Tuberculosis in children: Difference between revisions

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__NOTOC__
__NOTOC__
{{CMG}}; {{AE}} {{AL}}
 
{{CMG}}; {{AE}} {{Mashal Awais}}; {{AL}}
{{Tuberculosis}}
{{Tuberculosis}}


==Overview==
==Overview==
[[Tuberculosis]] in children aged 15 years or younger is considered a [[public health]] issue of special significance because it is a [[marker]] for recent [[Transmission (medicine)|transmission]] of TB. The likelihood of developing life-threatening forms of tuberculosis, such as [[miliary TB]] or [[TB meningitis]] is more in [[Infant|infants]] and young [[children]]. [[Screening]] in children is essential, because the [[signs]] and [[Symptom|symptoms]] are usually vague or non-specific.  History of close contact with [[tuberculosis]] patients plays an major role in the [[diagnosis]] of TB in children.  The [[treatment]] is similar to adults, with adjustment of the doses according to the child's weight.


==Screening for Tuberculosis==
==Screening for Tuberculosis==


===Symptom-based Screening Approach ===
===Symptom-based Screening Approach===
<small><small>Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small></small>
<small><small>Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small></small>
<div style=" font-size: 95%;">
<div style=" font-size: 95%;">{{Family tree/start}}
{{Family tree/start}}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | | | | | | | A01 | | | | | | | | |A01=<div style="float: left; text-align: center; line-height: 150%; width: 13em">Child in close contact with a confirmed TB case</div>}}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | | | | | | | A01 | | | | | | | | |A01=<div style="float: left; text-align: center; line-height: 150%; width: 13em">Child in close contact with confirmed tuberculosis case</div>}}
{{family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | }}
{{family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | }}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | B01 | | | | | | | | | | B02 | | | | |B01=<div style="float: left; text-align: center; line-height: 150%; width: 8em">< 5 yrs old  </div>| B02=<div style="float: left; text-align: center; line-height: 150%; width: 8em"> > 5 yrs old </div> }}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | B01 | | | | | | | | | | B02 | | | | |B01=<div style="float: left; text-align: center; line-height: 150%; width: 8em">< 5 yrs old  </div>| B02=<div style="float: left; text-align: center; line-height: 150%; width: 8em"> > 5 yrs old </div> }}
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===Screening in Children with HIV===
===Screening Children with HIV===
<small><small>Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small></small><br>
<small><small>Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small></small><br>
<small> '''IPT:''' Isoniazid preventive therapy (INH 10 mg/kg/d x 6 months)</small>
<small> '''IPT:''' Isoniazid preventive therapy (INH 10 mg/kg/d x 6 months)</small>
<div style=" font-size: 95%;">
<div style=" font-size: 95%;">
{{Family tree/start}}
{{Family tree/start}}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | | | | | | | A01 | | | | | | | | |A01=<div style="float: left; text-align: center; line-height: 150%; width: 13em;">Child with HIV and older than 1 year</div>}}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | | | | | | | A01 | | | | | | | | |A01=<div style="float: left; text-align: center; line-height: 150%; width: 13em;">Child with [[HIV]] and older than 1 year</div>}}
{{family tree | | | | | | | | | | |!| | | | | | | | | | | }}
