ATS, CDC, and IDSA update recommendations on the treatment of tuberculosis.(Practice Guidelines American Thoracic Society, Centers for Disease Control and Prevention, Infectious Diseases Society of America )

Publication: American Family Physician

Publication Date: 01-NOV-03

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COPYRIGHT 2003 American Academy of Family Physicians

The American Thoracic Society (ATS), the Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of America (IDSA) recently published a joint statement of recommendations for the treatment of tuberculosis in settings where mycobacterial cultures, radiographic facilities, and drug susceptibility testing are available. The recommendations appeared in the June 20, 2003, issue of the Recommendations and Reports series of Morbidity and Morality Weekly Report (http://www.cdc.gov/ mmwr/preview/mmwrhtml/rr5211a1.htm).

Treatment

The goals for treatment of tuberculosis are to cure the individual patient and to minimize the transmission of Mycobacterium tuberculosis. It is the responsibility of the prescribing physician to oversee the successful completion of therapy, because this benefits the individual patient as well as the community in which the patient resides. Treatment should be tailored and supervised based on the clinical and social factors of each patient. This patient-centered approach should emphasize directly observed therapy (DOT), which involves providing the antituberculosis drug directly to the patient and watching as he or she swallows the medication. Additional measures that facilitate adherence to the drug regimen include social service support, housing assistance, coordination of tuberculosis services with those of other providers, referral for treatment of substance abuse, and treatment incentives and enablers.

Recommended Treatment Regimens

There are four recommended treatment regimens for patients with tuberculosis caused by drug-susceptible organisms. Each regimen has an initial two-month phase followed by a four-or seven-month continuation phase as described in Table 1. For most adult patients with previously untreated tuberculosis, the treatment regimen should consist of a two-month initial phase of isoniazid, rifampin, pyrazinamide, and ethambutol. If test results of drug susceptibility are available, ethambutol may not be necessary. The initial phase may be given daily (Regimens 1 and 4), daily for two weeks and then twice weekly for six weeks (Regimen 2), or three times weekly throughout (Regimen 3).

For the majority of patients, the continuation phase should last four months. A seven-month continuation phase is recommended only for the following groups: patients who have cavitary pulmonary tuberculosis caused by drug-susceptible organisms and who had a positive sputum culture obtained at the time of completion of two months of treatment; patients whose initial phase of treatment did not include pyrazinamide; and patients who are receiving isoniazid and rifapentine once weekly and who had a positive sputum culture obtained at the time of completion of two months of treatment. The continuation phase may be given daily (Regimens 1a and 4a), two times weekly by DOT (Regimens 1b, 2a, and 4b), or three times weekly by DOT (Regimen 3a). Doses for first-line antituberculosis drugs are shown in Tables 2 and 3.

Initiation of Treatment

The decision to initiate combination antituberculosis chemotherapy should be based on clinical, pathologic, and radiographic features of the patient, epidemiologic information, results of the initial series of acid-fast bacilli (AFB)-stained sputum...

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