Download Management of the Patient with Known or Suspected Tuberculosis

Management of the Patient with Known or Suspected Tuberculosis
Introduction: Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis. Historically,
Mississippi has had amongst the highest case rates in the nation. In recent years, our case rates have
declined dramatically, but it is still a disease we diagnose regularly. Tuberculosis is spread by small droplet
nuclei (aerosols) when patients with disease talk or cough. These small droplet nuclei may be suspended in
the air like small particles of dust and can potentially spread hundreds of feet. As such, special Airborne
Infection Isolation is required for patients diagnosed with or suspected of having tuberculosis.
Isolation of Tuberculosis Patients or Suspects:
• Patients known to have active, untreated tuberculosis or who are suspected of having tuberculosis
should be placed in Airborne Infection Isolation. IF TUBERCULOSIS IS LISTED IN THE
DIFFERENTIAL DIAGNOSIS OF A PULMONARY PROBLEM THE PATIENT
BELONGS IN ISOLATION. It is expected that the vast majority of patients placed in such
isolation will not ultimately be diagnosed with tuberculosis. It is impossible to tell clinically who
does and who does not have disease; as such, isolate all suspects to reduce risk of exposure of
patients and staff.
• Any patient infected with HIV and presenting with a pulmonary complaint with cough should be
placed in Airborne Infection Isolation until a diagnosis of tuberculosis is excluded. Patients with
HIV/AIDS are at high risk of developing active tuberculosis disease. Further, they may present in
an atypical fashion, indistinguishable from other, more common AIDS related pulmonary disease.
This is especially true in patients with advanced, late stage AIDS.
• Patients presently undergoing therapy for active tuberculosis newly admitted to the hospital
should be handled with caution. Place them in Airborne Infection Isolation until response to
therapy can be clarified with the Mississippi State Health Department (MSHD) 601-576-7700.
Patients who have responded to therapy (defined as negative sputum smears and cultures) do not
require isolation. They may need continuation of therapy while hospitalized. Patients who have
successfully completed therapy do not require isolation.
Placing a Patient in Isolation:
• See the section Airborne Infection Isolation and Detailed Guidelines for Setting Up and Carrying
Out Isolation for further information.
• The following should occur after an order is written for Airborne Infection Isolation: 1. The
patient is moved to a private room, either under negative air pressure or one equipped with a High
Efficiency Particulate Air (HEPA) filter (see below). 2. An appropriate isolation sign is placed on
the door. 3. Appropriate isolation equipment (especially N95 particulate respirator masks) are
placed on a cart outside the patient’s room. 4. Infection Control Department should be notified by
calling 42188.
• Patients known or suspected of having active tuberculosis disease must be housed in special rooms
designed to prevent spread of disease. In many rooms of the hospital, flow of air goes from within
the room into the hallway. Air from the room may also mix with air flowing into other rooms via
the air conditioning ducts. As such diseases spread by small droplet nuclei may escape
containment in these rooms and spread to infect patients and staff. To prevent this, the hospital has
installed special Negative Pressure Rooms. These are rooms engineered such that flow of air is
directed from the hallway through the room and is vented to the outside without mixing with air
flowing into other rooms. Once air is vented to the outside infectious agents are rendered noninfectious by dilution. Negative Pressure Rooms are located throughout the facility. Tuberculosis
cases or suspects should be preferentially managed in these rooms. Such patients should be
transferred to these rooms as soon as possible. Call 42188 if you require assistance in locating a
vacant room or assistance in facilitating transfer. Patients with laryngeal disease, cavitary
pulmonary disease, or sputum smear positive pulmonary disease are at highest risk of transmitting
infection and are given highest priority in occupying a Negative Pressure Room.
• If a Negative pressure room is not available an order should be written to place a portable High
Efficiency Particulate Air (HEPA) Filter in the patient’s room. These devices must remain on at
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all times. These devices effectively “scrub” the air and remove infectious particles. They work
very well, but are less desirable than a true Negative Pressure Room.
Any individual entering the room must wear an N95 Particulate Respirator mask. Employees
entering the room should have undergone fit testing of these masks to assure they fit and function
properly. Employees who have not or cannot be fitted with a mask should not enter the room
while occupied by a potentially infectious patient.
Family and Visitors: Family and visitors should observe isolation guidelines, including the wearing of an
N95 Particulate Respirator if tolerated. For known active cases of tuberculosis, staff should question
household members regarding symptoms suggestive of tuberculosis. If any household members are
symptomatic, call Infection Control at 42188 for referral to the Mississippi State Health Department for
follow-up. These individuals should be asked to wear surgical masks (or N95 Particulate Respirators)
whenever they enter the hospital.
