of mortality and long-term neurologic impairment. Corticosteroids may be considered for children with pleural and pericardial effusions (to hasten reabsorption of fluid), severe miliary disease (to mitigate alveolocapillary block), endobronchial disease (to relieve obstruction and atelectasis) and abdominal tuberculosis (to decrease the risk of strictures). Corticosteroids should be given only when accompanied by appropriate antituberculosis therapy. Most experts consider 2 mg/kg per day of prednisone (maximum 60 mg/day) or its equivalent for 4 to 6 weeks followed by tapering to be appropriate. Tuberculosis Disease and HIV Infection. Adults and children with HIV infection have an increased incidence of tuberculosis disease. Hence, HIV testing is indicated for all people with tuberculosis disease. The clinical manifestations and radiographic appearance of tuberculosis disease in children with HIV infection tend to be similar to those in immunocompetent children, but manifestations in these children can be more severe and unusual and can include extrapulmonary involvement of multiple organs. In HIV- infected patients, a TST result of 5-mm induration or more is considered positive (see Table 3.69, p 680); however, a negative TST result attributable to HIV-related immunosuppression also can occur. Specimens for culture should be obtained from all HIV-infected children with suspected tuberculosis. Most HIV-infected adults with drug-susceptible tuberculosis respond well to antituberculosis drugs when appropriate therapy is given early. However, optimal therapy for tuberculosis in children with HIV infection has not been established. Therapy always should include at least 4 drugs initially and be continued for at least 9 months. Isoniazid, rifampin, and pyrazinamide, usually with ethambutol or an aminoglycoside, should be given for at least the first 2 months. A 3-drug regimen can be used once drug-resistant tuberculosis disease is excluded. Rifampin may be contraindicated in people who are receiving highly active antiretroviral therapy. Rifabutin can be substituted for rifampin in some circumstances. Consultation with a specialist who has experience in managing HIV-infected patients with tuberculosis is advised strongly. Evaluation and Monitoring of Therapy in Children and Adolescents. Careful monthly monitoring of the clinical and bacteriologic responses to therapy is important. With DOT, clinical evaluation is an integral component of each visit for drug administration. For patients with pulmonary tuberculosis, chest radiographs should be obtained after 2 months of therapy to evaluate response. Even with successful 6-month regimens, hilar adenopathy can persist for 2 to 3 years; normal radiographic findings are not necessary to discontinue therapy. Follow-up chest radiographs beyond termination of successful therapy usually are not necessary unless clinical deterioration occurs. If therapy has been interrupted, the date of completion should be extended. Although guidelines cannot be provided for every situation, factors to consider when establishing the date of completion include the following: (1) length of interruption of therapy; (2) time during therapy (early or late) when interruption occurred; and (3) the patient's clinical, radiographic, and bacteriologic status before, during, and after interruption of therapy. The total doses administered by DOT should be calculated to guide the duration of therapy. Consultation with a specialist in tuberculosis is advised. Untoward effects of isoniazid therapy, including severe hepatitis in otherwise healthy infants, children, and adolescents, are rare. Routine determination of serum transaminase concentrations is not recommended. However, for children with severe tuberculosis disease, especially children with meningitis or disseminated disease, transaminase concentrations should be monitored approximately monthly during the first several months of treatment. Other indications for testing include the following: (1) having concurrent or recent liver or biliary disease; (2) being pregnant or in the first 6 weeks postpartum; (3) having clinical evidence of hepatotoxic effects; or (4) concurrently using other hepatotoxic drugs (eg, anticonvulsant agents). In most other circumstances, monthly clinical evaluations to observe for signs or symptoms of hepatitis and other adverse effects of drug therapy without routine monitoring of transaminase concentrations is appropriate follow-up. In all cases, regular physician-patient contact to assess drug adherence, efficacy, and toxic effects is an important aspect of management. Immunizations. Patients who are receiving treatment for tuberculosis can be given measles and other age-appropriate live-virus vaccines unless they are receiving high-dose corticosteroids, are severely ill, or have other specific contraindications to immunization. Tuberculosis During Pregnancy and Breastfeeding. Tuberculosis treatment during pregnancy varies because of the complexity of management decisions. During pregnancy, if tuberculosis disease is diagnosed, a regimen of isoniazid, rifampin, and ethambutol is recommended. Pyrazinamide commonly is used in a 3- or 4-drug regimen, but safety during pregnancy has not been established. At least 6 months of therapy is indicated for drug- susceptible tuberculosis disease if pyrazinamide is used; at least 9 months of therapy is indicated if pyrazinamide is not used. Prompt initiation of therapy is mandatory to protect mother and fetus. Asymptomatic pregnant women with a positive TST result, normal chest radiographic findings, and recent contact with a contagious person should receive isoniazid therapy. The recommended duration of therapy is 9 months. Therapy in these circumstances should begin after the first trimester. Pyridoxine is indicated for all pregnant and breastfeeding women receiving isoniazid. Isoniazid, ethambutol, and rifampin are relatively safe for the fetus. The benefit of ethambutol and rifampin for therapy of tuberculosis disease in the mother outweighs the risk to the infant. Because streptomycin can cause ototoxic effects in the fetus, it should not be used