{{family tree | | | | | | | | | | |!| | | | | | | | | | | }}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | | | | | | | A02 | | | | | | | | |A02=<div style="float: left; text-align: left; line-height: 150%; width: 13em">Does the patient has any of the following symptoms?<br>
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | | | | | | | A02 | | | | | | | | |A02=<div style="float: left; text-align: left; line-height: 150%; width: 13em">Does the patient has any of the following symptoms?<br>
*Weight loss or poor weight gain<br>
*[[Weight loss]] or poor weight gain<br>
*Cough<br>
*[[Cough]]<br>
*Fever<br>
*[[Fever]]<br>
*History of close contact with a TB case<br> </div>}}
*History of close contact with a TB case<br> </div>}}
{{family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | }}
{{family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | }}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | B01 | | | | | | | | | | B02 | | | | |B01=<div style="float: left; text-align: center; line-height: 150%; width: 12em">'''Yes'''</div>| B02=<div style="float: left; text-align: center; line-height: 150%; width: 12em"> '''No''' </div> }}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | B01 | | | | | | | | | | B02 | | | | |B01=<div style="float: left; text-align: center; line-height: 150%; width: 12em">'''Yes'''</div>| B02=<div style="float: left; text-align: center; line-height: 150%; width: 12em"> '''No''' </div> }}
{{family tree | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{family tree | | | | |!| | | | | | | | | | | |!| | | | | |}}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | C01 | | | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; line-height: 150%; width: 12em">Assess for the diagnosis of TB (TST, chest X-ray, sputum studies) and rule out other diseases</div>| C02=<div style="float: left; text-align: left; line-height: 150%; width: 12em"> Does the patient has any of the following contraindications for IPT?
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| | | | C01 | | | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; line-height: 150%; width: 12em">Assess for the diagnosis of TB ([[TST]], [[chest X-ray]], [[sputum]] studies) and rule out other diseases</div>| C02=<div style="float: left; text-align: left; line-height: 150%; width: 12em"> Does the patient has any of the following contraindications for IPT?
*Active hepatitis<br>
*[[Active hepatitis]]<br>
*Peripheral neuropathy<br> </div>}}
*[[Peripheral neuropathy]]<br> </div>}}
{{family tree | |,|-|-|^|-|-|.| | | | | |,|-|-|^|-|-|.| | | | | | }}
{{family tree | |,|-|-|^|-|-|.| | | | | |,|-|-|^|-|-|.| | | | | | }}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| D01 | | | | D02 | | | | D03 | | | | D04 | | | | | | D01=<div style="float: left; text-align: center; line-height: 150%; width: 12em"> TB confirmed</div> |D02=<div style="float: left; text-align: center; line-height: 150%; width: 12em"> TB ruled out, other diagnosis confirmed</div> |D03=<div style="float: left; text-align: center; line-height: 150%; width: 12em">'''Yes''' </div>| D04=<div style="float: left; text-align: center; line-height: 150%; width: 12em">'''No'''</div>}}
{{family tree |boxstyle = border-radius: 5px 5px 5px 5px;| D01 | | | | D02 | | | | D03 | | | | D04 | | | | | | D01=<div style="float: left; text-align: center; line-height: 150%; width: 12em"> TB confirmed</div> |D02=<div style="float: left; text-align: center; line-height: 150%; width: 12em"> TB ruled out, other diagnosis confirmed</div> |D03=<div style="float: left; text-align: center; line-height: 150%; width: 12em">'''Yes''' </div>| D04=<div style="float: left; text-align: center; line-height: 150%; width: 12em">'''No'''</div>}}
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==Diagnosis==
==Diagnosis==
*Children must be evaluated with a complete assessment, which includes:
 
