When do we use Isoniazid Monotherapy for TB treatment? - USMLE Forums
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Drug When do we use Isoniazid Monotherapy for TB treatment?

When will be Isoniazid + pyridoxine for 6 months answer for Tuberculosis Q

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Latent tuberculosis


There are several treatment regimens currently in use:
  • 9H — Isoniazid for 9 months is the gold standard (93% effective).
  • 6H — Isoniazid for 6 months might be adopted by a local TB program based on cost-effectiveness and patient compliance. This is the regimen currently recommended in the UK for routine use. The U.S. guidance excludes this regimen from use in children or persons with radiographic evidence of prior tuberculosis (old fibrotic lesions) (69% effective).


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A 2000 Cochran review containing 11 double-blinded, randomized control trials and 73,375 patients examined six and 12 month courses of isoniazid (INH) for treatment of latent tuberculosis. HIV positive and patients currently or previously treated for tuberculosis were excluded. The main result was a relative risk (RR) of 0.40 (95% confidence interval (CI) 0.31 to 0.52) for development of active tuberculosis over two years or longer for patients treated with INH, with no significant difference between treatment courses of six or 12 months (RR 0.44, 95% CI 0.27 to 0.73 for six months, and 0.38, 95% CI 0.28 to 0.50 for 12 months).[126]
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I got confused between active and latent tuberculosis and their treatment .Thanks a lot
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Quote:
Originally Posted by step_enhancer View Post
I got confused between active and latent tuberculosis and their treatment .Thanks a lot
When there is latent TB (positive PPD + negative CXR or positive PPD + positive CXR but negative 3 sputum AFB smears) treat with INH for 9 months.

If there is active pulmonary TB: treat INH + RIFA + PYRI + either ethambutol or strepto for 2 months then continue INH+ rifa for another 4 months
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Quote:
Originally Posted by Ayman Qasrawi View Post
When there is latent TB (positive PPD + negative CXR or positive PPD + positive CXR but negative 3 sputum AFB smears) treat with INH for 9 months.

If there is active pulmonary TB: treat INH + RIFA + PYRI + either ethambutol or strepto for 2 months then continue INH+ rifa for another 4 months
Awesome ....thank you so much
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You are welcome
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Quote:
Originally Posted by Ayman Qasrawi View Post
When there is latent TB (positive PPD + negative CXR or positive PPD + positive CXR but negative 3 sputum AFB smears) treat with INH for 9 months.

If there is active pulmonary TB: treat INH + RIFA + PYRI + either ethambutol or strepto for 2 months then continue INH+ rifa for another 4 months
So patient with postive PPD(>15 mm) + positive chest Xray ,next step would be treatment for active TB or sputum AFB test ??
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Originally Posted by step_enhancer View Post
So patient with postive PPD(>15 mm) + positive chest Xray ,next step would be treatment for active TB or sputum AFB test ??
This is from Kaplan, 2011:
When PPD is + (remmeber the criteria for >5, > 10, and > 15, it depends), then do a CXR.
If the CXR is negative - it is latent TB

If the CXR is positive - the patient SHOULD have 3 sputum AFB stains done to see if they have active disease.

Positive smears - mean active disease
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So a negative CXR OR an abnormal CXR AND three negative AFB smears are sufficient to exclude active disease (Kaplan 2011, page 202)
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Quote:
Originally Posted by Ayman Qasrawi View Post
This is from Kaplan, 2011:
When PPD is + (remmeber the criteria for >5, > 10, and > 15, it depends), then do a CXR.
If the CXR is negative - it is latent TB

If the CXR is positive - the patient SHOULD have 3 sputum AFB stains done to see if they have active disease.