Movement of Patients within the Facility:
• Patients should remain in their rooms and leave only for medically urgent procedures that cannot
be performed in the room.
• If a patient must be moved within the facility, call the unit about to receive the patient and inform
them of their isolation status. The patient should be scheduled as last case of the day and a
portable HEPA filter should be placed in the room prior to the patient’s arrival. The HEPA filter
should run for at least one hour before another patient is brought into the room. Any individual
entering the room during this time must wear an N95 particulate respirator.
• The patient should wear a surgical mask while out of the room and be encouraged to cough into a
tissue.
• Individuals present in the room while the test/procedure is performed should wear N95 particulate
respirators.
Discontinuation of Isolation:
• Patients who are suspected of having tuberculosis must have three flurochrome stains of sputum
negative for tuberculosis obtained at least eight hours apart to discontinue Airborne Infection
Isolation. Three negative sputum stains does not exclude a diagnosis of tuberculosis, but it does
predict that the patient posses little risk of spreading the disease to others. If the patient cannot
produce sputum and has responded symptomatically to therapy for condition(s) other than
tuberculosis, or an alternative diagnosis established, please call the Infection Control
Department at 42188 to discuss the possibility of discontinuation of isolation precautions.
• Patients not infected with HIV who are smear positive for acid fast bacilli may be removed from
isolation if it is determined that the positive smear is due to a species of mycobacterium other than
M. tuberculosis. Alternatively, isolation may be discontinued after two weeks of specific therapy
accompanied by improving symptomatology and improving semi-quantitative sputum smears (that
is 4+ positive sputum improves to 3+, etc) Removing a patient from Airborne Infection Isolation is
not a prerequisite for hospital discharge (see below)
• Patients who are HIV infected who are smear positive for acid fast bacilli may also be removed
from isolation if it is found they are infected with a mycobacterium other than M. tuberculosis.
Otherwise, they should remain in Airborne Infection Isolation for the duration of hospitalization,
since their risk of infecting others is less well defined. Isolation should continue on this and
subsequent admissions until it is established by MSHD that the patient’s sputum cultures are now
negative. Again, discontinuation of Airborne Infection Isolation is not a prerequisite for hospital
discharge.
Discharging the Patient from the Hospital:
• Tuberculosis is a disease managed most commonly in the outpatient setting. Known tuberculosis
cases or suspects should be managed as outpatients as soon as their medical condition permits. We
prefer to discharge them from the hospital as soon as feasible since they pose a risk of infecting
other patients or staff. On the face of things it would seem we are putting the patient’s household
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at risk of contracting tuberculosis; however they have probably already been exposed, and are at
no increased risk, especially if follow-up by MSDH is arranged (see below).
At least 24 hours prior to anticipated discharge contact TB Control at the MSHD (601-576-7700).
They will contact the appropriate county health department who will investigate the patient’s
home situation. They want to assure the patient isn’t homeless and that there aren’t small children
or immunocompromised individuals etc. present. MSDH will arrange for evaluation and follow-up
of anyone the patient may have exposed.
Send the patient home with prescriptions for anti-tuberculosis medications to be filled at the
county health department. This is to assure that there is no interruption in therapy if the local TB
control nurse must seek a doctor’s order on weekends or holidays.
Following hospital discharge ALL aspects of management of tuberculosis is directed by the
MSHD by state law. They will place the patient in home quarantine, administer medications and
monitor for response to therapy and drug toxicity. All tuberculosis suspects and tuberculosis cases
receive Directly Observed Therapy (DOT) administered by the MSDH.
Patients receiving DOT are placed in home quarantine until MSDH makes the determination that
the patient is no longer infectious (usually around 2 months). All elective admissions and clinic
visits should be delayed until after this occurs. If a patient must return, he/she should not be placed
in an open waiting area, but should be given a surgical mask to cover the face then placed in a
negative pressure room or HEPA filtered room as soon as possible.
Re-occupying the Room after Patient Discharge:
• After the room is vacated it may be occupied by another patient after the HEPA filter or negative
pressure unit have run for one hour.
• During this time the isolation sign should remain on the door.
• During this time the room may be cleaned by housekeeping but housekeepers must wear N95
particulate respirators. Anyone else entering the room must also wear an N95 particulate
respirator.