:*Meticulous medical history (symptoms and close contacts with TB)
*Children must have a complete evaluation for tuberculosis, which includes a meticulous medical history, a complete physical examination, [[tuberculin skin test]] ([[TST]]), [[chest X-ray]], [[sputum]] or gastric aspirate studies ([[microscopy]] and culture), and [[HIV]] testing.
:*Physical examination, that should include growth evaluation.
:*[[TST]]
:*[[Chest X-ray]]
:*Sputum or gastric aspirate studies (microscopy and culture)
:*HIV testing
*Bacteriological testing might be difficult among children, but it should be performed whenever possible.
*Bacteriological testing might be difficult among children, but it should be performed whenever possible.
*Adolescents usually have the adult clinical presentation, but may also present with symptoms and findings seen in smaller children.
*Even though a scoring system has been developed in some countries<ref>{{Cite journal
| author = [[Isabella Coimbra]], [[Magda Maruza]], [[Maria de Fatima Pessoa Militao Albuquerque]], [[Joanna D.'Arc Lyra Batista]], [[Maria Cynthia Braga]], [[Libia Vilela Moura]], [[Democrito Barros Miranda-Filho]], [[Ulisses Ramos Montarroyos]], [[Heloisa Ramos Lacerda]], [[Laura Cunha Rodrigues]] & [[Ricardo Arraes de Alencar Ximenes]]
| title = Validating a scoring system for the diagnosis of smear-negative pulmonary tuberculosis in HIV-infected adults
| journal = [[PloS one]]
| volume = 9
| issue = 4
| pages = e95828
| year = 2014
| month =
| doi = 10.1371/journal.pone.0095828
| pmid = 24755628
}}</ref><ref>{{Cite journal
| author = [[Constantino Giovani Braga Cartaxo]], [[Laura C. Rodrigues]], [[Carolina Pinheiro Braga]] & [[Ricardo Arraes de Alencar Ximenes]]
| title = Measuring the accuracy of a point system to diagnose tuberculosis in children with a negative smear or with no smear or culture
| journal = [[Journal of epidemiology and global health]]
| volume = 4
| issue = 1
| pages = 29–34
| year = 2014
| month = March
| doi = 10.1016/j.jegh.2013.10.002
| pmid = 24534333
}}</ref><ref>{{Cite journal
| author = [[Sandra Christo dos Santos]], [[Ana Maria Campos Marques]], [[Roselene Lopes de Oliveira]] & [[Rivaldo Venancio da Cunha]]
| title = Scoring system for the diagnosis of tuberculosis in indigenous children and adolescents under 15 years of age in the state of Mato Grosso do Sul, Brazil
| journal = [[Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia]]
| volume = 39
| issue = 1
| pages = 84–91
| year = 2013
| month = January-February
| pmid = 23503490
}}</ref><ref>{{Cite journal
| author = [[Stephen M. Graham]]
| title = The use of diagnostic systems for tuberculosis in children
| journal = [[Indian journal of pediatrics]]
| volume = 78
| issue = 3
| pages = 334–339
| year = 2011
| month = March
| doi = 10.1007/s12098-010-0307-7
| pmid = 21165720
}}</ref><ref>{{Cite journal
| author = [[Emily C. Pearce]], [[Jason F. Woodward]], [[Winstone M. Nyandiko]], [[Rachel C. Vreeman]] & [[Samuel O. Ayaya]]
| title = A systematic review of clinical diagnostic systems used in the diagnosis of tuberculosis in children
| journal = [[AIDS research and treatment]]
| volume = 2012
| pages = 401896
| year = 2012
| month =
| doi = 10.1155/2012/401896
| pmid = 22848799
}}</ref>, the WHO does not recommend this system for the evaluation of children with suspected TB.<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}}</ref>
{| style="border: 0px; font-size: 90%; margin: 3px; width: 700px;" align="center"
| valign="top" |
|+
! colspan="2" style="background: #4479BA;" |{{fontcolor|#FFF|Diagnostic Approach in Children with Suspected Tuberculosis}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; width: 200px;" |History and Symptoms
| style="padding: 5px 5px; background: #F5F5F5;" |
*Evaluate for close contact with a case of TB.  <br>
*Symptoms include [[cough]], [[fever]], [[poor appetite]], [[weight loss]], [[lethargy]], [[fatigue]].
*Growth chart should be evaluated to determine an altered growth development.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Physical Examination
| style="padding: 5px 5px; background: #F5F5F5;" |
*The physical examination might be unremarkable in children.  <br>
*Extrapulmonary tuberculosis presents with abnormal physical findings.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Tuberculin Skin Test
| style="padding: 5px 5px; background: #F5F5F5;" |
*Important for evaluating children with no history of close contact and to screen for TB infection. <br>
*In immunocompetent children, > 10 mm is considered positive. <br>
*In immunosuppressed children, > 5mm is considered positive.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Chest X-ray
| style="padding: 5px 5px; background: #F5F5F5;" |
*Common findings include consolidation associated with an enlarged [[lymph node]] in the hilum. <br>
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Bacteriological Tests
| style="padding: 5px 5px; background: #F5F5F5;" |
*Sputum or gastric aspirates should be assessed for the presence of [[M. tuberculosis]].<br>
*Microscopy and culture should be done in every case possible to confirm the diagnosis.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |HIV Test
| style="padding: 5px 5px; background: #F5F5F5;" |
*In children with suspected TB, [[HIV]] testing should be offered.
|-
| colspan="2" style="padding: 5px 5px; background: #F5F5F5;" |<small> Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}}</ref></small>
|-
|}