Positive smears - mean active disease
Perfect ........thanks for being so helpful
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What do you do for close contact of someone with active TB but have a negative PPD ?
In other words- high pre-test probability with negative PPD ?
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Quote:
Originally Posted by Novobiocin View Post
What do you do for close contact of someone with active TB but have a negative PPD ?
In other words- high pre-test probability with negative PPD ?
may be Repeat PPD in 2 weeks .......!!!!!
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may be Repeat PPD in 2 weeks .......!!!!!
Patients who have been a close contact of someone with active TB but have a negative PPD can either be observed or treated for LTBI,depending on their risk;
eg, an HIV-positive patient should be be treated, Children definitely get treatment.
A healthy person with no other risks should be observed. Retest the negative cases in 10–12 weeks
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Patients who have been a close contact of someone with active TB but have a negative PPD can either be observed or treated for LTBI,depending on their risk;
eg, an HIV-positive patient should be be treated, Children definitely get treatment.
A healthy person with no other risks should be observed. Retest the negative cases in 10–12 weeks
'A healthy person with no other risks should be observed ' means they should undergo PPD test ??
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Quote:
Originally Posted by step_enhancer View Post
'A healthy person with no other risks should be observed ' means they should undergo PPD test ??
Yes. They should undergo a repeat PPD test in 10-12 weeks because it takes 10-12 weeks minimum for a PPD to become positive after exposure.
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What do you do in a healthy patient with a negative PPD and a sputum sample positive for AFB ?
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Originally Posted by Novobiocin View Post
What do you do in a healthy patient with a negative PPD and a sputum sample positive for AFB ?
Retest sputum ,if positive for 2 more times then its active Tuberculosis ??
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Originally Posted by Novobiocin View Post
What do you do in a healthy patient with a negative PPD and a sputum sample positive for AFB ?
I think proceed directly to Anti-TB therapy......just a guess
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Originally Posted by step_enhancer View Post
Retest sputum ,if positive for 2 more times then its active Tuberculosis ??
OK, the sputum is positive for a total of three times. What next?

Look down for hint (if you want to)

.
.
.
.
.
.
.
.
.
.

.

Hint: AFB doesn't always mean M. Tuberculosis.
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Quote:
Originally Posted by Novobiocin View Post
OK, the sputum is positive for a total of three times. What next?

Look down for hint (if you want to)

.
.
.
.
.
.
.
.
.
.

.

Hint: AFB doesn't always mean M. Tuberculosis.
Proceed to therapy for active TB ?? but your hint tells otherwise ,so i don't know
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Originally Posted by step_enhancer View Post
Proceed to therapy for active TB ?? but your hint tells otherwise ,so i don't know
AFB can be an atypical mycobacteria as well as Nocardia etc. Negative PPD tells us that it may not be M Tuberculosis since it's sensitivity is 80%.
So the only way to find out is by doing nuclear amplification/PCR to differentiate.
Also, a CxR is helpful-If it shows features of bronchiectasis or cystic fibrosis then it is most likely an atypical mycobacteria (ssince these patients have incresed incidence of infection with atypical mycobacteria ). If the CxR shows a typical cavitary lesion in upper lobe then it is most likely M Tuberculosis infection and you treat it with 4 drug regimen.
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Quote:
Originally Posted by Novobiocin View Post
AFB can be an atypical mycobacteria as well as Nocardia etc. Negative PPD tells us that it may not be M Tuberculosis since it's sensitivity is 80%.
So the only way to find out is by doing nuclear amplification/PCR to differentiate.
Also, a CxR is helpful-If it shows features of bronchiectasis or cystic fibrosis then it is most likely an atypical mycobacteria (ssince these patients have incresed incidence of infection with atypical mycobacteria ). If the CxR shows a typical cavitary lesion in upper lobe then it is most likely M Tuberculosis infection and you treat it with 4 drug regimen.
we have to look for atypical mycobacteria too

So a positive PPD(>15 mm) + 3 positive AFP sputum =active TB right ? I mean PPD is for typical TB .I think I am getting confused .I hope they just keep it to typical ,otherwise Its tough .

already there are so many guidelines -all this is overwhelming
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we have to look for atypical mycobacteria too

So a positive PPD(>15 mm) + 3 positive AFP sputum =active TB right ? I mean PPD is for typical TB .I think I am getting confused .I hope they just keep it to typical ,otherwise Its tough .

already there are so many guidelines -all this is overwhelming
This for 99.99% score.
For less than that just remember the usual guidelines for typical i.e. PPD +ve with different risk categories.
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