Treatment of TB in Special Situations
The following general treatment recommendations address special situations such as drug-resistant forms of HIV-related TB, TB among HIV-infected pregnant women, TB among HIV-infected children, and extrapulmonary HIV-related TB. Detailed recommendations for managing these patients are published elsewhere (2,64,147-150), and consultation with experts in these areas is highly recommended.

Treatment of Drug-Resistant TB
A.II TB disease resistant to isoniazid only. The treatment regimen should generally consist of a rifamycin (rifampin or rifabutin), pyrazinamide, and ethambutol for the duration of treatment. Intermittent therapy administered twice weekly can be used following at least 2 weeks (14 doses) of daily induction therapy (see Duration of TB Treatment). The recommended duration of treatment is 6-9 months or 4 months after culture conversion. Isoniazid is generally stopped when resistance (greater than 1% of bacilli resistant to 1.0 ug/mL of isoniazid) to this drug is discovered; however, when low-level resistance is discovered (greater than 1% of bacilli resistant to 0.2 ug/mL of isoniazid, but no resistance to 1.0 ug/mL of isoniazid), some experts suggest continuing to use isoniazid as part of the treatment regimen. Because the development of acquired rifamycin resistance would result in MDR TB, clinicians should carefully supervise and manage TB treatment for these patients.

A.II TB disease resistant to rifampin only. The 9-month treatment regimen should generally consist of an initial 2-month phase of isoniazid, streptomycin, pyrazinamide, and ethambutol (see Nine-month SM-based therapy in Table 1A of Appendix). The second phase of treatment should consist of isoniazid, streptomycin, and pyrazinamide administered for 7 months. Because the development of acquired isoniazid resistance would result in MDR TB, clinicians should carefully supervise and manage TB treatment for these patients.

A.III Multidrug-resistant TB (resistant to both isoniazid and rifampin). These patients should be managed by or in consultation with physicians experienced in the management of MDR TB. Findings from a retrospective study of patients with MDR TB strongly indicate that early aggressive treatment with appropriate regimens (based on the known or suspected drug-resistance pattern of the M. tuberculosis isolate) markedly decreases deaths associated with MDR TB (63,151-153). Most drug regimens currently used to treat MDR TB include an aminoglycoside (e.g., streptomycin, kanamycin, amikacin) or capreomycin, and a fluoroquinolone. The recommended duration of treatment for MDR TB in HIV-seropositive patients is 24 months after culture conversion, and posttreatment follow-up visits to monitor for TB relapse should be conducted every 4 months for 24 months. Because of the serious personal and public health concerns associated with MDR TB, health departments should always use DOT for these patients and take whatever steps are needed to ensure their adherence to therapy.

A.III TB Treatment for HIV-Infected Pregnant Women HIV-infected pregnant women who have a positive M. tuberculosis culture or who are suspected of having TB disease should be treated without delay. Choices of T B treatment regimens for HIV-infected pregnant women are those that include a rifamycin (Table 1A of Appendix). Routine use of pyrazinamide during pregnancy is recommended by international organizations but has not been recommended in the United States because of inadequate teratogenicity data (2). However, for HIV-infected pregnant women, the benefits of a TB treatment regimen that includes pyrazinamide outweigh potential pyrazinamide-related risks to the fetus. Aminoglycosides (e.g, streptomycin, kanamycin, amikacin) and capreomycin are contraindicated for all pregnant women because of potential adverse effects on the fetus. Considerations for antiretroviral therapy for pregnant HIV-infected women have been published elsewhere (4).

A.II TB Treatment for HIV-Infected Children HIV-infected children who are suspected of having TB disease should be treated without delay. For HIV-infected children, even those who are too young to be evaluated for visual acuity and red-green perception, ethambutol at a dosage of 15 mg/kg body weight (Table 2A of Appendix) should generally be included as part of the initial regimen, unless the infecting strain of M. tuberculosis is known or suspected of being susceptible to isoniazid and rifampin. If drug-susceptibility results are not available, a four-drug regimen (e.g., isoniazid, rifamycin, pyrazinamide, and ethambutol) for 2 months, followed by intermittent administration of isoniazid and a rifamycin for 4 months, is recommended. Considerations for antiretroviral therapy for children and adolescents have been published elsewhere (154).

A.II TB Treatment for HIV-Infected Patients with Extrapulmonary TB The basic principles that support the treatment of pulmonary TB in HIV-infected patients also apply to extrapulmonary forms of the disease. Most extrapulmonary forms of TB (including TB meningitis, tuberculous lymphadenitis, pericardial TB, pleural TB, and disseminated or miliary TB) are more common among persons with advanced-stage HIV disease (155,156) than among patients with asymptomatic HIV infection. The drug regimens and treatment durations that are recommended for treating pulmonary TB in HIV-infected adults and children (Table 1A of Appendix) are also recommended for treating most patients with extrapulmonary disease. However, for certain forms of extrapulmonary disease, such as meningioma, bone, and joint TB, using a rifamycin-based regimen for at least 9 months is generally recommended.

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