==Treatment Regimens==
===Diagnostic Approach for Extrapulmonary Tuberculosis===
{| style="border: 0px; font-size: 90%; margin: 3px; width: 700px;" align="center"
| valign="top" |
|+
! style="background: #4479BA;" |{{fontcolor|#FFF|Location}}
! style="background: #4479BA;" |{{fontcolor|#FFF|Common Clinical Presentation}}
! style="background: #4479BA;" |{{fontcolor|#FFF|Diagnostic Workup}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; width: 175px;" |Peripheral [[Adenopathy]]
| style="padding: 5px 5px; background: #F5F5F5;" |Painless [[lymph node]] enlargement, commonly in one side of the neck.
| style="padding: 5px 5px; background: #F5F5F5;" |[[Fine needle aspiration]] or [[biopsy]] of the [[lymph node]], culture of aspirate.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Miliary Tuberculosis]]
| style="padding: 5px 5px; background: #F5F5F5;" |[[Lethargy]], [[fever]], non-specific symptoms.
| style="padding: 5px 5px; background: #F5F5F5;" |Order a [[chest X-ray]] and a [[lumbar puncture]] in suspicion of [[meningeal]] involvement.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Tuberculous Meningitis
| style="padding: 5px 5px; background: #F5F5F5;" |[[Lethargy]], [[neck stiffness]], [[headache]], [[irritability]], bulging [[fontanelle]].
| style="padding: 5px 5px; background: #F5F5F5;" |[[Lumbar puncture]], head CT.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Pleural Effusion
| style="padding: 5px 5px; background: #F5F5F5;" |Decreased breath sounds, dullness to percussion, chest pain.
| style="padding: 5px 5px; background: #F5F5F5;" |Order a [[chest X-ray]], perform an analysis of the [[pleural fluid]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Tuberculous Peritonitis
| style="padding: 5px 5px; background: #F5F5F5;" |Order an abdominal [[ultrasound]], consider [[ascites|abdominal fluid]] aspiration for analysis.
| style="padding: 5px 5px; background: #F5F5F5;" |[[Abdominal tenderness]], [[ascites]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Bone or Joint Infection
| style="padding: 5px 5px; background: #F5F5F5;" |Altered [[range of motion|ROM]], [[joint swelling]], mono[[arthralgia|articular pain]].
| style="padding: 5px 5px; background: #F5F5F5;" |[[X-ray]] of the affected limb, [[joint]] fluid aspiration and analysis.
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Tuberculous Pericarditis]]
| style="padding: 5px 5px; background: #F5F5F5;" |Distant [[heart sounds]], [[tachycardia]], signs of [[heart failure]] ([[edema]], [[dyspnea]]).
| style="padding: 5px 5px; background: #F5F5F5;" |[[Echocardiography]], consider [[pericardiocentesis]] for fluid analysis.
|-
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" |<small> Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}}</ref> and WHO Childhood TB: Training Toolkit <ref name="Toolkit"> {{cite web| url=http://www.who.int/tb/challenges/childtbtraining_manual/en/| title=WHO Childhood TB: Training Toolkit}}</ref>
</small>
|-
|}
 
