tuberculosis%20-%20pulmonary%20(pediatric)
TUBERCULOSIS - PULMONARY (PEDIATRIC)
Tuberculosis (TB) is caused by Mycobacterium tuberculosis, a gram-positive bacteria with slow growth rate that is enhanced by 6-8% carbon dioxide and temperature of 35-40ºC.
It is primarily transmitted through airborne route.
The number of tubercle bacilli expelled in the air by a TB infected person is directly related to their infectiousness.
TB transmission is rare in children <10 years old due to their inability to expectorate sputum and low TB bacilli load in their sputum.
TB infection in children is usually obtained from an infectious adolescent or adult depending on the closeness and length of contact and the index case's severity of lung involvement and infectiousness.

Tuberculosis%20-%20pulmonary%20(pediatric) Management

Monitoring

  • Each patient should be assessed by individual country’s National Tuberculosis Program at the following intervals:
    • 2 weeks after initiation of treatment
    • At the end of intensive phase
    • Every 2 months until the completion of treatment
  • Assessment during follow-up should include symptoms evaluation, treatment adherence assessment, adverse drug reactions and weight management
  • Perform sputum smear at the end of the 2nd month in patient who was smear positive at diagnosis
  • Repeat sputum exam should be performed at months 3 of therapy if sputum microscopy was positive at end of 2 months of treatment
    • Line probe assay or Xpert MTB/RIF for repeat exam is highly recommended
  • Since patients have a slow radiological response to treatment, repeat chest X-ray is not routinely required
  • Adverse drug reactions are less common compared in adults
  • For patients on Ethambutol, monthly evaluations of visual acuity and color discrimination are advised
Multidrug Resistant TB (MDR-TB)
  • Smear sputum microscopy and culture should be performed monthly until 3 consecutive negative results are obtained
    • Gastric aspirate or induced sputa may be used for sputum culture in children unable to expectorate
  • Follow-up sputum culture should be performed every 2-3 months
Latent TB Infection
  • Healthcare practitioners who are managing patients undergoing Isoniazid-Rifapentine combination therapy weekly for 12 weeks or 3 HP should:
    • Monitor all patients, prior to and during therapy for the the presence of active TB disease
    • Educate patients, parents or caretakers regarding side effects and advise them to immediately seek consultation upon recognition of such reactions (eg rashes, decrease in blood pressure and platelet count, as well as those that are drug allergy-related)
    • Evaluate patients monthly for treatment compliance and presence of side effects
    • Request for liver function tests (LFTs) (or at least an aspartate aminotransferase [AST]) in patients with liver disease, HIV, juvenile alcoholics and drug-users using injection paraphernalias or those who are taking medications with interactions with other drugs
    • Facilitate blood tests for patients with abnormal results and those who are prone to hepatic disorder
      • 3 HP regimen should be discontinued if AST result is ≥5x the upper limit of normal (ULN) with no concomitant symptoms or ≥3x ULN with accompanying symptoms
    • In the presence of severe adverse reactions, discontinue 3HP regimen and manage side-effects
      • 3 HP may be continued if adverse reactions are mild-moderate and tolerable, with continuous monitoring of patient status
Drug-induced Hepatitis
  • Usually seen with Isoniazid, Rifampicin or Pyrazinamide therapy
  • Routine measurement of liver function tests is not usually necessary during therapy unless there is occurrence of jaundice, hepatomegaly or liver tenderness
Pyridoxine Deficiency
  • Commonly seen with Isoniazid therapy
  • Oral Pyridoxine is recommended in the following patients: Severely malnourished, HIV-infected, breastfeeding and pregnant adolescents
    • Supplementation of 5-10 mg/day is recommended
Orange-red Color Discoloration of Body Secretions
  • Associated with Rifampicin therapy
  • Benign in nature; reassure patient and parent

Prevention

Vaccination
Bacille-Calmette-Guerin (BCG) Vaccination
  • Prevents life-threatening forms of tuberculosis (TB)
    • Has significant protective effect of about 50-80% for disseminated or miliary disease
  • Protective effect of BCG against pulmonary tuberculosis (PTB) is variable
  • Not recommended in immunocompromised patients
  • Multiple BCG vaccination is not recommended

Isoniazid Preventive Therapy

  • Reduces the risk of developing PTB by ~90% with good adherence
  • Recommended for patients <5 years of age presumed to have latent TB infection due to close contact with smear positive TB or human immunodeficiency virus (HIV) positive patient
    • HIV-infected infants <12 months in close contact with a TB-positive patient but negative for TB upon screening
    • HIV-infected children ≥12 months without symptoms of TB and not living with TB-positive persons but currently living in areas with high TB prevalence
    • May consider starting preventive therapy even if smear negative upon screening if in close contact with smear-positive patients and currently living in a country with high TB incidence
  • Recommended Isoniazid dosage is 10 mg/kg/day PO once daily x 6 months
    • Additional 6 months of Isoniazid may be considered in children with HIV who completed TB treatment
  • Follow-up is done every 2 months until treatment is complete
  • The addition of Rifampicin in Isoniazid monotherapy given for 3 months has been shown to be as effective as Isoniazid monotherapy
  • Isoniazid-Rifapentine combination, administered weekly for 12 weeks (3 HP) for the treatment of LTBI is approved for use in adults, patients 2-17 years of age, those who are afflicted with HIV and acquired immunodeficiency syndrome (AIDS) and are under ART which does not affect the actions of Rifapentine
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