unless administration is essential for effective treatment. Although isoniazid is secreted in human milk, no adverse effects of isoniazid on nursing infants have been demonstrated (see Human Milk, p 123). Breastfed infants do not require pyridoxine unless they are receiving isoniazid. Congenital Tuberculosis. Women who have only pulmonary tuberculosis are not likely to infect the fetus but can infect their infant after delivery. Congenital tuberculosis is rare, but in utero infections can occur after maternal M tuberculosis bacillemia. If a newborn is suspected of having congenital tuberculosis, a TST, chest radiograph, lumbar puncture, and appropriate cultures should be performed promptly. The TST result usually is negative in newborn infants with congenital or perinatally acquired infection. Hence, regardless of the TST results, treatment of the infant should be initiated promptly with isoniazid, rifampin, pyrazinamide, and an aminoglycoside (eg, amikacin). The placenta should be examined histologically and cultured for M tuberculosis. The mother should be evaluated for the presence of pulmonary or extrapulmonary disease, including uterine tuberculosis disease. If the maternal physical examination and chest radiographic findings support the diagnosis of tuberculosis disease, the newborn infant should be treated with regimens recommended for tuberculosis disease. If meningitis is confirmed, corticosteroids should be added (see Corticosteroids, p 692). Drug susceptibility testing of the organism recovered from the mother or household contact, infant, or both should be performed. Management of the Newborn Infant Whose Mother (or Other Household Contact) Has LTBI or Tuberculosis Disease. Management of the newborn infant is based on categorization of the maternal (or household contact) infection. Although protection of the infant from tuberculosis disease is of paramount importance, contact between infant and mother should be allowed when possible. Differing circumstances and resulting recommendations are as follows: Mother (or household contact) has a positive TST result and normal chest radiographic findings. If the mother (or household contact) is asymptomatic, no separation is required. The mother usually is a candidate for treatment of LTBI after the initial postpartum period. The newborn infant needs no special evaluation or therapy. Because the positive TST result could be a marker of an unrecognized case of contagious tuberculosis within the household, other household members should have a TST and further evaluation, but this should not delay the infant's discharge from the hospital. Mother (or household contact) has clinical signs and symptoms or abnormal findings on chest radiograph consistent with tuberculosis disease. Cases of tuberculosis disease in mothers (or household contacts) should be reported immediately to the local health department, and investigation of all household members should start within several days. If the mother has tuberculosis disease, the infant should be evaluated for congenital tuberculosis (see Congenital Tuberculosis) and the mother should be tested for HIV infection. The mother (or household contact) and the infant should be separated until the mother (or household contact) has been evaluated and, if tuberculosis disease is suspected, until the mother (or household contact) and infant are receiving appropriate antituberculosis therapy, the mother wears a mask, and the mother understands and is willing to adhere to infection control measures. Once the infant is receiving isoniazid, separation is not necessary unless the mother (or household contact) has possible multidrug-resistant M tuberculosis disease or has poor adherence to treatment and DOT is not possible. In this circumstance, the infant should be separated from the mother (or household contact), and BCG immunization should be considered for the infant. If the mother is suspected of having multidrug-resistant tuberculosis, an expert in tuberculosis disease treatment should be consulted. If congenital tuberculosis is excluded, isoniazid is given until the infant is 3 or 4 months of age, when a TST should be performed. If the TST result is positive, the infant should be reassessed for tuberculosis disease. If tuberculosis disease is excluded, isoniazid should be continued for a total of 9 months. The infant should be evaluated at monthly intervals during treatment. If the TST result is negative and the mother (or household contact) has good adherence and response to treatment and no longer is contagious, isoniazid is discontinued. Mother (or household contact) has abnormal findings on chest radiography but no evidence of tuberculosis disease. If the chest radiograph of the mother (or household contact) appears abnormal but is not characteristic of tuberculosis disease and the history, physical examination, and sputum smear indicate no evidence of tuberculosis disease, the infant can be assumed to be at low risk of M tuberculosis infection and need not be separated from the mother (or household contact). The mother and her infant should receive follow-up care and the mother should be treated for LTBI. Other household members should have a TST and further evaluation. Isolation of the Hospitalized Patient: Most children with tuberculosis disease are not contagious. Exceptions are the following: (1) children with cavitary pulmonary tuberculosis; (2) children with positive sputum AFB smears; (3) children with laryngeal involvement; (4) children with extensive pulmonary infection; or (5) children with congenital tuberculosis undergoing procedures that involve the oropharyngeal airway (eg, endotracheal intubation). In these instances, isolation for tuberculosis or AFB are indicated until effective therapy has been initiated, sputum smears demonstrate a diminishing number of organisms, and cough is abating. Children with no cough and negative sputum AFB smears can be hospitalized in an open ward. Infection control measures for hospital personnel exposed to contagious patients should include the use of personally "fitted" and "sealed" particulate respirators for all patient contacts (see Infection Control for Hospitalized Children, p 153). The contagious patient should be placed in an airborne infection isolation room in the hospital. The major concern in infection control relates to adult household members and contacts who may be the source case. Visitation should be limited to people who have a chest radiograph to exclude contagious tuberculosis. Household members and contacts should be managed with tuberculosis precautions when visiting until they are demonstrated not to have contagious tuberculosis. Nonadherent household contacts should be excluded from hospital visitation until evaluation is complete and tuberculosis disease is excluded or treatment has rendered source cases noncontagious. Control Measures*: * American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America. Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep. 2005;54(RR-12):1-80 Control of tuberculosis disease in the United States requires collaboration between health care professionals and health department personnel, obtaining a thorough history of exposure(s) to people with infectious tuberculosis, timely and effective contact investigations, proper interpretation of TST results, and appropriate antituberculosis therapy, including DOT services. Eliminating the ingestion of unpasteurized dairy products will prevent M bovis infection. Management of Contacts, Including Epidemiologic Investigation. a a National Tuberculosis Controllers Association and Centers for Disease Control and Prevention. Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR Recomm Rep. 2005;54(RR-15):1-47 [...]... Health Service and the Infectious Diseases Society of America MMWR Recomm Rep 2002;51(RR-8): 1-4 6 Prophylaxis for preventing the first MAC infection should be offered to HIVinfected children younger than 13 years of age with the following CD4+ Tlymphocyte counts: children 6 years of age or older, less than 50 cells 106 /L ( 50/uL); children 2 to 6 years of age, less than 75 cells 106 /L ( 75/uL); children... or high-dose rifabutin (with another drug) should be observed for the rifabutin-related development of leukopenia, uveitis, polyarthralgias, and pseudojaundice Chemoprophylaxis According to the 2002 US Public Health Service and Infectious Diseases Society of America guidelines* for preventing the first MAC episode, prophylaxis with azithromycin or clarithromycin should be considered for HIV-infected... throughout the world, including Asia, Africa, some parts of Europe, and Central and South America Typhus is most common during winter, when conditions favor person-to-person transmission of the vector, the body louse Rickettsiae are present in the blood and tissues of patients during the early febrile phase but are not found in secretions Direct person-to-person spread of the disease does not occur in... the only documented natural host, but free-living V cholerae organisms can exist in the aquatic environment The usual mode of infection is ingestion of large numbers of organisms from contaminated water or food (particularly raw or undercooked shellfish, raw or partially dried fish, or moist grains or vegetables held at ambient temperature) Direct person-to-person spread has not been documented People... between 2 sera obtained at least 2 weeks apart, with one of the specimens having a minimum titer of 1:128 (MA) or 1:160 (TA) Slide agglutination tests are less reliable than TA tests Nonspecific cross-reactions can occur with specimens containing heterophil antibodies or antibodies to Brucella species, Legionella species, or other gram-negative bacteria However, cross-reactions rarely result in MA or TA... receiving therapy (see Children in Out-of-Home Child Care, p 130) They can return to regular activities as soon as effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms have diminished substantially Children with LTBI can participate in all activities whether they are receiving treatment or not BCG Vaccines The bacille Calmette-Guerin (BCG) vaccine is a live... therapy for this potentially lifethreatening disease In people who are intolerant of tetracyclines, intravenous chloramphenicol or fluoroquinolones can be considered Fluoroquinolones are not approved for this indication in children younger than 18 years of age, but if illness is life-threatening, the benefit may outweigh potential risks To halt the spread of disease to other people, louse-infested patients... is recommended by the Expanded Programme on Immunization of the World Health Organization for administration at birth (see Table 1.3, p 10) and currently is used in more than 100 countries Bacille Calmette-Guerin vaccine is used to prevent disseminated and other life-threatening manifestations of M tuberculosis infection in infants and young children However, BCG immunization appears to decrease the... Oral Rehydration Solution (ORS) has been the standard, but data suggest that rice-based ORS or amylase-resistant starch ORS is more effective * Centers for Disease Control and Prevention Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy MMWR Recomm Rep 2003;52(RR-16): 1-1 6 Antimicrobial therapy results in prompt eradication of vibrios, decreases the... should be tested for WNV-specific immunoglobulin (Ig) M antibody Enzyme immunoassays or immunofluorescent assays for WNV-specific IgM currently are available commercially or through state public health laboratories Microsphere immunoassays are being developed at reference laboratories Positive tests for WNV-specific IgM provide good evidence of recent WNV infection but may cross-react with antibody to . tuberculosis with isoniazid- and rifampin-resistant strains, 6-month drug regimens are not recommended. Twelve to 24 months of therapy usually is necessary for cure. Twice- and thrice-a-week regimens. infections among HIV-infected personsmdash2002. Recommendations of the US Public Health Service and the Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-8): 1-4 6 Prophylaxis. foreign-born children or in circumstances of international travel. If this information is not available, a 4-drug initial regimen is recommended. In the 6-month regimen with triple-drug therapy,