==Treatment <small><small><small> Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}}</ref> and WHO Childhood TB: Training Toolkit <ref name="Toolkit"> {{cite web| url=http://www.who.int/tb/challenges/childtbtraining_manual/en/| title=WHO Childhood TB: Training Toolkit}}</ref></small></small></small>==
 
*[[Empirical|Empirica]]<nowiki/>l treatment should be started and the regimen should be modified according to the [[DST]] ([[Drug susceptibility testing]]) results.
*Drug dosing should be calculated according to the child's weight, regardless the age.
*Pediatricians should closely monitor adverse drug reactions and manage them appropriately.
*For [[drug-resistant tuberculosis]], hospitalization is often required for the administration of IV medications.
*The treatment duration for drug-susceptible TB is 6 months.
*The treatment duration for drug-resistant tuberculosis will depend on the culture results. The duration of therapy should be at least 18 months after the culture is negative.
*Weight gain and resolution of symptoms are good markers for a good response to treatment.
 
<br>
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
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! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Drug Susceptible TB Regimen}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align="center" |{{fontcolor|#FFF|Drug Susceptible TB Regimen}}
|-
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align="center" |'''''Initial phase <br> (Administer each drug daily for 8 weeks)'''''
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left |<small>Table adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed.<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref></small>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |▸ '''''[[Isoniazid]] 10 mg/kg PO (Max: 300 mg/day)'''''<br> PLUS <br> ▸ '''''[[Rifampicin]] 15 mg/kg PO (Max: 600 mg/day)'''''<br> PLUS<br> ▸ '''''[[Pyrazinamide]] 35 mg/kg PO  (Max: 2 g/day)'''''<br> PLUS <br> ▸ '''''[[Ethambutol]] 20 mg/kg PO (Max: 1.6 g/day)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align="center" |'''''Continuation phase <br> (Administer each drug daily for 18 weeks)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |▸ '''''[[Isoniazid]] 10 mg/kg PO  (Max: 300 mg/day) '''''<br> PLUS<br> ▸ ''''' [[Rifampicin]] 15 mg/kg PO (Max: 600 mg/day )'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align="left" |<small>Table adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed.<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref></small>
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! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|MDR-TB Regimen}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align="center" |{{fontcolor|#FFF|MDR-TB Regimen}}
|-
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Standard Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align="center" |'''''Standard Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 1: First-line oral drugs</u>''' <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 1: First-line oral drugs</u>''' <br>
▸ ''' [[Pyrazinamide]] 20-30 mg/kg (Max: 600 mg)''' <br> OR <br> ▸ '''[[Ethambutol]] 15-20 mg/kg''' <br> OR <br> ▸ '''[[Rifabutin]] 5 mg/kg'''
▸ ''' [[Pyrazinamide]] 20-30 mg/kg (Max: 600 mg)''' <br> OR <br> ▸ '''[[Ethambutol]] 15-20 mg/kg''' <br> OR <br> ▸ '''[[Rifabutin]] 5 mg/kg'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 2: Injectable drugs</u>''' <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 2: Injectable drugs</u>''' <br>
▸ '''[[Capreomycin]] 15-30 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Kanamycin]] 15-30 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Amikacin]] 15-22.5 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Streptomycin]] 12-18 mg/kg'''
▸ '''[[Capreomycin]] 15-30 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Kanamycin]] 15-30 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Amikacin]] 15-22.5 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Streptomycin]] 12-18 mg/kg'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 3: Fluoroquinolones</u>''' <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 3: Fluoroquinolones</u>''' <br>
▸ '''[[Levofloxacin]] 7.5-10 mg/kg'''<br> OR <br> ▸ '''[[Moxifloxacin]] 7.5-10 mg/kg'''<br> OR <br> ▸ '''[[Ofloxacin]] 15-20 mg/kg divided q12h (Max:800 mg)'''
▸ '''[[Levofloxacin]] 7.5-10 mg/kg'''<br> OR <br> ▸ '''[[Moxifloxacin]] 7.5-10 mg/kg'''<br> OR <br> ▸ '''[[Ofloxacin]] 15-20 mg/kg divided q12h (Max:800 mg)'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 4:Oral bacteriostatic second-line drugs</u>''' <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 4:Oral bacteriostatic second-line drugs</u>''' <br>
▸ '''[[Ethionamide]] 15-20 mg/kg divided q12h (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Protionamide]] 15-20 mg/kg divided q12h (Max: 1000 mg)''' <br> OR <br> ▸ '''[[Cycloserine]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Terizidone]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Aminosalicylic acid|Para-aminosalicylic acid]] 150 mg/kg divided q8-12h(Max: 12 000 mg)'''
▸ '''[[Ethionamide]] 15-20 mg/kg divided q12h (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Protionamide]] 15-20 mg/kg divided q12h (Max: 1000 mg)''' <br> OR <br> ▸ '''[[Cycloserine]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Terizidone]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Aminosalicylic acid|Para-aminosalicylic acid]] 150 mg/kg divided q8-12h(Max: 12 000 mg)'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left |<small>Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref> and Guidance for national tuberculosis programmes on the management of tuberculosis in children <ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small>
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align="left" |<small>Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref> and Guidance for national tuberculosis programmes on the management of tuberculosis in children <ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small>
|}
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! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align="center" |{{fontcolor|#FFF|XDR-TB Regimen}}
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Standard Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align="center" |'''''Standard Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 1: First-line oral drugs</u>''' <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 1: First-line oral drugs</u>''' <br>
▸ ''' [[Pyrazinamide]] 20-30 mg/kg (Max: 600 mg)''' <br> OR <br> ▸ '''[[Ethambutol]] 15 mg/kg ''' <br> OR <br> ▸ '''[[Rifabutin]]  5 mg/kg'''
▸ ''' [[Pyrazinamide]] 20-30 mg/kg (Max: 600 mg)''' <br> OR <br> ▸ '''[[Ethambutol]] 15 mg/kg ''' <br> OR <br> ▸ '''[[Rifabutin]]  5 mg/kg'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 4:Oral bacteriostatic second-line drugs</u>''' <br>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 4:Oral bacteriostatic second-line drugs</u>''' <br>
▸ '''[[Ethionamide]] 15-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Protionamide]] 15-20 mg/kg (Max: 1000 mg)''' <br> OR <br> ▸ '''[[Cycloserine]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Terizidone]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br>▸ '''[[Aminosalicylic acid|Para-aminosalicylic acid]] 150 mg/kg/d divided q8-12h'''
▸ '''[[Ethionamide]] 15-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Protionamide]] 15-20 mg/kg (Max: 1000 mg)''' <br> OR <br> ▸ '''[[Cycloserine]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br> ▸ '''[[Terizidone]] 10-20 mg/kg (Max: 1000 mg)'''<br> OR <br>▸ '''[[Aminosalicylic acid|Para-aminosalicylic acid]] 150 mg/kg/d divided q8-12h'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |PLUS
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | '''<u>Group 5</u>''' <br>'''''Use at least 2 of the following:'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align="left" |'''<u>Group 5</u>''' <br>'''''Use at least 2 of the following:'''''
▸ '''[[Clofazimine]] 50 mg/d AND 300 mg once a month'''<br> OR <br> ▸ '''[[Amoxicillin]]/[[clavulanate]]''' <br> OR <br> ▸ '''[[Linezolid]] 300-600 mg'''<br> OR <br> ▸ '''[[Imipenem]] 500mg q6h'''<br> OR <br>▸ '''[[Clarithromycin]] 500-1000 mg q12h '''<br> OR <br>▸ '''[[Thioacetazone]] 2.5 mg/kg'''<br> OR <br>▸ '''[[Isoniazid]] (high-dose) 16–20 mg/kg'''
▸ '''[[Clofazimine]] 50 mg/d AND 300 mg once a month'''<br> OR <br> ▸ '''[[Amoxicillin]]/[[clavulanate]]''' <br> OR <br> ▸ '''[[Linezolid]] 300-600 mg'''<br> OR <br> ▸ '''[[Imipenem]] 500mg q6h'''<br> OR <br>▸ '''[[Clarithromycin]] 500-1000 mg q12h '''<br> OR <br>▸ '''[[Thioacetazone]] 2.5 mg/kg'''<br> OR <br>▸ '''[[Isoniazid]] (high-dose) 16–20 mg/kg'''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left |<small>Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref> and WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children <ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small>
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align="left" |<small>Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.<ref name="WHO 2013"> {{cite web|  url=http://www.who.int/tb/publications/tb_treatmentguidelines/en/| title=2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition) }}</ref> and WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children <ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref></small>
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<!---
Because of the high risk of disseminated tuberculosis in infants and children younger than 4 years of age, treatment should be started as soon as the diagnosis of tuberculosis is suspected. In general, the regimens recommended for adults are also the regimens of choice for infants, children, and adolescents with tuberculosis, with the exception that [[ethambutol]] is not used routinely in children. Because there is a lower bacillary burden in childhood-type tuberculosis there is less concern with the development of acquired [[drug resistance]]. However, children and adolescents may develop "adult-type" tuberculosis with upper lobe infiltration, cavitation, and [[sputum]] production. In such situations an initial phase of four drugs should be given until susceptibility is proven. When clinical or epidemiologic circumstances suggest an increased probability of [[INH]] resistance, [[EMB]] can be used safely at a dose of 15--20 mg/kg per day, even in children too young for routine eye testing. [[Streptomycin]], [[kanamycin]], or [[amikacin]] also can be used as the fourth drug, when necessary.
Most studies of treatment in children have used 6 months of [[INH]] and [[RIF]] supplemented during the first 2 months with [[PZA]]. This three-drug combination has a success rate of greater than 95% and an [[adverse drug reaction]] rate of less than 2%. Most treatment studies of intermittent dosing in children have used daily drug administration for the first 2 weeks to 2 months. DOT should always be used in treating children.
Because it is difficult to isolate ''M. tuberculosis'' from a child with pulmonary tuberculosis, it is frequently necessary to rely on the results of drug susceptibility tests of the organisms isolated from the presumed source case to guide the choice of drugs for the child. In cases of suspected drug-resistant tuberculosis in a child or when a source case isolate is not available, specimens for [[microbiological]] evaluation should be obtained via early morning [[gastric]] [[aspiration]], [[bronchoalveolar lavage]], or [[biopsy]].
In general, extrapulmonary tuberculosis in children can be treated with the same regimens as [[pulmonary]] disease. Exceptions are disseminated tuberculosis and tuberculous meningitis, for which there are inadequate data to support 6-month therapy; thus 9--12 months of treatment is recommended.
The optimal treatment of pulmonary tuberculosis in children and adolescents with [[HIV]] infection is unknown. The [[American Academy of Pediatrics]] recommends that initial therapy should always include at least three drugs, and the total duration of therapy should be at least 9 months, although there are no data to support this recommendation.
--->


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category: Pulmonology]]
[[Category:Pulmonology]]
[[Category:Primary care]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
{{WH}}
{{WS}}

Latest revision as of 03:25, 29 March 2021


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mashal Awais, M.D.[2]; Alejandro Lemor, M.D. [3]

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Overview

Tuberculosis in children aged 15 years or younger is considered a public health issue of special significance because it is a marker for recent transmission of TB. The likelihood of developing life-threatening forms of tuberculosis, such as miliary TB or TB meningitis is more in infants and young children. Screening in children is essential, because the signs and symptoms are usually vague or non-specific. History of close contact with tuberculosis patients plays an major role in the diagnosis of TB in children. The treatment is similar to adults, with adjustment of the doses according to the child's weight.

Screening for Tuberculosis

Symptom-based Screening Approach

Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]

 
 
 
 
 
 
 
 
 
Child in close contact with a confirmed TB case
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 5 yrs old
 
 
 
 
 
 
 
 
 
> 5 yrs old
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic
 
 
 
Symptomatic
 
 
 
Symptomatic
 
 
 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer INH 10 mg/kg/d x 6 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No preventive treatment is recommended.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the child develops symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the child develops symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm the diagnosis of TB with:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Screening Children with HIV

Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]
IPT: Isoniazid preventive therapy (INH 10 mg/kg/d x 6 months)

 
 
 
 
 
 
 
 
 
Child with HIV and older than 1 year
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient has any of the following symptoms?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess for the diagnosis of TB (TST, chest X-ray, sputum studies) and rule out other diseases
 
 
 
 
 
 
 
 
 
Does the patient has any of the following contraindications for IPT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TB confirmed
 
 
 
TB ruled out, other diagnosis confirmed
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer 2HRZE/4HR regimen
 
 
 
Give appropriate treatment for the disease and consider IPT
 
 
 
Do not administer IPT
 
 
 
Administer IPT
 
 
 
 
 

Diagnosis

  • Children must have a complete evaluation for tuberculosis, which includes a meticulous medical history, a complete physical examination, tuberculin skin test (TST), chest X-ray, sputum or gastric aspirate studies (microscopy and culture), and HIV testing.
  • Bacteriological testing might be difficult among children, but it should be performed whenever possible.
  • Adolescents usually have the adult clinical presentation, but may also present with symptoms and findings seen in smaller children.
  • Even though a scoring system has been developed in some countries[2][3][4][5][6], the WHO does not recommend this system for the evaluation of children with suspected TB.[1]
Diagnostic Approach in Children with Suspected Tuberculosis
History and Symptoms
Physical Examination
  • The physical examination might be unremarkable in children.
  • Extrapulmonary tuberculosis presents with abnormal physical findings.
Tuberculin Skin Test
  • Important for evaluating children with no history of close contact and to screen for TB infection.
  • In immunocompetent children, > 10 mm is considered positive.
  • In immunosuppressed children, > 5mm is considered positive.
Chest X-ray
  • Common findings include consolidation associated with an enlarged lymph node in the hilum.
Bacteriological Tests
  • Sputum or gastric aspirates should be assessed for the presence of M. tuberculosis.
  • Microscopy and culture should be done in every case possible to confirm the diagnosis.
HIV Test
  • In children with suspected TB, HIV testing should be offered.
Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]

Diagnostic Approach for Extrapulmonary Tuberculosis

Location Common Clinical Presentation Diagnostic Workup
Peripheral Adenopathy Painless lymph node enlargement, commonly in one side of the neck. Fine needle aspiration or biopsy of the lymph node, culture of aspirate.
Miliary Tuberculosis Lethargy, fever, non-specific symptoms. Order a chest X-ray and a lumbar puncture in suspicion of meningeal involvement.
Tuberculous Meningitis Lethargy, neck stiffness, headache, irritability, bulging fontanelle. Lumbar puncture, head CT.
Pleural Effusion Decreased breath sounds, dullness to percussion, chest pain. Order a chest X-ray, perform an analysis of the pleural fluid.
Tuberculous Peritonitis Order an abdominal ultrasound, consider abdominal fluid aspiration for analysis. Abdominal tenderness, ascites.
Bone or Joint Infection Altered ROM, joint swelling, monoarticular pain. X-ray of the affected limb, joint fluid aspiration and analysis.
Tuberculous Pericarditis Distant heart sounds, tachycardia, signs of heart failure (edema, dyspnea). Echocardiography, consider pericardiocentesis for fluid analysis.
Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1] and WHO Childhood TB: Training Toolkit [7]

Treatment Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1] and WHO Childhood TB: Training Toolkit [7]

  • Empirical treatment should be started and the regimen should be modified according to the DST (Drug susceptibility testing) results.
  • Drug dosing should be calculated according to the child's weight, regardless the age.
  • Pediatricians should closely monitor adverse drug reactions and manage them appropriately.
  • For drug-resistant tuberculosis, hospitalization is often required for the administration of IV medications.
  • The treatment duration for drug-susceptible TB is 6 months.
  • The treatment duration for drug-resistant tuberculosis will depend on the culture results. The duration of therapy should be at least 18 months after the culture is negative.
  • Weight gain and resolution of symptoms are good markers for a good response to treatment.


▸ Click on the following categories to expand treatment regimens.

Tuberculosis in Children

  ▸  Drug Susceptible TB

  ▸  MDR-TB

  ▸  XDR-TB

Drug Susceptible TB Regimen
Initial phase
(Administer each drug daily for 8 weeks)
Isoniazid 10 mg/kg PO (Max: 300 mg/day)
PLUS
Rifampicin 15 mg/kg PO (Max: 600 mg/day)
PLUS
Pyrazinamide 35 mg/kg PO (Max: 2 g/day)
PLUS
Ethambutol 20 mg/kg PO (Max: 1.6 g/day)
Continuation phase
(Administer each drug daily for 18 weeks)
Isoniazid 10 mg/kg PO (Max: 300 mg/day)
PLUS
Rifampicin 15 mg/kg PO (Max: 600 mg/day )
Table adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed.[8]
MDR-TB Regimen
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20-30 mg/kg (Max: 600 mg)
OR
Ethambutol 15-20 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 2: Injectable drugs

Capreomycin 15-30 mg/kg (Max: 1000 mg)
OR
Kanamycin 15-30 mg/kg (Max: 1000 mg)
OR
Amikacin 15-22.5 mg/kg (Max: 1000 mg)
OR
Streptomycin 12-18 mg/kg

PLUS
Group 3: Fluoroquinolones

Levofloxacin 7.5-10 mg/kg
OR
Moxifloxacin 7.5-10 mg/kg
OR
Ofloxacin 15-20 mg/kg divided q12h (Max:800 mg)

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg divided q12h (Max: 1000 mg)
OR
Protionamide 15-20 mg/kg divided q12h (Max: 1000 mg)
OR
Cycloserine 10-20 mg/kg (Max: 1000 mg)
OR
Terizidone 10-20 mg/kg (Max: 1000 mg)
OR
Para-aminosalicylic acid 150 mg/kg divided q8-12h(Max: 12 000 mg)

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[8] and Guidance for national tuberculosis programmes on the management of tuberculosis in children [1]
XDR-TB Regimen
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20-30 mg/kg (Max: 600 mg)
OR
Ethambutol 15 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg (Max: 1000 mg)
OR
Protionamide 15-20 mg/kg (Max: 1000 mg)
OR
Cycloserine 10-20 mg/kg (Max: 1000 mg)
OR
Terizidone 10-20 mg/kg (Max: 1000 mg)
OR
Para-aminosalicylic acid 150 mg/kg/d divided q8-12h

PLUS
Group 5
Use at least 2 of the following:

Clofazimine 50 mg/d AND 300 mg once a month
OR
Amoxicillin/clavulanate
OR
Linezolid 300-600 mg
OR
Imipenem 500mg q6h
OR
Clarithromycin 500-1000 mg q12h
OR
Thioacetazone 2.5 mg/kg
OR
Isoniazid (high-dose) 16–20 mg/kg

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[8] and WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children [1]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 "WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014" (PDF).
  2. Isabella Coimbra, Magda Maruza, Maria de Fatima Pessoa Militao Albuquerque, Joanna D.'Arc Lyra Batista, Maria Cynthia Braga, Libia Vilela Moura, Democrito Barros Miranda-Filho, Ulisses Ramos Montarroyos, Heloisa Ramos Lacerda, Laura Cunha Rodrigues & Ricardo Arraes de Alencar Ximenes (2014). "Validating a scoring system for the diagnosis of smear-negative pulmonary tuberculosis in HIV-infected adults". PloS one. 9 (4): e95828. doi:10.1371/journal.pone.0095828. PMID 24755628.
  3. Constantino Giovani Braga Cartaxo, Laura C. Rodrigues, Carolina Pinheiro Braga & Ricardo Arraes de Alencar Ximenes (2014). "Measuring the accuracy of a point system to diagnose tuberculosis in children with a negative smear or with no smear or culture". Journal of epidemiology and global health. 4 (1): 29–34. doi:10.1016/j.jegh.2013.10.002. PMID 24534333. Unknown parameter |month= ignored (help)
  4. Sandra Christo dos Santos, Ana Maria Campos Marques, Roselene Lopes de Oliveira & Rivaldo Venancio da Cunha (2013). "Scoring system for the diagnosis of tuberculosis in indigenous children and adolescents under 15 years of age in the state of Mato Grosso do Sul, Brazil". Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 39 (1): 84–91. PMID 23503490. Unknown parameter |month= ignored (help)
  5. Stephen M. Graham (2011). "The use of diagnostic systems for tuberculosis in children". Indian journal of pediatrics. 78 (3): 334–339. doi:10.1007/s12098-010-0307-7. PMID 21165720. Unknown parameter |month= ignored (help)
  6. Emily C. Pearce, Jason F. Woodward, Winstone M. Nyandiko, Rachel C. Vreeman & Samuel O. Ayaya (2012). "A systematic review of clinical diagnostic systems used in the diagnosis of tuberculosis in children". AIDS research and treatment. 2012: 401896. doi:10.1155/2012/401896. PMID 22848799.
  7. 7.0 7.1 "WHO Childhood TB: Training Toolkit".
  8. 8.0 8.1 8.2 "2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition)".

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